A nurse is preparing to administer an IM injection to a client using a medication from an ampule. Which of the following actions should the nurse plan to take?

Administer the medication using a filter needle.

Break the ampule by bending the top to the side.

Flick the bottom of the ampule several times.

Withdraw medication from the center of the ampule.

None

Answer and Explanation

The Correct Answer is D

A. A filter needle is used when withdrawing medication from an ampule, but it is not used to administer the injection. After withdrawal, the filter needle should be replaced with a regular IM needle for administration.
B. The ampule should be broken by snapping the neck away from the body, not by bending it to the side, to prevent injury.
C. The nurse should gently tap the top of the ampule, not the bottom, to move the solution downward before opening.
D. The correct technique is to insert the needle into the center of the ampule to withdraw medication, ensuring that the bevel remains below the fluid line to avoid drawing up air.

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Correct Answer is ["A","B","D"]

Explanation

A. Streak formation along the vein is a characteristic sign of phlebitis. It indicates inflammation and possibly thrombophlebitis (inflammation with clot formation) within the vein.

B. Erythema (redness) at the insertion site is a common early sign of phlebitis. It indicates localized inflammation of the vein.

C. Blistering around the insertion site is not typically associated with phlebitis. It may suggest a severe reaction or infection, but it is not a common manifestation of phlebitis itself.

D. Warmth at the insertion site is a common sign of inflammation, including phlebitis. It indicates increased blood flow and localized inflammatory response.

E. A damp dressing over the insertion site can contribute to the risk of infection but is not a direct manifestation of phlebitis. However, it can be a contributing factor to the development of phlebitis if moisture leads to skin breakdown or infection.

A. "There's blood backing up my baby's IV tubing." B. "My baby's fingers are looking swollen." C. "There's a long red streak up my baby's arm." D. "The tape is coming off the IV needle."

Correct Answer is B

Explanation

B. Swelling around the IV site or in the extremity (such as the fingers) can be a sign of infiltration. This occurs because the IV fluid leaks into the surrounding tissues, causing localized swelling.

A. Blood backing up in the IV tubing could indicate issues like a clot in the line or a slow flow rate, but it does not specifically suggest infiltration. It might prompt the nurse to check for other issues such as patency of the IV line or the need for flushing.

C. A long red streak up the arm could indicate inflammation or infection along the vein (phlebitis) rather than infiltration. Phlebitis can be caused by mechanical irritation, chemical irritation from the IV fluids, or infection.

D. Tape coming off the IV needle suggests a need for re-securing the IV, but it does not directly indicate infiltration. However, if the tape is coming off, it's important to check the entire IV site to ensure the catheter is still properly inserted and there are no signs of infiltration or dislodgment.

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A nurse is preparing to administer an IM injection to a client using a medication from an ampule. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client's IV site. The nurse should report which of the following findings as manifestations of phlebitis? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is caring for an 8-month-old infant who is receiving intravenous (IV) fluids via a 24-gauge catheter. Which of the following statements by the client's mother indicates that the nurse should check the site for signs of infiltration?

Correct Answer is B

Explanation

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