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Holding the medication without notifying the provider puts the child at continued risk of receiving an unsafe dose later. The nurse must take action by contacting the prescriber.

Even if the prescription is written that way, nurses are legally responsible for identifying unsafe doses—especially in pediatrics where dosing is weight-based.

Nurses cannot independently change the dose. Verifying weight is appropriate, but altering the dose without provider direction is unsafe and outside scope.

20, 40, 60: While some older references may list these as macrodrip options, modern IV administration uses standardized drop factors. These values are inconsistent and could lead to miscalculations when setting infusion rates. Using nonstandard values increases the risk of delivering too much or too little fluid over time.

100, 150, 200: These drop factors are far too high for typical macrodrip sets and are not used in standard clinical practice. Values this high are more akin to specialized microdrip systems designed for very precise small-volume infusions, not for routine fluid replacement.

1, 5, 10: These drop factors are too low for practical macrodrip IV administration and would require excessive time to deliver routine fluid volumes. Using such low drops per milliliter could lead to underhydration or delayed therapy.

Slow the infusion rate is incorrect because reducing the flow rate does not eliminate the cause of the irritation, the IV catheter and current infusion solution. As long as the catheter remains in the vein, mechanical irritation, chemical irritation (from the medication or solution), or bacterial irritation can continue to worsen. Slowing the infusion only delays the appropriate intervention and increases the risk of complications such as thrombophlebitis or infection.

Apply a warm compress and continue monitoring is incorrect because warm compresses are an adjunct treatment after the catheter has been removed, not while it remains in place. Applying warmth without removing the catheter allows the source of inflammation to continue irritating the vein. Additionally, “continue monitoring” is insufficient because early phlebitis requires active intervention. Continuing the infusion despite early signs can lead to increased pain, swelling, redness, or even the development of a palpable cord.

Flush the IV site with normal saline is incorrect because flushing an IV that shows signs of phlebitis can worsen damage by forcing fluid through an already irritated vein. This can increase pain, promote clot formation, and potentially dislodge a thrombus if one is developing. Flushing also increases the risk of introducing bacteria deeper into the venous system if the phlebitis has an infectious component. Therefore, flushing is contraindicated when inflammation is already present.

Rinse the affected area and continue working unless symptoms develop is incorrect because simply rinsing the wound does not fulfill required safety protocols. Needlestick injuries carry the risk of exposure to bloodborne pathogens such as HIV, HBV, and HCV. Continuing to work without reporting the injury delays essential post-exposure evaluation and prophylaxis, which is most effective when started immediately after exposure.

Wait until the end of the shift to document the occurrence is incorrect because delaying reporting may compromise the nurse’s ability to receive timely testing and post-exposure prophylaxis. For certain pathogens, such as HIV, prophylaxis is most effective when initiated within hours. Waiting until the end of the shift puts the nurse at unnecessary risk and violates occupational safety policies.

Ignore the injury unless the source patient is known to be infectious is incorrect and unsafe. Many patients’ infectious status may be unknown, and even those who appear low-risk may carry bloodborne pathogens. OSHA and employer policies require that every needlestick injury be treated as a potential exposure, reported immediately, and properly evaluated. Ignoring it jeopardizes both the nurse’s health and organizational compliance with safety standards.

Use a transdermal patch to apply the medication over a hairless skin site for continuous absorption is incorrect because transdermal administration provides systemic, slow, continuous absorption, which is not appropriate for allergy testing. Allergy testing requires localized, controlled exposure to a very small amount of allergen within the dermis, not transdermal absorption through a patch.

Deliver the medication intramuscularly at a 90° angle into a large muscle to allow rapid absorption of the medication is incorrect because intramuscular (IM) injections deliver medication deeply into muscle tissue, where it is absorbed quickly into systemic circulation. This route would not allow the localized skin response needed for diagnostic allergy testing and could cause systemic reactions, making the results invalid and unsafe.

Administer the medication subcutaneously at a 45° angle into the fatty tissue to promote slow absorption is incorrect because subcutaneous injections deposit medication into adipose tissue beneath the dermis. This route still results in systemic absorption and will not stimulate the localized, visible wheal (bleb) required to evaluate hypersensitivity reactions. A subcutaneous injection will not produce accurate allergy test results.