1.
A nurse wants to prevent tissue fibrosis in a sickle cell anemia patient secondary to multiple intramuscular (IM) injections. The nurse should _____.
Correct Answer
B. Rotate IM injection sites.
Explanation
To prevent tissue fibrosis in a sickle cell anemia patient, it is important to rotate the intramuscular (IM) injection sites. This helps to prevent the buildup of scar tissue and fibrosis in a specific area. By rotating the injection sites, the nurse ensures that different muscles are used for each injection, reducing the risk of tissue damage and fibrosis. Massaging the site after administering the injection may help with absorption but does not specifically prevent tissue fibrosis. Allowing the patient to select the injection site or limiting it to specific sites may not be practical or effective in preventing tissue fibrosis.
2.
A nurse plans to administer an IM injection to a client. The nurse’s first action should be to _______.
Correct Answer
B. Review the five rights.
Explanation
Before administering any medication, it is essential for the nurse to review the five rights: right patient, right medication, right dose, right route, and right time. This ensures that the medication is being administered to the correct patient, in the correct dose, through the correct route, and at the correct time. By reviewing the five rights, the nurse can prevent medication errors and ensure the safety of the client. Washing hands, donning gloves, and preparing medication are important steps in the medication administration process, but reviewing the five rights should be the nurse's first action.
3.
Which one of the following is a contraindication to an IM injection?
Correct Answer
D. Thrombocytopenia
Explanation
Thrombocytopenia is a condition characterized by a low platelet count in the blood. Platelets are responsible for blood clotting, and a low platelet count can lead to excessive bleeding and difficulty in forming clots. Therefore, thrombocytopenia is a contraindication to an intramuscular (IM) injection, as it increases the risk of bleeding and hematoma formation at the injection site.
4.
The onset of action of a medication administered sublingually can occur within _____.
Correct Answer
A. Seconds.
Explanation
When a medication is administered sublingually, it is placed under the tongue where it is rapidly absorbed into the bloodstream through the thin mucous membranes. This route of administration bypasses the digestive system and liver metabolism, resulting in a quicker onset of action compared to oral ingestion. Therefore, the onset of action can occur within seconds after sublingual administration.
5.
When should a nurse use the Z-Track technique for IM injections?
Correct Answer
C. When the drug is extremely irritating to the tissue.
Explanation
The Z-Track technique for IM injections should be used when the drug being administered is extremely irritating to the tissue. This technique involves pulling the skin and tissue to the side before injecting the medication, and then releasing it after the injection. This creates a zigzag or "Z" pattern, which helps to prevent the medication from leaking back into the subcutaneous tissue and causing irritation or staining of the skin. Using the Z-Track technique is especially important when administering medications that can cause tissue damage or discomfort.
6.
Which two sites should a nurse administering an IM injection to an infant use?
Correct Answer
D. Rectus Femoris & Vastus Lateralis.
Explanation
A nurse administering an IM injection to an infant should use the Rectus Femoris and Vastus Lateralis sites. These sites are commonly used for IM injections in infants because they have a larger muscle mass and are less likely to cause injury to surrounding structures. The Dorsogluteal site is not recommended for infants due to the risk of injury to the sciatic nerve. The Deltoid site is not typically used in infants due to the small muscle size. The Ventrogluteal site is an alternative option for IM injections in infants, but it is not as commonly used as the Rectus Femoris and Vastus Lateralis sites.
7.
The nurse recognizes that aspiration is not necessary with subcutaneous (s.c.) injections because ______.
Correct Answer
A. S.c. tissue usually contains only small blood vessels.
Explanation
The nurse recognizes that aspiration is not necessary with subcutaneous (s.c.) injections because s.c. tissue usually contains only small blood vessels. Aspiration is the process of pulling back on the syringe plunger after inserting the needle to check for blood return. It is typically done with intramuscular injections to ensure that the needle is not in a blood vessel, which could lead to complications. However, in subcutaneous injections, the medication is injected into the fatty layer of tissue just below the skin, where there are usually only small blood vessels. Therefore, aspiration is not necessary as the risk of injecting into a blood vessel is minimal.
8.
A nurse administering an IM injection to an average adult would select a longer & heavier gauge needle in order to ______.
Correct Answer
A. Pass through subcutaneous tissue & penetrate muscle.
Explanation
When administering an intramuscular (IM) injection, a longer and heavier gauge needle is selected in order to pass through the subcutaneous tissue and penetrate the muscle. This is because the medication needs to be injected directly into the muscle for faster absorption and effectiveness. The subcutaneous tissue, which is the layer beneath the skin, needs to be bypassed to ensure proper delivery of the medication to the muscle tissue. Using a longer and heavier gauge needle helps to achieve this goal.
9.
The anterior lateral aspect of the thigh that extends in an adult from a handbreadth above the knee to a handbreadth below the greater trochanter of the femur are the landmarks for which IM injection site?
Correct Answer
C. Vastus Lateralis
Explanation
The correct answer is Vastus Lateralis. The question describes the landmarks on the thigh for an intramuscular (IM) injection site. The anterior lateral aspect of the thigh, which is the front and outer side of the thigh, extending from a handbreadth above the knee to a handbreadth below the greater trochanter of the femur, corresponds to the location of the Vastus Lateralis muscle. This muscle is commonly used for IM injections, especially in infants and young children.
10.
The nurse recognizes the rectal route represents the route of choice for which patient? (short answer)
11.
The nurse administering an IM injection to an infant use would use the Rectus Femoris & Vastus Lateralis.
Correct Answer
A. True
Explanation
The nurse administering an intramuscular (IM) injection to an infant would use the Rectus Femoris and Vastus Lateralis muscles. These muscles are commonly used for IM injections in infants because they are large and easily accessible. The Rectus Femoris muscle is located in the front of the thigh, while the Vastus Lateralis muscle is located on the outer side of the thigh. Using these muscles ensures that the medication is delivered directly into the muscle, allowing for better absorption and effectiveness.
12.
A nurse uses the Z-Track technique for IM injections when a large volume is being administered.
Correct Answer
B. False
Explanation
The Z-Track technique is not used when a large volume is being administered. It is actually used to prevent medication leakage into the subcutaneous tissue by creating a zigzag path for the needle. This technique is commonly used for medications that are irritating or can stain the skin. Therefore, the correct answer is false.
13.
Which IM injection site can accommodate only small doses of medication?
Correct Answer
C. Deltoid
Explanation
The deltoid muscle is a small muscle located in the upper arm. It is a common site for IM (intramuscular) injections, but it can only accommodate small doses of medication due to its limited size. The other options, such as the ventrogluteal, dorsogluteal, vastus lateralis, and rectus femoris, are larger muscles that can accommodate larger doses of medication.
14.
Which IM injection site has well developed muscle with few blood vessels?
Correct Answer
D. Vastus Lateralis
Explanation
The Vastus Lateralis is the correct answer because it is a well-developed muscle with few blood vessels. This muscle is located on the lateral side of the thigh and is commonly used as an injection site for intramuscular injections, particularly in infants and young children. The Vastus Lateralis is preferred due to its large size, which allows for the administration of larger volumes of medication. Additionally, the muscle has fewer blood vessels compared to other injection sites, reducing the risk of hitting a blood vessel during the injection.
15.
Which is a desirable IM injection site, free from nerves and adipose tissue?
Correct Answer
A. Ventrogluteal
Explanation
The ventrogluteal site is a desirable IM injection site because it is free from nerves and adipose tissue. This site is located on the hip, between the greater trochanter and the anterior superior iliac spine. It is a safe and reliable site for injections as it has a thick muscle mass and minimal nerve endings, reducing the risk of injury or pain during injection. Additionally, the absence of adipose tissue ensures that the medication is absorbed effectively into the bloodstream.
16.
Which is an appropriate IM injection site for infants?
Correct Answer
E. Rectus Femoris
Explanation
The rectus femoris is an appropriate IM injection site for infants because it is a large muscle located in the front of the thigh. It is easily accessible and has a good blood supply, making it a safe and effective site for injections. Additionally, the rectus femoris is less likely to damage nerves or blood vessels compared to other injection sites such as the deltoid or dorsogluteal.
17.
In which IM injection site exists the risk of striking the underlying sciatic nerve?
Correct Answer
B. Dorsogluteal
Explanation
The dorsogluteal site is located in the buttocks, specifically the upper outer quadrant. The risk of striking the underlying sciatic nerve is higher in this site compared to other IM injection sites. This is because the sciatic nerve runs through the buttocks and can be easily damaged if the injection is not administered correctly. Therefore, it is important to avoid this site when giving IM injections to minimize the risk of nerve injury.
18.
The Z-Track method for IM injections involves pulling the skin in such a way that the subcutaneous layers are staggered. This technique is selected specifically to ____________________________& ________________________________.
19.
Identify the five “rights” of drug administration. Provide the key points that describe the purpose of each “right.”