TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER
Chapter 24: Parenteral Medications Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse is teaching a patient to self-administer subcutaneous heparin at home. What does
the nurse include in patient teaching? a. Use a 22-gauge, 1-inch needle for the heparin injections. b. Change needles after withdrawing the heparin from the vial. c. Instruct the patient and family to recap all needles used at home. d. Administer the heparin in the abdomen, 2 cm away from umbilicus. ANS: D
The nurse instructs the patient to inject heparin in the “love handles” which is about 2 cm away from the umbilicus on the abdomen. A 22-gauge needle is too large for a subcutaneous injection; a 25- or 27-gauge needle is a better choice because a finer needle creates a smaller hole. As a result, the medication tends to remain in the subcutaneous space, the patient is more comfortable, and the skin develops scar tissue more slowly. Changing needles is not necessary. Needles are never recapped; the patient at home should obtain a sharps container or use an impenetrable container to hold used needles. The patient should label the container to prevent injury to others. DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation
OBJ: NCLEX: Physiological Integrity
2. The nurse prepares to administer 2.2 mL of an oil-based medication intramuscularly to a fit
N
young adult patient who is 5 feet 10 inches tall and weighs 165 pounds. Which needle and syringe combination will the nurse choose to administer the injection? a. 20-gauge, 1 1/2-inch needle on a 3-mL syringe b. 21-gauge, 1 1/2-inch needle on a 5-mL syringe c. 23-gauge, 1-inch needle on a 3-mL syringe d. 25-gauge, 1-inch needle on a 5-mL syringe ANS: A
The patient is well proportioned; because the medication is a thick solution requiring a deep intramuscular (IM) injection, the nurse chooses a slightly larger gauge needle, 20-gauge, which is 1 1/2 inches long, to accommodate the thick medication and to reach deep within the muscle. A 21-gauge needle is appropriate, but the syringe is too large. A 23-gauge needle is too small, and the oil would not be able to get through the lumen. A 25-gauge, 1-inch needle is far too narrow and short for an IM injection. DIF: Cognitive Level: Applying TOP: Nursing Process: Planning
OBJ: NCLEX: Physiological Integrity
3. A nurse sustains an accidental needlestick injury while performing a venipuncture on a
patient. What is the nurse’s priority? a. Determine whether the needle was sterile. b. Follow agency policy for employee injuries. c. Inform the provider to screen the patient for antibodies. d. Obtain patient history of communicable diseases.
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