1. The nurse is giving an IM injection. Upon aspiration, the nurse notices
blood return in the syringe. What should the nurse do?
a. Administer the injection at a slower rate.
b. Withdraw the needle and prepare the injection again.
c. Pull the needle back slightly and inject the medication.
d...
HESI MED SURG QUESTIONS & ANSWERS
(66 Q &A) ALL ARE CORRECT
1. The nurse is giving an IM injection. Upon aspiration, the nurse notices
blood return in the syringe. What should the nurse do?
a. Administer the injection at a slower rate.
b. Withdraw the needle and prepare the injection again.
c. Pull the needle back slightly and inject the medication.
d. Give the injection and hold pressure over the site for 3 minutes.
ANS: B
Blood return upon aspiration indicates improper placement, and the
injection should not be given. Instead withdraw the needle, dispose of the
syringe and needle properly, and prepare the medication again.
Administering the medication into a blood vessel could have dangerous
adverse effects, and the medication will be absorbed faster than intended
owing to increased blood flow. Holding pressure is not an appropriate
intervention. Pulling back the needle slightly does not guarantee proper
placement of the needle and medication administration.
2. The nurse is planning to administer a tuberculin test with a 27-gauge, -inch
needle. At which angle will the nurse insert the needle?
a. 15 degree
b. 30 degree
c. 45 degree
d. 90 degree
ANS: A
A 27-gauge, -inch needle is used for intradermal injections such as a
tuberculin test, which should be inserted at a 5- to 15-degree angle, just under
the dermis of the skin. Placing the needle at 30 degrees, 45 degrees, or 90
degrees will place the medication too deep.
3. The nurse closely monitors an older adult for signs of medication toxicity.
Which physiological change is the reason for the nurse’s action?
a. Reduced glomerular filtration
, b. Reduced esophageal stricture
c. Increased gastric motility
d. Increased liver mass
ANS: A
The reduced glomerular filtration rate delays excretion, increasing chance for
toxicity. In older adults, gastric motility and liver mass decrease. Esophageal
stricture is not a physiological change associated with normal aging.
4. A registered nurse interprets that a scribbled medication order reads 25 mg.
The nurse administers 25 mg of the medication to a patient and then discovers
that the dose was incorrectly interpreted and should have been 15 mg. Who is
ultimately responsible for the error?
a. Health care provider
b. Pharmacist
c. Hospital
d. Nurse
ANS: D
Ultimately, the person administering the medication is responsible for
ensuring that it is correct. The nurse administered the medication, so in this
case it is the nurse. Accept full accountability and responsibility for all
actions surrounding the administration of medications. Do not assume that a
medication that is ordered for a patient is the correct medication or the correct
dose. This is the importance of verifying the six rights of medication
administration. The ultimate responsibility and accountability are with the
nurse, not the health care provider, pharmacist, or hospital.
5. A patient is to receive a proton pump inhibitor through a
nasogastric (NG) feeding tube. Which is the most important nursing
action to ensure effective absorption?
a. Thoroughly shake the medication before administering.
b. Position patient in the supine position for 30 minutes to 1 hour.
c. Hold feeding for at least 30 minutes
after medication administration. Flush
tube with 10 to 15 mL of water, after
all medications are
d. administered.
ANS: C
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