The nurse is giving an intramuscular (IM) injection. Upon aspiration, the nurse notices blood return in the syringe. What should the nurse do?
Give the injection and hold pressure over the site for 3 minutes.
Administer the injection at a slower rate.
Withdraw the needle and prepare the injection again.
Pull the needle back slightly and inject the medication.
The Correct Answer is C
A. Continuing with the injection after seeing blood return increases the risk of injecting into a blood vessel, which is not safe for IM injections.
B. Administering at a slower rate does not address the issue of possible intravascular injection.
C. If blood is aspirated, the correct procedure is to withdraw the needle, dispose of the medication, and prepare a new dose to prevent intravascular administration, as IM injections are meant to be given into muscle tissue, not into a vein.
D. Pulling the needle back slightly is not recommended because it does not ensure that the needle is completely out of the blood vessel.
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Correct Answer is D
Explanation
A. Sequential compression devices are used to prevent deep vein thrombosis and are not relevant for assessing orthostatic hypotension.
B. Elastic stockings are used to promote venous return and prevent edema, not for measuring blood pressure.
C. A thermometer measures body temperature and does not provide information on blood pressure or orthostatic changes.
D. A blood pressure cuff is essential for assessing orthostatic hypotension. The nurse will measure blood pressure while the patient is supine, sitting, and standing to determine any significant changes that occur with position changes.
Correct Answer is C
Explanation
A. While monitoring cardiac output can provide insights into heart function, it does not directly determine the presence of dysrhythmias.
B. Peripheral extremity circulation is influenced by cardiac output but is not the primary focus of monitoring it.
C. Cardiac output is essential for determining the heart's ability to meet the body's oxygenation requirements; low cardiac output can lead to inadequate oxygen delivery.
D. Ventilation status refers to the respiratory function and is not directly assessed through cardiac output measurements.