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The nurse is giving an intramuscular (IM) injection. Upon aspiration, the nurse notices blood return in the syringe. What should the nurse do?

A.

Give the injection and hold pressure over the site for 3 minutes.

B.

Administer the injection at a slower rate.

C.

Withdraw the needle and prepare the injection again.

D.

Pull the needle back slightly and inject the medication.

Answer and Explanation

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 A

Explanation

A. This outcome is specific, measurable, and directly addresses the goal of managing constipation by aiming for a bowel movement.

B. Discontinuing pain medication abruptly may be unrealistic and can cause distress for the patient.

C. Ambulation may help with constipation but does not directly measure or ensure bowel movement.

D. Offering laxatives or stool softeners is an intervention rather than a measurable patient outcome.

Correct Answer is B

Explanation

A. "Risk for infection related to chest x-ray procedure" is not an appropriate diagnosis because a chest x-ray is a diagnostic tool, and pneumonia itself is the concern for infection.

B. "Impaired gas exchange related to alveolar-capillary membrane changes" is correct as pneumonia causes inflammation and consolidation in the lungs, which directly impacts gas exchange.

C. "Risk for deficient fluid volume related to dehydration" does not apply specifically to pneumonia unless the patient presents signs of dehydration, which is not indicated in the scenario.

D. "Ineffective breathing pattern related to pneumonia" could also be a valid diagnosis, but the primary concern given the information provided is gas exchange impairment.

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