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 A
Explanation
A. Blood flow starts from the right atrium, moves into the right ventricle, then to the lungs, where it is oxygenated and returns to the left atrium, and then flows into the left ventricle before being pumped into the aorta.
B. This sequence incorrectly places the left atrium before the right ventricle, which is not the correct flow of blood.
C. This sequence starts incorrectly with the right ventricle, skipping the left atrium entirely after blood is oxygenated.
D. This option also incorrectly starts with the right ventricle and does not include the proper sequence of blood flow.
Correct Answer is D
Explanation
A. Assessment has already been completed as the initial step, involving data collection.
B. Diagnosis is also completed, involving analysis and identification of the patient’s health problems.
C. Implementation occurs after planning, when nursing interventions are executed.
D. Planning is the appropriate next step, involving the creation of specific, measurable goals and interventions based on the identified nursing diagnoses.