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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. Encouraging self-care helps promote independence and functional recovery in stroke patients, supporting rehabilitation and enhancing self-esteem.

B. Bed rest is not recommended as it can contribute to muscle deconditioning and complications associated with immobility.

C. While coordination with therapy is beneficial, gait training is typically handled by physical therapy rather than occupational therapy.

D. Providing a complete bed bath limits the patient’s autonomy; encouraging partial participation supports the patient's involvement in self-care.

Correct Answer is D

Explanation

A. The superior vena cava is responsible for returning deoxygenated blood from the upper body to the heart and is not directly involved in myocardial ischemia.

B. The carotid artery supplies blood to the brain and is not the primary focus in the context of myocardial infarction.

C. The pulmonary artery carries deoxygenated blood from the heart to the lungs and is not involved in coronary circulation.

D. The coronary arteries supply blood to the heart muscle itself. Ischemia during a myocardial infarction occurs when these arteries are blocked or narrowed, leading to a lack of blood flow and oxygen to the heart tissue.

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