ATI NUR 125 Exam 4

Correct Answer: This medication order is most commonly given via the subcutaneous route.

Explanation:

Regular insulin and NPH insulin are typically administered subcutaneously (under the skin) for the management of diabetes. This is the most common route for insulin administration because it allows for slower absorption compared to intravenous administration, and it is suitable for both short-acting (regular) and intermediate-acting (NPH) insulins. NPH insulin, being intermediate-acting, is usually administered to provide longer-lasting blood sugar control, while regular insulin is fast-acting for immediate effects.

Why the Other Choices Are Incorrect:

The NPH insulin is the shortest acting form of insulin.

This statement is incorrect. NPH insulin is actually an intermediate-acting insulin, not short-acting. It has a slower onset and a longer duration of action compared to regular insulin. Regular insulin, on the other hand, is short-acting and is often used for immediate blood glucose control. NPH insulin typically has a peak action between 4-12 hours after administration.

This medication is given to treat a low blood glucose.

This statement is incorrect. Insulin is used to lower blood glucose levels, not to treat hypoglycemia (low blood glucose). Insulin is generally administered to help manage high blood glucose levels, particularly after meals or when blood glucose levels are elevated. For treating low blood glucose, other medications such as glucagon or glucose solutions would be used.

The insulin vial should be discarded if there are any bubbles in it.

This statement is incorrect. While it's important to remove air bubbles from the insulin syringe before administration, the insulin vial itself should not be discarded due to air bubbles. Air bubbles in the syringe can lead to inaccurate dosing. The bubbles should be gently tapped or expelled from the syringe before administering the insulin. However, the presence of air bubbles in the vial itself does not indicate that the vial should be discarded. The vial can still be used as long as the insulin is clear and not expired.

Summary:

The most accurate statement is "This medication order is most commonly given via the subcutaneous route." Insulin, including regular and NPH insulin, is most commonly administered subcutaneously for blood sugar control. Other options are incorrect due to misconceptions about insulin types, their actions, and their uses.

Correct Answer: Recommend acetaminophen and cold compresses

Explanation:

The symptoms described by the parent—redness and swelling at the injection sites and a low-grade fever (100.3°F)—are common mild side effects following immunization with vaccines such as the MMR, Varivax, and hepatitis A vaccines. These side effects usually resolve on their own within a few days. To help manage the child’s discomfort, the nurse can recommend acetaminophen for reducing fever and cold compresses for the injection site pain and swelling. These interventions are safe and effective for managing mild post-vaccination symptoms in children.

Why the Other Choices Are Incorrect:

Recommend aspirin or an NSAID for pain and fever. This is incorrect because aspirin is contraindicated in children due to the risk of Reye's syndrome, a rare but serious condition that can affect the liver and brain. NSAIDs (such as ibuprofen) are generally safe for children, but acetaminophen is often preferred for managing mild fevers and pain after vaccination. It is safer and does not carry the same risks as aspirin.

Report these adverse effects to the Vaccine Adverse Event Reporting System (VAERS). This is incorrect because the symptoms described—redness, swelling, and low-grade fever—are common and expected reactions to the vaccines given and do not require reporting to VAERS. VAERS is used for unusual or severe reactions, such as anaphylaxis or prolonged fever, which are not the case here. These symptoms are within the expected range for post-vaccination side effects.

Schedule an appointment in clinic so the provider can evaluate the child. This is incorrect because the symptoms described are mild and typical after receiving these vaccines. There is no indication of a severe reaction, such as a high fever, difficulty breathing, or a persistent or unusual reaction that would warrant a visit to the clinic. Managing the symptoms at home is usually sufficient.

Summary:

The parent’s report of mild redness, swelling, and a low-grade fever following the MMR, Varivax, and hepatitis A vaccines is a common response to vaccination. The appropriate action is to recommend acetaminophen to reduce the fever and cold compresses to alleviate injection site discomfort. Reporting to VAERS and scheduling an in-person appointment are not necessary for these mild and typical side effects.

Correct Answer: Blood vessel

Explanation:

IV (intravenous) administration delivers medication directly into the blood vessel, typically the vein. This route allows for rapid absorption of the medication into the bloodstream, providing quick therapeutic effects. Since the blood is immediately accessible via the veins, the medication is transported quickly to the desired site of action throughout the body.

Why the other choices are incorrect:

Arteries

Arteries are blood vessels that carry blood away from the heart to various parts of the body. However, IV administration is typically done via veins, not arteries, as veins are closer to the surface and easier to access for medication administration.

Muscles

Muscle tissue is involved in intramuscular (IM) injections, not IV administration. IM injections deliver medication into the muscle, where it is then absorbed into the bloodstream over time, but it is not the direct route for IV medications

Lymphatic system

The lymphatic system is a network of vessels that help with immune system functions and the transport of lymph. It is not involved in the direct delivery of medications via IV. Medications administered via the lymphatic system are typically delivered in a different manner, like subcutaneous or intradermal routes, not intravenously

Summary:

IV administration delivers medications directly into the blood vessel, typically through veins. This allows for immediate access to the bloodstream, leading to quick absorption and rapid therapeutic effects. Arteries, muscles, and the lymphatic system are not involved in the intravenous route.

Correct Answer: Monitor for possible anaphylaxis

Explanation:

After administering a vaccine, the nurse's priority is to monitor for anaphylaxis, a rare but life-threatening allergic reaction that can occur within minutes of injection. Anaphylaxis is a medical emergency requiring immediate intervention with epinephrine, airway management, and supportive care. The nurse should observe the child for at least 15 to 30 minutes after vaccination for signs such as:

- Difficulty breathing

- Swelling of the face, lips, or throat

- Hives or widespread rash

- Severe dizziness or fainting

Why the Other Choices Are Incorrect:

Assess for muscle pain – While muscle pain (myalgia) is a common side effect of some vaccines, it is not an immediate priority. It can be managed later if needed, but monitoring for a life-threatening reaction takes precedence.

Treat pain at the injection site – Localized pain and swelling at the injection site are common post-vaccination reactions, but they are not urgent concerns. Pain relief can be provided later with cool compresses or acetaminophen if needed.

Assess for infection – While infection at the injection site is a potential complication, it is rare and develops over time, not immediately after vaccination. The priority remains watching for immediate adverse reactions like anaphylaxis.

Summary

The most critical action after a child receives a vaccine is to monitor for anaphylaxis, as it can be life-threatening and requires immediate intervention. Other side effects, such as muscle pain, injection site pain, or infection, can be addressed after ensuring the child is not experiencing a severe allergic reaction.

Correct Answer: Tuberculin syringe

Explanation:

Tuberculin syringe:

A tuberculin syringe is specifically designed for intradermal injections. It has a small capacity, typically 1 mL, with finer graduations that allow for precise measurement of very small amounts of medication. The small gauge of the needle (typically 26 to 27 gauge) is ideal for intradermal injections, which are injected just beneath the skin's surface, often used for tests such as the tuberculosis (TB) test. The short needle (usually 1/2 inch or shorter) also helps to ensure the medication is placed into the dermis layer of the skin.

Why the Other Options Are Incorrect:

 Insulin syringe:

An insulin syringe is primarily used for subcutaneous injections of insulin. While it has a fine gauge needle, it is designed for different purposes and has a different scale (marked in units). It is not suitable for the precise small volume needed for intradermal injections, which require a tuberculin syringe for accuracy.

3 mL syringe:

A 3 mL syringe is commonly used for intramuscular (IM) and subcutaneous injections. However, it is too large for intradermal injections, where only a very small volume (often less than 0.1 mL) is required. The larger capacity and thicker needle would make it difficult to accurately administer a small intradermal dose.

5 mL syringe:

A 5 mL syringe is even larger than the 3 mL syringe and is typically used for intramuscular or subcutaneous injections that require a larger volume of medication. Like the 3 mL syringe, it is not suitable for intradermal injections, where the volume and needle gauge need to be much smaller.

Summary:

For intradermal injections, such as a TB test, a tuberculin syringe is the correct choice. This syringe is designed for precise, small-volume injections just beneath the skin’s surface. It features a small capacity (typically 1 mL) and a fine needle gauge, making it the ideal tool for intradermal procedures. Other syringes, such as insulin syringes or larger syringes like 3 mL or 5 mL, are not appropriate for intradermal use due to differences in volume capacity and needle size.

Correct Answer: topical

Explanation:

Ear drops are administered topically, meaning they are applied directly to the skin or mucous membranes. In the case of ear drops, the medication is instilled into the ear canal to treat conditions such as infections or inflammation. This route allows the medication to act locally at the site of the problem.

Why the Other Choices Are Incorrect:

sublingual – The sublingual route involves placing medication under the tongue, where it is absorbed into the bloodstream. This is not the correct route for ear drops.

 parenteral – Parenteral routes involve injections, such as intramuscular, intravenous, or subcutaneous injections. Ear drops are not administered via this route.

intravenous – Intravenous administration involves delivering medication directly into the vein. Ear drops are not given this way, as they are intended for local application

Summary:

The correct route of administration for ear drops is topical, as they are applied directly to the ear to treat local conditions.

Correct Answer: adverse

Explanation:

When a patient receiving morphine sulfate via PCA experiences depressed respirations, this is considered an adverse effect. Opioid medications, such as morphine, can depress the central nervous system, leading to respiratory depression, which is a serious side effect that can be life-threatening. Therefore, the effects are classified as adverse because they are harmful or unintended, and they require immediate nursing intervention to prevent complications.

Why the Other Choices Are Incorrect:

therapeutic – Therapeutic effects are those that are intended and beneficial, such as pain relief. Respiratory depression is not a desired or therapeutic effect of morphine.

synergistic – A synergistic effect occurs when two or more substances enhance each other's effects. While morphine may interact with other medications, the depression of respirations is not a synergistic effect, but rather a direct consequence of the opioid itself.

allergic – An allergic reaction typically involves an immune response to a substance and manifests as symptoms like rash, itching, or swelling. Respiratory depression is not an allergic response to morphine.

Summary:

The depressed respirations caused by morphine sulfate are classified as adverse effects. These are harmful side effects that are not intended by the medication and require immediate attention. Monitoring for such effects is crucial when administering opioids.

Correct Answer: Topical administration

Explanation:

Topical administration involves applying the medication directly to the skin or mucous membranes. It avoids puncturing the skin, reducing the risk of infection, tissue injury, and complications that can occur with injections. It is a safer alternative for patients who need localized treatment without the invasiveness of an injection.

Why the other options are incorrect:

Intravenous administration: This method involves inserting a needle into the vein, which punctures the skin and carries a higher risk for infection and tissue injury due to the invasive nature of the procedure. 

Subcutaneous injection: Like intravenous administration, subcutaneous injections involve puncturing the skin to administer the medication. While the risk for infection and injury may be lower than with intravenous injections, it still carries a degree of risk.

Intramuscular injection: This method also involves injecting medication into the muscle, requiring a needle to puncture the skin. As with other injection methods, it carries risks such as infection and tissue injury

Summary:

Topical administration is the best option for avoiding skin puncture and minimizing the risk for infection and tissue injury. It is a non-invasive method that can effectively treat localized areas of the body without the complications associated with injections.

Correct Answer: Use a pill-crushing device to crush pills; mix with a small amount of soft food

Explanation:

Use a pill-crushing device to crush pills; mix with a small amount of soft food

 If a patient has difficulty swallowing pills, one common solution is to crush the pills (using a pill-crushing device) and mix them with a small amount of soft food such as applesauce or yogurt. This makes it easier for the patient to swallow the medication. It’s important to check whether the medication can be crushed, as some medications should not be crushed due to the risk of altered absorption or potential harm. Always consult with the pharmacist or check the medication's guidelines before crushing.

Why the other choices are incorrect:

Instruct the patient to swallow the pills whole, even if it's difficult

Instructing the patient to swallow the pills whole despite difficulty is not appropriate. It may cause the patient to gag, choke, or experience additional discomfort. Instead, alternative methods of medication administration should be considered, such as crushing the pills or offering liquid forms of the medication.

Administer the medication intravenously instead of orally

 Administering medication intravenously instead of orally should only be done if the oral route is completely contraindicated (e.g., the patient is unable to swallow, the medication is not available in liquid form, or there is a medical condition requiring IV administration). This option is not a standard first-line solution for a patient having difficulty swallowing unless prescribed by a healthcare provider.

Withhold the medication until the patient can swallow properly

Withholding the medication until the patient can swallow properly is not ideal, as it can lead to delays in treatment. It's important to address the swallowing difficulty by finding alternative methods to administer the medication, rather than withholding it altogether.

Summary:

If a patient has difficulty swallowing, the appropriate action is to crush the pills using a pill-crushing device and mix them with a small amount of soft food, as long as the medication can be crushed safely. This method makes it easier for the patient to ingest the medication without risk of choking or discomfort. It is essential to check with the pharmacist to ensure that the medication can be safely crushed. Other options, such as instructing the patient to swallow the pills whole or withholding the medication, are not ideal solutions.