The nurse is preparing to administer an injection into the deltoid muscle of an adult patient weighing approximately 160 lb. Which needle size and length will the nurse choose?

Correct Answer: C

Rationale: For an intramuscular injection into an adult deltoid muscle, a 25-gauge, 1-inch needle is recommended. An 18-gauge needle is too big. While a 23-gauge needle can be used, a 1/2-inch needle is too small. A 27-gauge, 5/8-inch needle is used for intradermal.

Correct Answer: D

Rationale: The first response is to explore reasons the patient does not want the medication. After the assessment, the nurse can decide what to do next. Educating is important, but it is not the first action. Ultimately, the patient does have the right to refuse the medication; however, the nurse should first try to find out reasons for the refusal and provide education if needed based upon the assessment findings. Hiding medication and deceiving a patient into taking a medication is unethical and violates right to autonomy.

Correct Answer: B

Rationale: The nurse should ask the patient to verify identity and should check the patient's ID bracelet against the medication record to ensure right patient. Acceptable patient identifies include the patient's name, an identification number assigned by a health care facility, or a telephone number. Do not use the patient's room number as an identifier. To identify a patient correctly in an acute care setting, compare the patient identifiers on the MAR with the patient's identification bracelet while at the patient's bedside. Right medication, right dose, and right route are equally as important, but in this situation, right patient is the priority (two patients with the same last name).

Correct Answer: A

Rationale: If the patient uses a corticosteroid, have him or her wait 2 minutes and then rinse the mouth out with water or salt water or brush teeth after inhalation to reduce risk of fungal infection. Piercing a blood vessel during a subcutaneous injection is very rare. Therefore, aspiration is not necessary when administering subcutaneous injections. When giving immunizations to adults: to avoid injection into subcutaneous tissue, spread the skin of the selected vaccine administration site taut between the thumb and forefinger, isolating the muscle. Never administer IV medications through tubing that is infusing blood, blood products, or parenteral nutrition solutions.

Correct Answer: C

Rationale: Rate = Volume ÷ (Time in hours). 200 mL over 30 minutes = 200 mL ÷ (30/60) = 200 ÷ 0.5 = 400 mL/hour.