Upon aspirating a saline lock prior to administering intravenous ...

[RODY.ELKHALIL]

Upon aspirating a saline lock prior to administering intravenous medication, the nurse notes that there is no blood return. What nursing action should be taken?
 
  1. Discontinue this infiltrated lock and restart another site for medication administration.
  2. Slowly infuse 1 mL of saline into the lock, assessing for infiltration.
  3. Reinsert the needle into the lock and aspirate using more pressure.
  4. Pull the intravenous catheter out 1/8 inch and attempt aspiration.

Question 2

During administration of an intradermal injection, the nurse notices that the outline of the needle bevel is visible under the client's skin. How should the nurse proceed?
 
  1. Recognize that this is an expected finding in a properly administered intradermal injection.
  2. Withdraw the needle, prepare a new injection, and start again.
  3. Insert the needle further into the skin at a deeper angle.
  4. Turn the needle so that the bevel is down and inject the medication slowly, looking for development of a bleb.

[thall411]

Answer to Question 1

Correct Answer: 2
Rationale 1: Simple lack of blood upon aspiration does not indicate infiltration, so there is no need to discontinue the site.
Rationale 2: While the presence of blood upon aspiration confirms that the catheter is in a vein, the absence of blood does not rule out correct placement. If no blood returns, the nurse should slowly infuse 1 mL of saline into the lock while assessing the site for infiltration. If there is no infiltration present, the nurse should administer the medication.
Rationale 3: Often the reason for absence of blood return is that the vessel has collapsed around the catheter from the pressure of aspiration. Increasing the pressure will not increase the likelihood of blood return.
Rationale 4: Pulling the intravenous catheter out 1/8 inch will not increase the likelihood of blood return and may make the site more unstable.

Answer to Question 2

Correct Answer: 1
Rationale 1: Intradermal injections are given at a very shallow angle so that the medication is delivered into the area between the dermal layers. When properly given, the outline of the needle bevel will be visible prior to injection of the fluid.
Rationale 2: There is no need to withdraw the needle and start again.
Rationale 3: Inserting the needle further into the skin and at a deeper angle would result in delivery of the fluid into the subcutaneous tissues.
Rationale 4: The needle is inserted with the bevel up.

[RODY.ELKHALIL]

Gracias!

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