NCLEX-RNSafety and Infection Prevention and ControlMedium
A nurse is preparing to administer an intramuscular injection to an adult client. The client is receiving anticoagulant therapy. Which action is most important for the nurse to take to prevent complications?
- AAdminister the injection into the deltoid muscle.
- BAspirate for blood return before injecting the medication.
- CApply prolonged pressure to the injection site after administration.
- DUse a 25-gauge, 5/8-inch needle for the injection.
Show answer & explanationAnswer & explanation
Correct answer: C. Apply prolonged pressure to the injection site after administration.
Clients on anticoagulant therapy are at increased risk for bleeding and hematoma formation. Applying prolonged pressure to the injection site helps to minimize bleeding and bruising, which is the most critical intervention in this scenario.
Why the other options are wrong
- A. The deltoid muscle is a common site, but the specific site is less critical than managing the bleeding risk with anticoagulants.
- B. Aspiration for blood return before IM injection is no longer recommended by CDC for most vaccines and medications, as it increases pain and does not reliably prevent intravascular injection.
- D. A 25-gauge, 5/8-inch needle is typically for subcutaneous injections; IM injections usually require longer needles (e.g., 1-1.5 inches) for proper muscle penetration.
IM Injections & Anticoagulants
Special considerations for administering intramuscular injections to clients receiving anticoagulant therapy to minimize bleeding risks.
- Increased risk of bleeding/hematoma.
- Apply prolonged pressure post-injection.
- Select appropriate site and needle size.
Memory trick: Anticoagulants mean Pressure Prevents Painful Purple Bruises.