A nurse is discussing the Z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique?

"This technique prevents injury to the sciatic nerve."

"This technique decreases the risk of subcutaneous infiltration."

"This technique allows a larger amount of medication to be injected."

"This technique increases the absorption rate of the drug.”

Answer and Explanation

The Correct Answer is B

A. "This technique prevents injury to the sciatic nerve.": The Z-track method is not designed to prevent nerve injury. Proper site selection and injection technique address nerve safety, but the Z-track specifically targets tissue leakage, not nerve protection.

B. "This technique decreases the risk of subcutaneous infiltration.": The Z-track technique displaces the skin and subcutaneous tissue before intramuscular injection, creating a zigzag path that seals the medication in the muscle. This prevents leakage into subcutaneous tissue, reducing irritation and ensuring proper absorption.

C. "This technique allows a larger amount of medication to be injected.": The Z-track does not affect the volume that can be safely administered; it is intended to prevent leakage and irritation, not to increase injection capacity.

D. "This technique increases the absorption rate of the drug.": Z-track injections do not increase the absorption rate; they maintain the drug in the muscle, preventing subcutaneous irritation and ensuring proper medication delivery without affecting pharmacokinetics.

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Correct Answer is D

Explanation

A. A client who has a burn requiring a sterile dressing change: While burn care is important to prevent infection and promote healing, a dressing change is not immediately life-threatening. This task can be safely addressed after assessing clients with higher-priority acute risks.

B. A client who had an appendectomy 6 hr ago and has diminished bowel sounds: Diminished bowel sounds are common in the immediate postoperative period and do not usually indicate an emergent problem. This client requires ongoing monitoring, but there is no acute threat to life at this time.

C. A client who received a chemotherapy treatment and reports nausea: Nausea following chemotherapy is uncomfortable and should be managed promptly, but it is not immediately life-threatening. Interventions such as antiemetics can be provided after more urgent needs are addressed.

D. A client who has hypothyroidism and is stuporous: Stupor in a client with hypothyroidism may indicate myxedema or severe hypothyroid crisis, which can be life-threatening due to risk of respiratory depression, cardiovascular compromise, or altered mental status. This client requires immediate assessment and intervention, making them the highest priority.

A. Shakiness B. Confusion C. Thirst D. Diaphoresis

Correct Answer is C

Explanation

A. Shakiness: Shakiness is typically a manifestation of hypoglycemia, resulting from activation of the sympathetic nervous system. It occurs when blood glucose drops below normal levels, not with hyperglycemia, so it is not associated with a glucose level of 265 mg/dL.

B. Confusion: Confusion can occur with both severe hyperglycemia and hypoglycemia, but it is more pronounced in extreme elevations of blood glucose or in hyperosmolar hyperglycemic states. A level of 265 mg/dL may not yet cause marked cognitive changes in all clients.

C. Thirst: Hyperglycemia causes osmotic diuresis, leading to fluid loss and dehydration, which triggers excessive thirst (polydipsia). This is a common and early clinical manifestation associated with elevated blood glucose levels such as 265 mg/dL.

D. Diaphoresis: Diaphoresis, or excessive sweating, is primarily a symptom of hypoglycemia caused by adrenergic stimulation. It is not a typical manifestation of hyperglycemia and is unlikely to occur with a blood glucose of 265 mg/dL.

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A nurse is discussing the Z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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