A nurse is planning to administer ceftriaxone IM to an adult client. Which of the following actions should the nurse plan to take?

Administer the medication using a 5/8-inch needle.

Administer the medication using a Z-track technique.

Administer the medication in the deltoid muscle.

Administer the medication at a 45° angle.

Answer and Explanation

The Correct Answer is B

A) Administer the medication using a 5/8-inch needle:
Ceftriaxone is typically administered using a longer needle to ensure proper injection into the muscle. A 5/8-inch needle is more suitable for subcutaneous injections rather than intramuscular (IM) injections.

B) Administer the medication using a Z-track technique:
The Z-track technique is appropriate for IM injections of medications like ceftriaxone, which can be irritating to tissues. This technique helps prevent the medication from leaking into the subcutaneous tissue and minimizes discomfort by creating a zigzag path in the muscle.

C) Administer the medication in the deltoid muscle:
Ceftriaxone is generally administered in larger muscle groups, such as the vastus lateralis or gluteus muscle, rather than the deltoid. The deltoid is more commonly used for vaccines or smaller volume injections.

D) Administer the medication at a 45° angle:
For IM injections, the needle should be inserted at a 90° angle to the skin. A 45° angle is more appropriate for subcutaneous injections.

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Correct Answer is A

Explanation

A) Check the client's vital signs:
The first priority after administering the wrong medication is to assess the client's immediate condition and check for any adverse reactions or changes in vital signs. This helps determine if the medication has caused any immediate harm and guides further action to ensure the client's safety.

B) Document the client's condition in the electronic medical record:
Documenting the incident is important for legal and clinical reasons, but it should be done after addressing the immediate health concerns of the client. Ensuring the client’s safety is the top priority.

C) Notify the provider:
Notifying the healthcare provider is crucial, but it is important to first assess the client's condition. Once the client’s immediate needs are addressed, informing the provider will help in deciding further medical interventions or adjustments needed.

D) Fill out an incident report:
Filling out an incident report is a necessary step for documenting the error and contributing to quality improvement processes, but it should be done after the client’s safety has been assured and immediate medical concerns have been addressed.

A. Muscle pain B. Ototoxicity C. Hypotension D. Hyperthermia

Correct Answer is C

Explanation

A) Muscle pain:
Verapamil is a calcium channel blocker used to treat cardiac dysrhythmias and hypertension. Muscle pain is not a common adverse effect associated with verapamil. Instead, side effects related to cardiovascular function are more pertinent.

B) Ototoxicity:
Ototoxicity, which refers to hearing damage or tinnitus, is not a known side effect of verapamil. This is more commonly associated with certain antibiotics or chemotherapy agents, not calcium channel blockers like verapamil.

C) Hypotension:
Hypotension is a significant concern with verapamil, as it can lower blood pressure due to its vasodilatory effects. Monitoring blood pressure is crucial when administering verapamil, especially during an IV bolus, to ensure it does not drop too low and lead to symptoms of dizziness or fainting.

D) Hyperthermia:
Hyperthermia, or elevated body temperature, is not typically associated with verapamil use. Verapamil's side effects are more focused on cardiovascular and gastrointestinal systems, rather than temperature regulation.

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A nurse is planning to administer ceftriaxone IM to an adult client. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse administers the wrong medication to a client. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?

Correct Answer is C

Explanation

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