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 B

Explanation

A) "I've had a backache for several days."
A backache is not typically associated with digoxin toxicity. This symptom is more likely related to musculoskeletal issues rather than an adverse effect of digoxin.

B) "I feel nauseated and have no appetite."
Nausea and loss of appetite are common symptoms of digoxin toxicity. Digoxin can cause gastrointestinal disturbances as part of its adverse effects, and these symptoms are important indicators that the medication levels may be too high.

C) "I am urinating more frequently."
Increased urination is not an adverse effect of digoxin itself but may be a result of the diuretic effect of other medications often used in conjunction with digoxin for heart failure. It is not typically a direct sign of digoxin toxicity.

D) "I can walk a mile a day."
The ability to walk a mile a day indicates that the client is experiencing functional improvement, not adverse effects. Digoxin is used to improve symptoms of heart failure, and this statement suggests that the medication may be having a beneficial effect.

A. Explain the purpose for the medications. B. Ask the client why he is refusing to take the medications. C. Tell the client the physician wants him to take the medications. D. Document that the client refuses the medications.

Correct Answer is B

Explanation

A) Explain the purpose for the medications:
While explaining the purpose of the medications is important, it is crucial first to understand the reason behind the client's refusal. This can help tailor the explanation to address specific concerns or misconceptions.

B) Ask the client why he is refusing to take the medications:
Asking the client about their reasons for refusing the medications is a critical first step. This approach allows the nurse to address any concerns, educate the client, and potentially find alternative solutions or treatments that the client may be more willing to accept.

C) Tell the client the physician wants him to take the medications:
Simply telling the client that the physician wants them to take the medications does not address the underlying reasons for the refusal. It is important to engage with the client to understand their perspective and address any concerns they might have.

D) Document that the client refuses the medications:
Documentation of the refusal is necessary for legal and medical records, but it should not be the initial action. Understanding the client’s reasons for refusal and attempting to address those reasons should be prioritized before documenting the refusal.

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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

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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