A nurse is preparing to administer an IM injection to a client who has gonorrhea.
Which of the following actions should the nurse take?

Inject the medication at least 5 cm (2 in) from the umbilicus.

Use the Z-track technique to administer the medication.

Give the medication without aspirating prior to injection.

Administer the medication with a 27-gauge '/,-inch needle.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Injecting the medication at least 5 cm (2 in) from the umbilicus is not a standard guideline for IM injections. The site of injection depends on factors such as the volume of medication and patient’s age and muscle mass.

Choice B rationale:

Using the Z-track technique to administer the medication is correct. This technique helps to seal the medication in muscle tissue, reducing leakage into subcutaneous tissue.

Choice C rationale:

Giving the medication without aspirating prior to injection is not recommended. Aspiration ensures that the needle is not in a blood vessel before injecting.

Choice D rationale:

Administering the medication with a 27-gauge '/,-inch needle may not be appropriate for an IM injection, especially for adults. A longer and larger gauge needle is typically used for IM injections.

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Correct Answer is A

Explanation

Choice A rationale:

“Inject the medication into the subcutaneous tissue of your abdomen.” This is correct because exenatide is a type of medication that needs to be injected subcutaneously for it to be absorbed into the body properly.

Choice B rationale:

“Discard excess medication after 60 days.” This statement is incorrect because exenatide pens are usually good for 30 days after the first use.

Choice C rationale:

“Take the medication at bedtime.” This is incorrect because exenatide should be taken within 60 minutes before the morning and evening meal.

Choice D rationale:

“Contact the provider if you experience unexplained muscle pain.” While this is generally good advice when starting any new medication, muscle pain is not a common side effect of exenatide.

A. Urine output 600 mL in 8 hr. B. Blood pressure 88/50 mm Hg. C. Heart rate 110/min. D. Blood glucose 70 mg/dL.

Correct Answer is B

Explanation

Choice A rationale:

A urine output of 600 mL in 8 hours is within the normal range. The average urine output for adults is about 1 to 2 liters per day.

Choice B rationale:

Clonidine is an antihypertensive medication. If the client’s blood pressure is already low (88/50 mm Hg), administering clonidine could further lower the blood pressure and cause hypotension.

Choice C rationale:

A heart rate of 110/min is slightly high, but it’s not a direct indication to withhold clonidine. Clonidine can actually help lower an elevated heart rate by reducing the levels of certain chemicals in your blood.

Choice D rationale:

A blood glucose level of 70 mg/dL is at the lower end of the normal range (70-100 mg/dL) However, clonidine does not directly affect blood glucose levels, so this would not be a reason to withhold the medication.

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A nurse is preparing to administer an IM injection to a client who has gonorrhea.Which of the following actions should the nurse take?

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A nurse is preparing to administer an IM injection to a client who has gonorrhea.
Which of the following actions should the nurse take?