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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Docusate sodium is a stool softener and does not have a direct effect on blood pressure. It is generally safe for individuals with hypertension.
Choice B rationale:
Pseudoephedrine is a decongestant that can raise blood pressure or interfere with the effectiveness of some prescribed blood pressure medications. Therefore, it is contraindicated for clients with hypertension.
Choice C rationale:
Omeprazole is a proton pump inhibitor used to decrease stomach acid. It does not have a significant impact on blood pressure and is generally safe for individuals with hypertension.
Choice D rationale:
Guaifenesin is an expectorant used to thin mucus in the air passages. It does not have a significant impact on blood pressure and is generally safe for individuals with hypertension.
Correct Answer is D
Explanation
Choice A rationale:
Consulting a pharmaceutical sales representative is not the best option. While they are knowledgeable about the medications they promote, their primary role is to market their company’s products, and they may not have comprehensive information about other medications.
Choice B rationale:
While a nursing team member can be a valuable resource, they may not have the specific knowledge about the medication in question. It’s also important to remember that medication information can change frequently, and relying on another person’s knowledge may lead to errors.
Choice C rationale:
The client’s family can provide useful information about how the client has been taking the medication at home, but they are unlikely to have detailed pharmacological knowledge about the medication.
Choice D rationale:
A nursing drug guide is a reliable and up-to-date resource that provides comprehensive information about medications, including indications, contraindications, dosages, potential side effects, and interactions. Therefore, when unfamiliar with a medication, the nurse should consult a nursing drug guide.
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