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 D

Explanation

Choice A rationale:

Two loose stools in the past 24 hours could be a symptom of Clostridioides difficile infection, but it’s not necessarily a priority finding. The infection can cause diarrhea, but it’s not life-threatening.

Choice B rationale:

A WBC count of 11,000/mm³ is slightly elevated, indicating a possible infection. However, it’s not necessarily a priority finding as it’s not significantly high.

Choice C rationale:

A heart rate of 104/min is slightly elevated, indicating possible stress or anxiety. However, it’s not necessarily a priority finding as it’s not significantly high.

Choice D rationale:

Creatinine level of 3.1 mg/dL is significantly high, indicating possible kidney damage, which can be a side effect of vancomycin treatment. This should be reported to the provider immediately.

A. Blurred vision. B. Tinnitus. C. Headache. D. Dry mouth.

Correct Answer is C

Explanation

Choice A rationale:

Blurred vision is not a common side effect of the meningococcal conjugate vaccine.

Choice B rationale:

Tinnitus, or ringing in the ears, is also not a common side effect of this vaccine.

Choice C rationale:

Headache is a common side effect of the meningococcal conjugate vaccine.

Choice D rationale:

Dry mouth is not typically associated with this vaccine.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is receiving vancomycin for a Clostridium difficile infection.Which of the following findings is the priority for the nurse to report to the provider?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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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?