A nurse is preparing to administer ceftriaxone 3 mL intramuscularly to an adult client. Which of the following actions should the nurse plan to take?

Select a 5/8-inch needle.

Choose a 25-gauge needle.

Locate the ventrogluteal site.

Inject at a 45° angle.

Answer and Explanation

The Correct Answer is C

A. Select a 5/8-inch needle: A 5/8-inch needle is too short for an IM injection in an adult, as it may not reach the muscle tissue adequately.
B. Choose a 25-gauge needle: A 25-gauge needle is too small for an IM injection, as it may make the administration of a 3 mL volume difficult and painful.
C. Locate the ventrogluteal site: The ventrogluteal site is a preferred site for IM injections because it is free of major nerves and blood vessels and can accommodate larger volumes like 3 mL.
D. Inject at a 45° angle: IM injections should be administered at a 90° angle to ensure the medication is delivered into the muscle tissue.

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Correct Answer is D

Explanation

A. Allow the client to expel some fluid before continuing: This action may provide some relief but can disrupt the enema procedure and is not the most effective immediate response.
B. Encourage the client to bear down: Bearing down could increase discomfort and does not address the cause of the cramping.
C. Stop the enema and document that the client did not tolerate the procedure: This is not necessary unless the discomfort is severe. First, less invasive measures should be tried to relieve the discomfort.
D. Lower the height of the solution container: Lowering the height of the enema container reduces the flow rate of the solution, which can alleviate cramping and discomfort.

A. Observe the client. B. Complete an incident report. C. Notify the nurse manager. D. Call the client's provider.

Correct Answer is A

Explanation

A. Observe the client. The first priority is to monitor the client for any adverse reactions or side effects from the wrong medication.
B. Complete an incident report. While important, the incident report is not the first action to take.
C. Notify the nurse manager. Informing the nurse manager is necessary, but not the immediate first step.
D. Call the client's provider. Notifying the provider is also important but observing the client for any immediate effects takes precedence.

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A nurse is preparing to administer ceftriaxone 3 mL intramuscularly 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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