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. Increased salivation: Hypernatremia often causes dry mouth and decreased salivation.
B. Cool, clammy skin: Hypernatremia does not typically cause cool, clammy skin; this is more associated with hypovolemia.
C. Hypertension: While hypertension can occur, it is not as specific as decreased level of consciousness.
D. Decreased level of consciousness: Severe hypernatremia can lead to neurological changes, including decreased level of consciousness. Excess sodium draws water out of cells, leading to dehydration inside the cells, especially in the brain. Decreased brain cell function due to dehydration can manifest as confusion, lethargy, and potentially a decreased level of consciousness in severe cases (coma).

A. To remove gastric acid that might cause dyspepsia B. To identify delayed gastric emptying C. To confirm the placement of the NG tube D. To determine the client's electrolyte balance

Correct Answer is B

Explanation

not to remove gastric acid but to assess tolerance to feedings.
B. To identify delayed gastric emptying: Measuring gastric residual volume helps identify delayed gastric emptying, which can indicate a risk of aspiration or intolerance to the feeding.
C. To confirm the placement of the NG tube: Tube placement should be confirmed by other means, such as pH testing or X-ray, rather than measuring residual.
D. To determine the client's electrolyte balance: Measuring gastric residual does not provide information about the client's electrolyte balance.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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