A nurse is preparing to administer ceftriaxone using the z-track technique to a client who has gonorrhea. After the nurse performs hand hygiene and reconstitutes the medication, identify the sequence the nurse should use to administer the medication. (Move the steps, placing them in the order of performance. Use all the steps.)

Use the nondominant hand to pull the skin and subcutaneous tissue 2.5 cm (1 in) laterally.

Remove the needle and release the tissue.

Aspirate by pulling back on the plunger and inject the medication.

Answer and Explanation

The Correct Answer is A,C,B

Here’s the correct sequence for administering ceftriaxone using the Z-track technique: 1. Use the nondominant hand to pull the skin and subcutaneous tissue 2.5 cm (1 in) laterally. 2. Aspirate by pulling back on the plunger and inject the medication. 3. Remove the needle and release the tissue. This method helps to prevent the medication from leaking into the subcutaneous tissue, reducing irritation and discomfort.

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Correct Answer is A

Explanation

Monitor for at least 150 mL of drainage every hour. The nurse should monitor the chest tube drainage for excessive or sudden increases in order to detect any complications, such as pneumothorax. Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications. Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided. The chest tube unit should only be replaced when there is a problem with the unit or the seals.

Choice B: Clamping the tube for 30 minutes every 8 hours is not standard practice and can cause complications.

Choice C: Pinning the tubing to the client's bed sheets can cause traction on the chest tube and should be avoided.

Choice D: The chest tube unit should only be replaced when there is a problem with the unit or the seals.

A. Diaphoresis B. Pupillary dilation C. Chest pain D. Hypotension

Correct Answer is D

Explanation

Opioid toxicity causes central nervous system and respiratory depression, which can lead to low blood pressure or hypotension.

Choice A. Diaphoresis is not correct because opioid toxicity does not cause excessive sweating. Diaphoresis can be a sign of opioid withdrawal or other conditions.

Choice B. Pupillary dilation is not correct because opioid toxicity causes miosis or pinpoint pupils due to the stimulation of the parasympathetic nervous system .

Choice C. Chest pain is not correct because opioid toxicity does not cause chest pain. Chest pain can be a sign of cardiac ischemia, pulmonary embolism, or other serious conditions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is experiencing opioid toxicity. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is assisting with care for a client who received a tuberculin skin test 72 hr ago. When collecting data from the test site, which of the following findings indicates a need for further testing?

A nurse enters a client's room and sees smoke coming from the trash can next to the client's bed. Which of the following actions should the nurse take first?

A nurse is caring for a client who is experiencing muscle spasms and has a new prescription for an aquathermia pad. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who has anemia and has a prescription for ferrous sulfate. Which of the following foods should the nurse recommend that the client consume to increase the absorption of this medication?

A nurse is reinforcing teaching with a client who has heart failure and a new prescription for furosemide. The nurse should instruct the client to monitor for which of the following adverse effects?

A nurse on the oncology unit is evaluating a client's response after receiving a dose of aprepitant. Which of the following therapeutic effects should the nurse expect?

A nurse is assisting with the care of a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?

A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?