The nurse calculates that a patient must receive 1.3 mL of an anti-infective agent. The dose is ordered IM. Which of the following choices demonstrates safe, evidence-based practice?

23g 1 in (2.54 cm) needle to the right deltoid. Use the acromion process as a landmark.

25g 0.5 in (1.3 cm) long needle to the left rectus femoris. Aspirate prior to injection.

27g 1.5 in (3.8 cm) long needle to the left vastus lateralis area. Massage area wearing clean gloves after injection.

21g 1.5 in (3.8 cm) needle to the right ventrogluteal area. Use Z-track technique.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Using a 23-gauge, 1-inch needle for an intramuscular (IM) injection in the deltoid muscle is generally appropriate for adults. The deltoid muscle is a common site for IM injections, especially for small volumes of medication (up to 2 mL). The acromion process is a correct landmark for locating the deltoid muscle. However, the deltoid muscle is not the best site for larger volumes or more viscous medications. Additionally, the needle length might not be sufficient for individuals with more subcutaneous fat, potentially leading to suboptimal medication delivery.

Choice B Reason:

A 25-gauge, 0.5-inch needle is typically used for subcutaneous injections rather than intramuscular injections. The rectus femoris muscle can be used for IM injections, but it is not the preferred site due to the potential for increased pain and discomfort. Aspiration before injection is a debated practice; current guidelines suggest that aspiration is not necessary for most IM injections, except when injecting into the dorsogluteal site, which is not recommended due to the risk of hitting the sciatic nerve.

Choice C Reason:

A 27-gauge, 1.5-inch needle is appropriate for IM injections, and the vastus lateralis is a suitable site, especially for infants and young children. However, massaging the injection site after administering an IM injection is not recommended. Massaging can cause the medication to disperse into the subcutaneous tissue, reducing its effectiveness and potentially causing irritation or bruising.

Choice D Reason:

Using a 21-gauge, 1.5-inch needle for an IM injection in the ventrogluteal area is considered safe and effective. The ventrogluteal site is preferred for IM injections because it is free from major nerves and blood vessels, reducing the risk of injury. The Z-track technique is used to prevent medication from leaking into the subcutaneous tissue, ensuring that it remains in the muscle for proper absorption. This technique is particularly useful for medications that can stain or irritate the skin and subcutaneous tissue.

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Correct Answer is A

Explanation

Choice A Reason:

Clozapine is known to cause agranulocytosis, a potentially life-threatening condition where the white blood cell count drops significantly, leading to a higher risk of infection. Patients on clozapine must have regular blood tests to monitor their white blood cell count. Any signs of infection, such as fever, sore throat, or flu-like symptoms, should be reported to a physician immediately as they could indicate agranulocytosis.

Choice B Reason:

A decrease in hallucinations is generally a positive sign indicating that the medication is working effectively. It is not a reason to call the physician immediately. Instead, this should be discussed during regular follow-up appointments to assess the overall effectiveness of the treatment.

Choice C Reason:

While a decrease in appetite can be a side effect of clozapine, it is not typically an emergency unless it leads to significant weight loss or malnutrition. This should be monitored and discussed with the physician during regular visits. If the decrease in appetite is severe or persistent, it may warrant a call to the physician, but it is not as urgent as signs of infection.

Choice D Reason:

Insomnia can occur with clozapine use, but it is usually managed with adjustments to the medication regimen or additional treatments for sleep. While it is important to address insomnia, it does not require immediate medical attention unless it severely impacts the patient’s well-being.

A. Consult the interdisciplinary team regarding behavior modification techniques. B. Assess for environmental triggers and potential unmet needs. C. Assess for potential injury to the client’s arms, legs, and back. D. Anticipate the behavior and physically restrain the client when pacing begins.

Correct Answer is B

Explanation

Choice B: Assess for environmental triggers and potential unmet needs.

Choice A Reason:

Consulting the interdisciplinary team regarding behavior modification techniques is important for long-term management of behavioral problems in clients with major neurocognitive disorder. However, it is not the immediate priority when a client is exhibiting acute behavioral escalation. Immediate assessment and intervention are necessary to address the current situation and ensure the client’s safety.

Choice B Reason:

Assessing for environmental triggers and potential unmet needs is the priority in this scenario. Clients with major neurocognitive disorder often exhibit behavioral problems due to unmet needs or environmental factors that they cannot communicate effectively. Identifying and addressing these triggers can help de-escalate the situation and prevent further agitation. This approach aligns with evidence-based practice, which emphasizes understanding the underlying causes of behavioral issues to provide appropriate interventions.

Choice C Reason:

Assessing for potential injury to the client’s arms, legs, and back is crucial, especially if the client is on the ground and exhibiting aggressive behavior. However, this assessment should follow the initial step of identifying and addressing environmental triggers and unmet needs. Ensuring the client’s immediate safety by understanding the cause of their behavior is the first priority.

Choice D Reason:

Anticipating the behavior and physically restraining the client when pacing begins is not recommended as the first line of action. Physical restraint should be a last resort due to the potential for causing harm and increasing the client’s agitation. Instead, non-pharmacological interventions, such as identifying triggers and unmet needs, should be prioritized to manage the behavior safely and effectively.

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The nurse calculates that a patient must receive 1.3 mL of an anti-infective agent. The dose is ordered IM. Which of the following choices demonstrates safe, evidence-based practice?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with schizophrenia is prescribed clozapine. The nurse teaches the client and family to call the physician immediately if:

Correct Answer is A

Explanation

A client diagnosed with major neurocognitive disorder is exhibiting behavioral problems. At the change of shift, the client’s behavior escalates from pacing in the hallway to screaming and waving their arms while on the ground. Which of the following represents a priority for the nurse?

Correct Answer is B

Explanation

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The nurse calculates that a patient must receive 1.3 mL of an anti-infective agent. The dose is ordered IM. Which of the following choices demonstrates safe, evidence-based practice?

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