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

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:

Flumazenil is a benzodiazepine receptor antagonist used to reverse the effects of benzodiazepines like diazepam. It works by competitively inhibiting the action of benzodiazepines at the GABA receptor, thereby reversing sedation and other effects. Flumazenil is typically administered in cases of benzodiazepine overdose to counteract the sedative effects and restore normal respiratory function. However, it should be used cautiously as it can precipitate withdrawal and seizures in patients with long-term benzodiazepine use.

Choice B Reason:

Chlorpromazine is an antipsychotic medication primarily used to treat schizophrenia and other psychotic disorders. It is not indicated for the treatment of benzodiazepine overdose. Chlorpromazine works by blocking dopamine receptors in the brain, which helps to manage symptoms of psychosis but does not counteract the effects of benzodiazepines. Therefore, it would not be an appropriate choice in this scenario.

Choice C Reason:

Lithium carbonate is a mood stabilizer commonly used in the treatment of bipolar disorder. It helps to reduce the severity and frequency of mania and can also help to relieve or prevent bipolar depression. Lithium does not have any antagonistic effects on benzodiazepines and is not used in the treatment of benzodiazepine overdose. Thus, it would not be the correct medication to administer in this case.

Choice D Reason:

Methadone is a long-acting opioid used for pain management and as part of medication-assisted treatment for opioid use disorder. It works by binding to the same receptors in the brain as other opioids, helping to reduce withdrawal symptoms and cravings. Methadone does not counteract the effects of benzodiazepines and is not used in the treatment of benzodiazepine overdose. Therefore, it would not be an appropriate choice in this scenario.

A. Draws attention and approval from significant others. B. Provides temporary and partial relief from anxiety. C. Increases the inhibitory powers of their superego. D. Blocks delusions and hallucinations from awareness.

Correct Answer is B

Explanation

Choice A Reason:

Draws attention and approval from significant others.

This statement is incorrect. Compulsive washing rituals in Obsessive-Compulsive Disorder (OCD) are not typically performed to draw attention or gain approval from others. Instead, these rituals are driven by an internal need to reduce anxiety and distress associated with obsessive thoughts. The primary function of these behaviors is to manage the individual’s own anxiety rather than to seek external validation.

Choice B Reason:

Provides temporary and partial relief from anxiety.

This is the correct response. Compulsive washing rituals in OCD are performed to alleviate the intense anxiety and distress caused by obsessive thoughts. Although the relief is temporary and partial, it reinforces the behavior, creating a cycle where the individual feels compelled to repeat the ritual to manage their anxiety. This temporary relief is a key characteristic of compulsive behaviors in OCD.

Choice C Reason:

Increases the inhibitory powers of their superego.

This statement is incorrect. The concept of the superego is related to Freud’s psychoanalytic theory, where it represents the internalized moral standards and ideals. Compulsive washing rituals in OCD are not performed to increase the inhibitory powers of the superego but rather to reduce anxiety and distress. The rituals are a response to obsessive thoughts rather than a means of enhancing moral inhibition.

Choice D Reason:

Blocks delusions and hallucinations from awareness.

This statement is incorrect. Delusions and hallucinations are more commonly associated with psychotic disorders, such as schizophrenia, rather than OCD. Compulsive washing rituals in OCD are not intended to block delusions or hallucinations but to manage anxiety related to obsessive thoughts. The focus of these rituals is on reducing distress rather than addressing psychotic symptoms.

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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

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Correct Answer is A

Explanation

A client diagnosed with Obsessive-Compulsive Disorder has developed a number of compulsive washing rituals over the years. The nurse recognizes that these behavioral rituals serve which purpose?

Correct Answer is B

Explanation

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