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 D

Explanation

Choice A Reason:

Encouraging social interaction might not be appropriate in this situation. The client’s bizarre behavior is already causing distress to others, and encouraging more interaction could exacerbate the problem. The priority should be to address the immediate safety and well-being of both the client and others. Once the client is in a safe environment, social interaction can be encouraged in a controlled and therapeutic manner.

Choice B Reason:

Discussing the bizarre behavior with the client might not be effective in the moment, especially if the client is not in a state to understand or engage in such a discussion. The primary focus should be on ensuring safety and stability before addressing specific behaviors. Once the client is calm and in a safe environment, discussions about behavior can be more productive.

Choice C Reason:

Providing information about the client’s illness is important for long-term management and understanding, but it is not the immediate priority in this situation. The client’s current state requires immediate intervention to ensure safety. Education about the illness can be provided once the client is stabilized and in a better position to comprehend the information.

Choice D Reason:

Providing a safe environment is the most immediate and crucial priority. The client’s behavior is not only distressing to others but could also pose a risk to herself and others. Ensuring the client is in a safe, controlled environment helps to prevent harm and allows for further assessment and appropriate interventions. Safety is always the first priority in managing acute behavioral disturbances.

A. There are any signs of infection. B. There is a decrease in hallucinations. C. Appetite continues to decrease after one week. D. Insomnia occurs for more than two nights.

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.

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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

The nurse notices a client wandering in the hospital hall giggling, with bizarre behavior that is annoying and frightening other clients. A priority in caring for her is to:

Correct Answer is D

Explanation

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

The nurse must give 25 micrograms of fentanyl IVP X1 dose. Fentanyl is available in an ampule 100 micrograms per 2m How many mL will the nurse give for the correct dose? round to the nearest tenth. Use a preceding zero if necessary. Do not use trailing zeros.

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A client with schizophrenia has had 2 hospitalizations within the past 9 months due to non-adherence to medications and their counseling plan. What measures should the nurse and the mental health treatment team recommend for tertiary prevention? (Select All That Apply)

A client with schizophrenia approaches the nurse with a look of distress and anguish on his face. He says, “Can’t you hear him? It’s the devil. He’s telling me I’m going to hell.” Which is the most appropriate response by the nurse?

The nurse is completing an admission assessment of a client who is admitted to milieu. Which piece of information obtained from the client during the assessment would require immediate investigation from the nurse regarding the client’s use of complementary and alternative therapies?

A nurse notices that a client with paranoid schizophrenia stops in mid-sentence when talking and tilts his head to the side as if to listen. The most appropriate intervention by the nurse would be to:

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