The nurse must give a client an intramuscular injection of a medication which is very irritating to the subcutaneous tissues. To attempt to reduce irritation of the tissues, which action should the nurse take?
Use a small gauge needle
Use the Z-track method
Administer at a 45-degree angle
Apply ice to the injection site
The Correct Answer is B
Choice A rationale: Using a small gauge needle may reduce pain but does not specifically address tissue irritation.
Choice B rationale: The Z-track method is used to reduce irritation and prevent leakage of irritating medications into the subcutaneous tissues.
Choice C rationale: Administering at a 45-degree angle is a common angle for intramuscular injections but does not specifically address tissue irritation.
Choice D rationale: Applying ice to the injection site is not a standard practice for reducing tissue irritation with intramuscular injections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: White skin around the wound edges is not necessarily indicative of too much moisture in the wound bed.
Choice B rationale: White skin around the wound edges may suggest nonviable tissue, and surgical debridement may be needed.
Choice C rationale: Turning and positioning every two hours is important for preventing pressure injuries but is not directly related to the observed skin color.
Choice D rationale: White skin around the wound edges is not a normal finding and indicates a potential issue with tissue viability.
Correct Answer is B
Explanation
Choice A rationale: Administering the medication against the client's will is not respectful of the client's autonomy and right to make decisions about her own care.
Choice B rationale: Withholding the medication and reporting it to the prescriber is appropriate. The prescriber can reassess the situation and determine the next course of action.
Choice C rationale: Withholding the medication and filing an incident report may be premature; it is essential to involve the prescriber first.
Choice D rationale: Informing the client that the medication must be taken until the nurse gets an order to discontinue it may not be the best approach, as it does not respect the client's right to refuse treatment. The prescriber should be involved in the decision-making process.
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