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

Answer and Explanation

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.

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Correct Answer is ["C","E"]

Explanation

Choice A rationale: Diluting potassium elixir in juice is not a priority intervention for a critically elevated potassium level. Immediate actions are needed.

Choice B rationale: Monitoring intake and output is important, but it is not the highest priority when the potassium level is critically elevated.

Choice C rationale: Assessing the client for muscle weakness and flaccid paralysis is a high priority because hyperkalemia can lead to serious cardiac and neuromuscular complications.

Choice D rationale: Encouraging intake of orange juice or a banana may be appropriate for managing mild hypokalemia, but it is not the priority for a client with critically elevated potassium.

Choice E rationale: Obtaining a physician's order for cardiac monitoring is crucial, as hyperkalemia can lead to life-threatening cardiac dysrhythmias.

A. ineffective gas exchange. B. ineffective breathing pattern C. activity intolerance. D. decreased cardiac function

Correct Answer is B

Explanation

Choice A rationale: Ineffective gas exchange is related to respiratory issues but may not be the priority in this case.

Choice B rationale: Ineffective breathing pattern is the priority problem, as evidenced by shallow respirations and reluctance to perform coughing and deep breathing, which can lead to respiratory complications.

Choice C rationale: Activity intolerance is not the priority problem based on the given data.

Choice D rationale: Decreased cardiac function is not the priority problem based on the given data.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has a serum potassium level of 6.3 mEq/L. The nurse recognizes that the highest priority intervention(s) for this client are to: (SELECT ALL THAT APPLY)

Correct Answer is ["C","E"]

Explanation

A one-day post-operative client complains of severe abdominal pain and has shallow respirations at 22/minute. The client is reluctant to perform coughing and deep breathing. Based on the data, the priority problem that the nurse could assign to this patient is:

Correct Answer is B

Explanation

An alert, competent client refuses to take her antihypertensive medication. The nurse has explained why the medication is important and the client states that she understands but doesn't want to take the medication. What is the best nursing action?

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The nurse is administering medications to a client who has severe liver damage. Which medications, as ordered below, will avoid the first pass effect? (SELECT ALL THAT APPLY)

In order to minimize discomfort when giving an injection to a client, the nurse should: