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 D

Explanation

Choice A rationale: Suctioning is not typically performed as part of routine pulmonary nursing care every eight hours. It is indicated based on the client's clinical need.

Choice B rationale: Suctioning frequency should be determined by the client's condition and physician's orders, not a fixed hourly schedule.

Choice C rationale: Routine coughing and swallowing of sputum do not necessarily warrant suctioning. Suctioning is indicated when the client is unable to manage secretions effectively.

Choice D rationale: Suctioning is appropriate when the client has gurgling respirations and is unable to cough effectively, indicating the need to clear the airway.

A. read previous documentation on the client's chart. B. observe the client at rest and during activity. C. ask if shortness of breath is being experienced. D. auscultate lung sounds.

Correct Answer is B

Explanation

Choice A rationale: Reading previous documentation provides historical information but may not reflect the current level of dyspnea.

Choice B rationale: Observing the client at rest and during activity is the best way to assess the current level of dyspnea.

Choice C rationale: Asking if shortness of breath is being experienced provides subjective information but may not be as reliable as direct observation.

Choice D rationale: Auscultating lung sounds is important for assessing respiratory function but may not provide a comprehensive picture of dyspnea.

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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

The nurse recognizes that the most appropriate reason to suction a client is that:

Correct Answer is D

Explanation

The best way for the nurse to assess a client's level of dyspnea is to:

Correct Answer is B

Explanation

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