Which action should a nurse perform when administering an intramuscular injection via the Z- track method?
Limit the total volume of the injection to 1 milliliter.
Leave the needle in place for at least 10 seconds before removing it to trap the medication in the muscle.
Use a 1 inch, 23 gauge needle to prevent tissue trauma.
Administer the medication rapidly to disperse it into the muscle.
The Correct Answer is B
Leave the needle in place for at least 10 seconds before removing it to trap the medication in the muscle.
The Z-track method is a technique used to administer intramuscular injections that prevent leakage of medication into the subcutaneous tissue. The nurse should pull the skin laterally before inserting the needle, inject the medication slowly, leave the needle in place for at least 10 seconds, and release the skin after withdrawing the needle.
Choice A is wrong because the total volume of the injection is not limited to 1 milliliter in the Z-track method. The Z-track method can be used to administer up to 3 milliliters of medication depending on the site and muscle mass of the client.
Choice C is wrong because the needle size and gauge depend on the site, medication, and client characteristics, not on the Z-track method. The Z-track method can be performed with different needle sizes and gauges as long as they are appropriate for intramuscular injections.
Choice D is wrong because the nurse should not administer the medication rapidly in the Z- track method.
Rapid injection can cause pain, tissue damage, and leakage of medication into the subcutaneous tissue. The nurse should inject the medication slowly and steadily in the Z-track method.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Orthostatic hypotension noted with dangling.
This means that the client’s blood pressure drops when changing position from lying down to sitting or standing. This can cause symptoms such as paleness, sweating, rapid pulse, weakness, and dizziness.
The nurse should document this finding and report it to the physician.
Choice A is wrong because a normal reaction to a position change would not cause such severe symptoms.
Choice B is wrong because the gait belt applied is not a finding but an intervention.
Choice D is wrong because elevated blood sugar probable is not a finding but a speculation.
Choice E is wrong because spot accucheck obtained is not a finding but an action.
Choice F is wrong because fear of falling expressed by a client is not a finding related to the client’s vital signs or physical condition.
Choice G is wrong because provided reassurance is not a finding but a nursing measure.
Correct Answer is A
Explanation
This is the most appropriate action because it respects the client’s right to know and the family’s right to privacy.
It also allows the nurse to collaborate with the family and the healthcare provider to provide the best care for the client.
Choice B is wrong because it violates the client’s autonomy and dignity.
It also prevents the client from making informed decisions about end-of-life care.
Choice C is wrong because it denies the reality of the situation and does not address the client’s concerns.
It also may increase the client’s anxiety and frustration.
Choice D is wrong because it disregards the family’s wishes and cultural values.
It also may cause harm to the client and the family by breaking their trust and creating conflict.
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