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.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
Orient the client to the arrangement of the room to promote independence. This strategy helps the client who is blind to navigate the environment safely and confidently. It also shows respect for the client’s autonomy and dignity.
Choice A is wrong because speaking loudly is not necessary for a client who is blind, unless they also have hearing impairment. Speaking loudly may imply that the client is less intelligent or capable, which is not true.
Choice B is wrong because touching the client prior to speaking may startle or frighten them. It is better to identify oneself verbally and ask for permission before touching the client.
Choice D is wrong because keeping the bed in the highest position may increase the risk of injury if the client tries to get out of bed alone. It also restricts the client’s mobility and independence, which may affect their self-esteem and quality of life.
Correct Answer is B
Explanation
This is because anti-embolism stockings are designed to prevent swelling and blood clots in the legs by applying graduated compression, which is tighter around the ankle and looser as it moves up the leg. Applying the stockings in the morning before any swelling occurs ensures a proper fit and optimal blood flow.
Choice A is wrong because massaging the legs can dislodge a blood clot and cause a pulmonary embolism.
Choice C is wrong because wetting the stockings can make them harder to apply and reduce their effectiveness.
Choice D is wrong because removing the stockings before bathing can increase the risk of swelling and clotting, and applying fresh ones afterward can be difficult and uncomfortable.
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