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 D
Explanation
Levofloxacin (Levaquin) is a fluoroquinolone antibiotic that is not structurally related to penicillin and has a very low risk of cross-reactivity with penicillin.
Levofloxacin can be safely used in patients with penicillin allergy unless they have a history of hypersensitivity to other fluoroquinolones.
Choice A is wrong because cephalexin (Keflex) is a first-generation cephalosporin that has a similar side chain to some penicillins and may cause cross-reactivity in penicillin-allergic patients. The risk of cross-reactivity is higher for first- and second-generation cephalosporins than for third- and fourth-generation cephalosporins.
Choice B is wrong because cefaclor (Ceclor) is a second-generation cep
Correct Answer is D
Explanation
This is because a client who has been diaphoretic for the past six hours is likely to have wet and uncomfortable bed linens that can cause skin breakdown and infection. Changing the bed linens frequently can help keep the client dry and comfortable.
Choice A is wrong because offering the client a bedpan every three hours is not related to diaphoresis and may not meet the client’s elimination needs.
Choice B is wrong because keeping an emesis basin near the bedside is not related to diaphoresis and may not be necessary unless the client has nausea or vomiting.
Choice C is wrong because providing oral care every four hours is not enough to prevent dehydration and dry mouth in a client who has been diaphoretic for the past six hours. The client may need more frequent oral care and fluid intake.
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