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 A
Explanation
An idiosyncratic drug effect is an unpredictable and uncommon reaction to a drug that is not related to the dose, the pharmacology, or the patient’s allergy or intolerance. It may be caused by genetic factors, metabolic abnormalities, or interactions with other drugs or substances. An example of an idiosyncratic drug effect is paradoxical agitation or excitement after receiving a sedative.
B. A toxic drug effect is a harmful reaction to a drug that is related to the dose or the pharmacology of the drug. It may cause symptoms such as nausea, vomiting, drowsiness, confusion, or respiratory depression. A toxic drug effect is unlikely to cause agitation after receiving a sedative unless there is an overdose or a drug interaction that increases the level of the sedative in the blood.
C. An allergic drug response is an immunological reaction to a drug that is not related to the dose or the pharmacology of the drug. It may cause symptoms such as rash, itching, swelling, fever, or anaphylaxis. An allergic drug response is unlikely to cause agitation after receiving a sedative unless there is a severe anaphylactic reaction that affects the brain or the circulation.
D. An unexpected drug interaction is a modification of the effect of one drug by another drug or substance that is not predictable based on their pharmacology. It may cause an increase or a decrease in the efficacy or toxicity of one or both drugs. An unexpected drug interaction may cause agitation after receiving a sedative if there is a synergistic effect that enhances the central nervous system stimulation of another drug or substance (such as caffeine, cocaine, or amphetamines) or if there is an antagonistic effect that reduces the central nervous system depression of the sedative (such as flumazenil, naloxone, or physostigmine). However, these interactions are usually known and avoidable by checking the patient’s history and medication list.
Correct Answer is C
Explanation
This is because responding inappropriately to questions can indicate that the client has difficulty hearing or understanding what is being asked. According to, hearing loss makes communication with the outside world difficult, and can result in new or exaggerated symptoms that are mistakenly attributed to cognitive decline.
Choice A is wrong because speaking in a low voice does not necessarily imply hearing loss. It could be due to other factors such as shyness, anxiety, or vocal cord problems.
Choice B is wrong because refusing to answer questions does not necessarily imply hearing loss.
It could be due to other factors such as lack of interest, defiance, or distrust.
Choice D is wrong because looking away from persons while speaking does not necessarily imply hearing loss.
It could be due to other factors such as cultural norms, eye contact avoidance, or distraction.
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