Which statement made by the patient is an indication for the nurse to use the Z-track method?
“I’m worried about the medication staining my skin.”
“I don’t want the injection to hurt too much.”
“I’m allergic to this medication.”
“I want the medicine to work as fast as possible.”
The Correct Answer is A
Choice A reason: Concern about skin staining indicates the Z-track method, which prevents medication leakage into subcutaneous tissue, reducing irritation or discoloration. This technique is used for medications like iron dextran, where staining is a risk, making this the correct patient statement.
Choice B reason: Wanting to reduce injection pain does not specifically indicate Z-track, which is used to prevent leakage, not primarily pain. Other techniques (e.g., slow injection) address pain, making this statement unrelated to Z-track use.
Choice C reason: An allergy to the medication contraindicates administration, not indicates a specific technique like Z-track. The method addresses leakage, not hypersensitivity, making this statement irrelevant to the Z-track method’s purpose.
Choice D reason: Wanting fast-acting medication does not relate to Z-track, which ensures deep delivery but does not affect onset speed. Intramuscular routes generally have fixed absorption rates, making this statement unrelated to the Z-track indication.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Stating that older patients usually ask for help is inaccurate, as some may avoid requesting assistance due to pride or unawareness. Providing information empowers informed decisions, promoting independence more effectively than relying on assumptions about help-seeking behavior.
Choice B reason: Suggesting permanent nursing home placement dismisses rehabilitation potential. Providing information about care options supports tailored plans for independence, as many patients can regain self-care abilities with therapy, making this choice incorrect.
Choice C reason: Providing information and answering questions empowers the patient and family to choose care options (e.g., therapy, aids) that promote independence. This collaborative approach fosters self-care by aligning interventions with the patient’s goals, making it the most effective action.
Choice D reason: Enrolling in a ceramics class may enhance quality of life but does not directly address mobility or self-care post-hip fracture. Education on care options better supports functional recovery, making this choice less relevant to promoting independence.
Correct Answer is B
Explanation
Choice A reason: Inhaling quickly reduces medication deposition in the lungs. A slow, deep inhalation ensures proper delivery, making this incorrect for effective albuterol inhaler use.
Choice B reason: Rinsing the mouth after inhalation removes residue, preventing irritation or thrush, though less common with albuterol. This is a standard instruction, making it the correct choice.
Choice C reason: Two puffs every 2 minutes exceeds typical albuterol dosing (1–2 puffs every 4–6 hours). This risks overuse, causing side effects, making it incorrect.
Choice D reason: Holding the mouthpiece 6 inches away is incorrect; it should be 1–2 inches or in a spacer. This ensures proper aerosol delivery, making this incorrect.
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