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.”

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A reason: Stopping smoking is beneficial for lung health but does not directly address immediate fatigue from ineffective breathing during sleep. Elevating the head improves airway patency overnight, providing faster relief for sleep-related breathing issues, making this less effective.

Choice B reason: Running 30 minutes daily is inappropriate for an obese patient with fatigue and ineffective breathing, as it may exacerbate respiratory strain. Elevating the head during sleep directly improves oxygenation, making exercise a long-term rather than immediate solution for sleep promotion.

Choice C reason: Limiting diet to 1500 calories addresses obesity but not acute fatigue from ineffective breathing during sleep. Sleeping with pillows elevates the head, reducing airway obstruction and improving rest, making dietary changes a secondary intervention for this specific issue.

Choice D reason: Sleeping on two to three pillows is the most appropriate intervention, as it elevates the head, reducing airway collapse in obese patients with ineffective breathing. This promotes better oxygenation during sleep, alleviating fatigue, making it the most effective immediate strategy.

A. A Kayexalate enema for a patient with severe hypokalemia B. A hypertonic solution enema for a patient with fluid overload volume excess C. A normal saline enema to be repeated until the patient passes stool is obtained D. An oil retention enema for a patient with constipation

Correct Answer is A

Explanation

Choice A reason: A Kayexalate enema for severe hypokalemia should be questioned, as Kayexalate removes potassium to treat hyperkalemia, not hypokalemia. Administering it for low potassium would worsen the condition, risking arrhythmias, making this an incorrect and dangerous order.

Choice B reason: A hypertonic solution enema for fluid volume excess is appropriate, as it draws fluid into the bowel, aiding evacuation and reducing systemic fluid overload. This aligns with the patient’s condition, making it a correct order that does not require questioning.

Choice C reason: A normal saline enema repeated until stool is produced is safe, as saline is isotonic and effective for constipation relief without causing fluid or electrolyte imbalances. This is a standard order, making it appropriate and not requiring no questioning.

Choice D reason: An oil retention enema for constipation is appropriate, as it lubricates stool, facilitating evacuation. This is a standard treatment for relieving constipation, aligning with the patient’s needs, making it a correct order that does not require questioning.

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Which statement made by the patient is an indication for the nurse to use the Z-track method?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention would be most appropriate to promote sleep?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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