A nurse is administering an intramuscular injection to a client using the Z-track method.
Which of the following actions should the nurse take?
Release the skin before withdrawing the needle.
Insert at a 45° angle.
Withdraw the needle quickly.
Pull the skin laterally.
The Correct Answer is D
A. With the Z-track method, the skin is pulled laterally or to the side before the needle is inserted and released after the injection is administered to ensure the medication remains within the muscle and does not leak into the subcutaneous tissue.
B. The angle of insertion for intramuscular injections can vary depending on factors such as the client's body habitus and the length of the needle but is typically 90 degrees.
C. The needle should be withdrawn slowly and steadily to minimize tissue trauma and prevent medication leakage.
D. The Z-track method involves pulling the skin laterally or to the side before inserting the needle to create a zigzag pathway for the medication. This helps seal the needle track after the injection, reducing the risk of medication leakage into subcutaneous tissues.
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Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Povidone-iodine is not recommended for cleaning around the stoma as it may cause irritation.
B. Ensuring the pouch opening is slightly larger than the stoma helps prevent irritation and ensures proper fit.
C. Regular emptying of the ostomy pouch prevents leakage and skin irritation. It also prevents it from becoming too heavy and pulling away from the skin.
D. The nurse should advise the client to place a piece of gauze over the stoma while changing the pouch to protect it from injury and contamination.
E. A purplish-blue change in the stoma is an indication of impaired blood supply to the stoma and should be promptly reported to the healthcare provider.
Correct Answer is A
Explanation
A. Obtaining the client's type and cross-match is the first action the nurse should take because it ensures that the client will have compatible blood available for transfusion if needed during surgery.
B. This is important but should only be done after obtaining the client’s type and cross-match.
C. This should be done after obtaining the client’s type and cross-match.
D. While an incident report may be necessary, the immediate priority is to address the oversight and ensure patient safety.
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