A nurse is planning to administer ceftriaxone IM to an adult client. Which of the following actions should the nurse plan to take?

Administer the medication using a 5/8-inch needle.

Administer the medication using a Z-track technique.

Administer the medication in the deltoid muscle.

Administer the medication at a 45° angle.

Answer and Explanation

The Correct Answer is B

A) Administer the medication using a 5/8-inch needle:
Ceftriaxone is typically administered using a longer needle to ensure proper injection into the muscle. A 5/8-inch needle is more suitable for subcutaneous injections rather than intramuscular (IM) injections.

B) Administer the medication using a Z-track technique:
The Z-track technique is appropriate for IM injections of medications like ceftriaxone, which can be irritating to tissues. This technique helps prevent the medication from leaking into the subcutaneous tissue and minimizes discomfort by creating a zigzag path in the muscle.

C) Administer the medication in the deltoid muscle:
Ceftriaxone is generally administered in larger muscle groups, such as the vastus lateralis or gluteus muscle, rather than the deltoid. The deltoid is more commonly used for vaccines or smaller volume injections.

D) Administer the medication at a 45° angle:
For IM injections, the needle should be inserted at a 90° angle to the skin. A 45° angle is more appropriate for subcutaneous injections.

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Correct Answer is B

Explanation

A) Discontinue medication if nausea occurs:
While nausea can be a side effect of cyclobenzaprine, it is not typically a reason to discontinue the medication immediately. The client should contact their healthcare provider if they experience nausea or other side effects, but discontinuation should be based on medical advice.

B) Avoid driving until effects are known:
Cyclobenzaprine is a muscle relaxant that can cause drowsiness, dizziness, or impaired cognitive function. It is important for clients to avoid driving or operating heavy machinery until they are aware of how the medication affects them and if they can do so safely.

C) Monitor for increased muscle spasms:
Cyclobenzaprine is prescribed to reduce muscle spasms, so an increase in muscle spasms would be contrary to the intended effect of the medication. Clients should monitor for effectiveness and report any increase in symptoms to their healthcare provider.

D) Expect urine to turn orange:
Cyclobenzaprine does not typically cause urine to change color. Urine discoloration is not a common side effect of this medication. Clients should be informed about possible side effects, but urine discoloration is not associated with cyclobenzaprine.

A. Wear sterile gloves and break off the neck of the glass ampule with a single snap to the right side. B. Tap the bottom of the ampule, place a gauze pad around the ampule neck, and break off the bottom with a forward motion away from the body. C. Tap the top of the ampule, place a sterile gauze pad around the ampule neck, and break off the top by bending it toward the body. D. Wear sterile gloves and break off the neck of the glass ampule with a single snap in a downward motion.

Correct Answer is C

Explanation

A) Wear sterile gloves and break off the neck of the glass ampule with a single snap to the right side:
While wearing gloves can be part of the technique, breaking the ampule to the right side is not standard practice. It is more important to use a sterile gauze pad and break the ampule carefully to avoid glass shards falling into the medication.

B) Tap the bottom of the ampule, place a gauze pad around the ampule neck, and break off the bottom with a forward motion away from the body:
Tapping the bottom of the ampule is not the recommended practice; the top of the ampule should be tapped instead. Additionally, breaking the ampule away from the body is good practice, but it’s crucial to break the top of the ampule, not the bottom.

C) Tap the top of the ampule, place a sterile gauze pad around the ampule neck, and break off the top by bending it toward the body:
This is the correct technique. Tapping the top of the ampule helps to ensure that all the liquid is at the bottom, and placing a sterile gauze pad around the neck protects against glass shards. Breaking the top away from the body reduces the risk of injury and contamination.

D) Wear sterile gloves and break off the neck of the glass ampule with a single snap in a downward motion:
Breaking the ampule downward is not recommended because it can increase the risk of glass shards falling into the medication or causing injury. Proper technique involves breaking the ampule away from the body to ensure safety and avoid contamination.

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A nurse is planning to administer ceftriaxone IM to an adult client. Which of the following actions should the nurse plan to take?

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