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 D

Explanation

A) Epinephrine:
Epinephrine is used in emergency situations such as anaphylaxis or cardiac arrest. It does not reverse the effects of anticoagulants like warfarin and is not indicated for managing an elevated INR.

B) Atropine:
Atropine is used to treat bradycardia (slow heart rate) and other conditions but does not counteract the effects of warfarin. It is not appropriate for managing an elevated INR.

C) Protamine:
Protamine is used to reverse the effects of heparin, an anticoagulant, not warfarin. It is not effective in managing high INR levels associated with warfarin therapy.

D) Vitamin K:
Vitamin K is the appropriate antidote for reversing the effects of warfarin. An INR of 5.2 indicates a high risk of bleeding, and administering Vitamin K can help to reduce the anticoagulant effects of warfarin and bring the INR back to a safer range.

A. Mix the medication at the client's bedside. B. Document that the medication was administered. C. Determine the client's response to the medication. D. Check the client for allergies. E. Full screen mode is in effect during your proctored testing.

Correct Answer is D

Explanation

A) Mix the medication at the client's bedside:
Mixing the medication at the client's bedside is a necessary step in the medication administration process but should be done after ensuring that all safety checks, including allergy checks, have been completed.

B) Document that the medication was administered:
Documentation of medication administration is an important step, but it should only occur after all other steps, including verifying the client's allergies and preparing the medication, have been completed.

C) Determine the client's response to the medication:
Determining the client's response to the medication should be done after administration, not before or during the preparation. This step involves assessing the effectiveness and any adverse effects following medication administration.

D) Check the client for allergies:
Checking the client for allergies is the first and most critical step to prevent potential allergic reactions or adverse effects. It ensures that the medication is safe for the client and prevents harm.

E) Full-screen mode is in effect during your proctored testing:
This statement is not related to the process of administering a medication and does not pertain to the actions required for medication administration.

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