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 A

Explanation

A) Catheter dislodgment:
Hearing a gurgling sound near the catheter insertion site may indicate that the catheter is partially dislodged. This dislodgment can cause air to enter the catheter or affect the proper flow of fluids. Immediate assessment and intervention are required to address the dislodgment and prevent complications such as air embolism.

B) Catheter rupture:
A catheter rupture would typically present with signs of leakage or blood in the surrounding area, rather than a gurgling sound. While a rupture is a serious complication, it does not usually cause a gurgling noise.

C) Catheter migration:
Catheter migration occurs when the catheter moves from its original position, which could lead to issues with catheter function or placement. However, migration is less likely to cause a gurgling sound and more likely to present with changes in catheter function or resistance during infusion.

D) Catheter occlusion:
Catheter occlusion usually presents with difficulty in infusing fluids or withdrawing blood, not a gurgling sound. An occlusion is characterized by blockage or reduced flow rather than an audible gurgling.

A. Ask the client to inhale the medication quickly for 1 second. B. Ask the client to hold their breath for 2 seconds after inhalation. C. Shake the MDI prior to administration. D. Wash the MDI canister in warm water after each use.

Correct Answer is C

Explanation

A) Ask the client to inhale the medication quickly for 1 second:
The client should inhale the medication slowly and deeply, not quickly. A rapid inhalation can reduce the effectiveness of the medication as it may not reach the deeper parts of the lungs effectively.

B) Ask the client to hold their breath for 2 seconds after inhalation:
The client should hold their breath for about 10 seconds after inhalation to allow the medication to settle in the lungs and be absorbed. Holding the breath for just 2 seconds is typically insufficient for optimal medication delivery.

C) Shake the MDI prior to administration:
Shaking the MDI before use is important to ensure that the medication is properly mixed and delivered in the correct dose. Failure to shake the MDI can result in an uneven distribution of medication.

D) Wash the MDI canister in warm water after each use:
The MDI canister should not be washed frequently, as this can affect the device's function and lead to potential contamination. The canister should be cleaned as per the manufacturer’s instructions, typically every few days or as needed.

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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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