A nurse is preparing to administer an IM injection to a client who has gonorrhea.
Which of the following actions should the nurse take?

Inject the medication at least 5 cm (2 in) from the umbilicus.

Use the Z-track technique to administer the medication.

Give the medication without aspirating prior to injection.

Administer the medication with a 27-gauge '/,-inch needle.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Injecting the medication at least 5 cm (2 in) from the umbilicus is not a standard guideline for IM injections. The site of injection depends on factors such as the volume of medication and patient’s age and muscle mass.

Choice B rationale:

Using the Z-track technique to administer the medication is correct. This technique helps to seal the medication in muscle tissue, reducing leakage into subcutaneous tissue.

Choice C rationale:

Giving the medication without aspirating prior to injection is not recommended. Aspiration ensures that the needle is not in a blood vessel before injecting.

Choice D rationale:

Administering the medication with a 27-gauge '/,-inch needle may not be appropriate for an IM injection, especially for adults. A longer and larger gauge needle is typically used for IM injections.

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Correct Answer is C

Explanation

Choice A rationale:

Increased temperature is not a direct indication of naloxone’s effectiveness. Naloxone works by reversing the effects of opioids, which do not typically include fever.

Choice B rationale:

While naloxone can cause an abrupt withdrawal in opioid-dependent individuals, leading to symptoms such as hypertension, it does not typically decrease blood pressure in opioid overdose cases.

Choice C rationale:

Naloxone works by reversing the life-threatening depression of the central nervous system and respiratory system caused by an opioid overdose. Therefore, an increased respiratory rate after administration would indicate that the medication is effective.

Choice D rationale:

Naloxone reverses the effects of opioids, including pain relief. Therefore, a report of decreased pain would not indicate that the medication is effective.

A. "The first dose of this vaccine is given after the child is 3 years old.” B. "Give your child three doses of aspirin following administration of this vaccine.” C. "The vaccine should be avoided in children who have leukemia.” D. "This vaccine is contraindicated for children who are allergic to eggs.”

Correct Answer is C

Explanation

Choice A rationale:

The first dose of the varicella vaccine is usually given when the child is between 12 to 15 months old, not after 3 years.

Choice B rationale:

Aspirin should not be given to children due to the risk of Reye’s syndrome. This syndrome is a rare but serious condition that causes swelling in the liver and brain.

Choice C rationale:

The varicella vaccine should be avoided in children who have leukemia or any other condition that weakens the immune system.

Choice D rationale:

The varicella vaccine is not contraindicated for children who are allergic to eggs. It’s some other vaccines like influenza that have this restriction.

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A nurse is preparing to administer an IM injection to a client who has gonorrhea.Which of the following actions should the nurse take?

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A nurse is preparing to administer an IM injection to a client who has gonorrhea.
Which of the following actions should the nurse take?