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 D

Explanation

Choice A rationale:

Oxycodone overdose typically results in constricted (not dilated) pupils due to its action on the central nervous system.

Choice B rationale:

Oxycodone overdose can cause respiratory depression, leading to slow and shallow breathing (bradypnea), not rapid breathing (tachypnea)

Choice C rationale:

Oxycodone does not typically cause tachycardia. It can cause bradycardia due to its action on the central nervous system.

Choice D rationale:

Sedation is a common effect of oxycodone and can be more pronounced in cases of overdose due to the drug’s depressant effect on the central nervous system.

A. "What is your home phone number?” B. "Can you tell me your room number?” C. "Is your name Sarah Jones?” D. "Are you 65 years of age?”

Correct Answer is C

Explanation

Choice A rationale:

Asking for a home phone number is not an effective method for identifying a patient. Phone numbers can be easily forgotten or mixed up, especially in a hospital setting where a patient may be under stress or experiencing health issues.

Choice B rationale:

Room numbers can change if the patient is moved, and other patients may have previously occupied the same room. Therefore, room numbers are not reliable identifiers.

Choice C rationale:

Asking the patient to confirm their own name is one of the most direct and reliable ways to verify their identity. This method respects patient autonomy and privacy while ensuring accurate identification.

Choice D rationale:

Age alone is not a reliable identifier because it does not distinguish between different patients of the same age.

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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?

Nursing Test Bank

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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?