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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
A Positive Chvostek’s sign is a clinical finding associated with hypocalcemia, or low levels of calcium in the blood. It’s not directly related to glyburide usage or symptoms of anxiety and profuse sweating.
Choice B rationale:
Pitting pedal edema occurs when excess fluid builds up in the body, causing swelling. It’s not directly related to glyburide usage or symptoms of anxiety and profuse sweating.
Choice C rationale:
Decreased deep-tendon reflexes or hyporeflexia happens when your skeletal muscles have a decreased or absent reflex response. It’s not directly related to glyburide usage or symptoms of anxiety and profuse sweating.
Choice D rationale:
Decreased blood glucose level or hypoglycemia occurs when your blood sugar (glucose) level falls too low. Glyburide is an oral diabetes medicine that helps control blood sugar levels. Anxiety and profuse sweating are symptoms of low blood sugar.
Correct Answer is B
Explanation
Choice A rationale:
Instructing the client to chew the medication is not recommended for enteric-coated tablets as it could result in stomach upset or damage to the protective coating.
Choice B rationale:
Placing the medication on the client’s tongue allows for easier swallowing without compromising the integrity of the enteric coating.
Choice C rationale:
Dissolving the medication in juice is not recommended as it could damage the enteric coating and result in stomach upset.
Choice D rationale:
Placing the medication between the client’s cheek and gum is not typically recommended for enteric-coated tablets as it could result in discomfort or damage to the protective coating.
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