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:

Checking blood pressure with the client standing could exacerbate the client’s symptoms due to orthostatic hypotension, which is a common side effect of captopril.

Choice B rationale:

Administering a 0.9% sodium chloride IV bolus could be considered if the client’s blood pressure does not improve with positioning changes or if the client’s condition worsens.

Choice C rationale:

Placing the client in a supine position can help increase blood flow to the brain and alleviate symptoms of low blood pressure. This should be the first action taken by the nurse.

Choice D rationale:

Measuring blood pressure with the client sitting could also exacerbate symptoms due to orthostatic hypotension. It would be more appropriate after the client’s condition has stabilized.

A. Two loose stools in the past 24 hr. B. WBC 11,000/mm³. C. Heart rate 104/min. D. Creatinine 3.1 mg/dL.

Correct Answer is D

Explanation

Choice A rationale:

Two loose stools in the past 24 hours could be a symptom of Clostridioides difficile infection, but it’s not necessarily a priority finding. The infection can cause diarrhea, but it’s not life-threatening.

Choice B rationale:

A WBC count of 11,000/mm³ is slightly elevated, indicating a possible infection. However, it’s not necessarily a priority finding as it’s not significantly high.

Choice C rationale:

A heart rate of 104/min is slightly elevated, indicating possible stress or anxiety. However, it’s not necessarily a priority finding as it’s not significantly high.

Choice D rationale:

Creatinine level of 3.1 mg/dL is significantly high, indicating possible kidney damage, which can be a side effect of vancomycin treatment. This should be reported to the provider immediately.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

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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?