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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?

A.

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

B.

Use the Z-track technique to administer the medication.

C.

Give the medication without aspirating prior to injection.

D.

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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Related Questions

Correct Answer is B

Explanation

Choice A rationale:

While a tuberculin syringe can be used for insulin administration, it’s not necessary when mixing NPH and regular insulin. Insulin syringes are typically used for this purpose.

Choice B rationale:

Injecting air into each vial before withdrawing insulin helps equalize pressure and makes it easier to draw up the insulin. This should be done before withdrawing any insulin.

Choice C rationale:

Withdrawing NPH insulin first contradicts the standard practice of drawing up insulins. The usual recommendation is to draw up short-acting (regular) insulin before intermediate-acting (NPH) insulin.

Choice D rationale:

Shaking the regular insulin vial is unnecessary and could potentially create bubbles, making it harder to draw up the correct dose of insulin.

Correct Answer is B

Explanation

Choice A rationale:

While headache can be a side effect of aspirin, it’s usually not severe enough to warrant reporting to the provider unless it’s persistent or severe.

Choice B rationale:

Rhinitis, or inflammation of the mucous membrane of the nose, can be an allergic reaction to aspirin and should be reported to the provider.

Choice C rationale:

Hematocrit (Hct) level of 43% is within the normal range for both men (38.8–50.0 %) and women (34.9–44.5 %), so this finding would not need to be reported.

Choice D rationale:

A blood pressure reading of 120/70 mm Hg is within the normal range and would not need to be reported.

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