A nurse is preparing to administer ceftriaxone using the z-track technique to a client who has gonorrhea. After the nurse performs hand hygiene and reconstitutes the medication, identify the sequence the nurse should use to administer the medication. (Move the steps, placing them in the order of performance. Use all the steps.)
Use the nondominant hand to pull the skin and subcutaneous tissue 2.5 cm (1 in) laterally.
Remove the needle and release the tissue.
Aspirate by pulling back on the plunger and inject the medication.
The Correct Answer is A,C,B
Here’s the correct sequence for administering ceftriaxone using the Z-track technique: 1. Use the nondominant hand to pull the skin and subcutaneous tissue 2.5 cm (1 in) laterally. 2. Aspirate by pulling back on the plunger and inject the medication. 3. Remove the needle and release the tissue. This method helps to prevent the medication from leaking into the subcutaneous tissue, reducing irritation and discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B, a client who had abdominal surgery 2 days ago and the incision line is separating. This client requires immediate attention as a separating incision can indicate wound dehiscence or evisceration, which are surgical emergencies. Choice A is incorrect because although C. difficile is a serious infection, liquid stools are a common symptom and do not require immediate attention. Choice C is incorrect because intermittent coughing up clear sputum is a normal finding for a client with a tracheostomy, and does not indicate a change in the client's condition. Choice D is incorrect because the client fell 12 hours ago and reports pain as 4 on a scale of 0 to 10, which indicates a low level of pain.
Choice A: A client who has Clostridium difficile and has liquid stools is incorrect because although C. difficile is a serious infection, liquid stools are a common symptom and do not require immediate attention.
Choice C: A client who has a chronic tracheostomy and is intermittently coughing up clear sputum is incorrect because intermittent coughing up clear sputum is a normal finding for a client with a tracheostomy, and does not indicate a change in the client's condition.
Choice D: A client who fell 12 hours ago and reports pain as 4 on a scale of 0 to 10 is incorrect because the level of pain is low and does not require immediate attention.
Correct Answer is C
Explanation
Choice A rationale: Breast self-examinations should be performed monthly, not every other month. This regularity helps with early detection of any changes.
Choice B rationale: Dimpling of the skin on the breasts is not common and can be a sign of breast cancer or other conditions. This statement indicates a misunderstanding.
Choice C rationale: It is indeed common for one breast to be slightly larger than the other. This is a normal variation and not usually a cause for concern.
Choice D rationale: Breast self-examinations should be performed several days after the menstrual period ends, not the day the period begins. This timing helps to reduce the likelihood of hormonal changes affecting breast tissue.
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