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 into the box on the right, 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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is c. Inform the client to seek medical attention following administration of the injection.

Choice A reason: Reviewing the signs of anaphylaxis with the client is important, but it’s not the priority. The client must first know what to do in case of an emergency.

Choice B reason: Instructing the client to store the injector at room temperature is a part of the storage instructions, but it’s not the immediate action to take during an anaphylactic reaction.

Choice C reason: This is the priority because anaphylaxis is a potentially life-threatening condition and even after administering epinephrine, it’s crucial to seek immediate medical attention.

Choice D reason: Having the client perform a return demonstration of the equipment is a good teaching method, but it’s not the immediate action to take when an anaphylactic reaction occurs.

A. Monitor the client for weight loss. B. Advise the client about increased dry mouth. C. Inform the client of the adverse effect of diarrhea. D. Check the client for increased hypopigmentation under the patch.

Correct Answer is B

Explanation

Advise the client about increased dry mouth. Transdermal clonidine can cause xerostomia, or dry mouth, due to a decrease in salivary secretion. The nurse should advise the client to maintain good oral hygiene and to increase fluid intake to prevent oral and dental problems.

An explanation for incorrect choices:

A. Weight loss is not a common adverse effect or risk associated with transdermal clonidine.

C. Diarrhea can occur with transdermal clonidine, but it is not a common adverse effect or risk.

D. Hypopigmentation is rare with transdermal clonidine; it is more common with corticosteroids.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at risk for anaphylaxis due to bee stings. When reinforcing teaching about the use of an automatic epinephrine injector, which of the following actions is the priority?

Correct Answer is C

Explanation

A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse is providing care for a client who has hemophilia and is bleeding from a small laceration on his arm. After applying a sterile dressing, which of the following actions should the nurse take next?

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A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke. Which of the following statements by the client indicates an understanding of the teaching?

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A nurse is collecting data from a client who has suspected appendicitis. What finding should the nurse prioritize to report to the provider?

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