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.

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 A

Explanation

The correct answer is choice A: Elevate the head of the client's bed for 1 hr after the feeding. This is because elevating the head of the client's bed to at least 30 degrees can help prevent aspiration and gastric reflux. Choice B is incorrect because administering the feeding solution at a cold temperature can cause discomfort and diarrhea. Choice C is incorrect because rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site. Choice D is incorrect because flushing the tube with 90 mL of sterile water before and after the feeding is not necessary as long as the tube is adequately flushed before and after each feeding.

Explanation for why the other choices are not answers: B – Administering the feeding solution at a cold temperature can cause discomfort and diarrhea, so it should not be done. C – Rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site, so this is not the correct action. D – Flushing the tube with 90 mL of sterile water before and after the feeding is unnecessary to do as long as the tube is adequately flushed before and after each feeding. Thus, this is not the correct answer.

A. Decreased calcium levels. B. Increased serum glucose levels. C. Absent bowel sounds. D. Intermittent abdominal pain.

Correct Answer is B

No explanation

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has partial-thickness burns on 50% of his body and is receiving total parenteral nutrition. The nurse should actively monitor the client for which of the following?

Correct Answer is B

A nurse is reinforcing discharge teaching with a client who had an abdominal hysterectomy 2 days ago. Which of the following instructions should the nurse include in the teaching?

A nurse is collecting data from a client who has mitral valve regurgitation. In which of the following areas should the nurse place the stethoscope to auscultate a murmur? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

A home health nurse is reinforcing teaching with an older adult client about safety precautions to take in the home. Which of the following instructions should the nurse include?

A nurse is examining the abdominal wound of a client who is 3 days postoperative following a hemicolectomy. Which of the following findings indicates a wound infection?

A nurse is caring for a client who is experiencing muscle spasms and has a new prescription for an aquathermia pad. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with the partner of a client who has contact precautions in place for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements by the client's partner indicates an understanding of the teaching?

A nurse is contributing to the plan of care for a client who has disuse syndrome following cast removal from a lower extremity. Which of the following referrals should the nurse include in the plan of care?

A nurse is reinforcing teaching with a client who has angina. Which of the following statements by the client indicates an understanding of the teaching?