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 D

Explanation

The correct answer is choice D. Requires nasogastric suction.

Nasogastric suction removes gastric secretions that contain potassium, leading to a loss of potassium from the body.

This can cause hypokalemia, which is a low level of potassium in the blood.

Choice A is wrong because Addison’s disease causes hyperkalemia, which is a high level of potassium in the blood.

Choice B is wrong because tissue damage can release potassium from the cells into the blood, causing hyperkalemia.

Choice C is wrong because uric acid level is not related to potassium level.

Uric acid is a waste product of purine metabolism that can cause gout or kidney stones if elevated.

A. Temperature 37.2° C (99° F) B. Serosanguineous drainage at the incision site C. Red streaks along the incision D. Hypoactive bowel sounds in all four quadrants

Correct Answer is C

Explanation

Red streaks along the incision. This is a possible sign of infection and should be reported to the healthcare provider. A temperature of 37.2°C (99°F) is within the normal range and does not require reporting. Serosanguineous drainage at the incision site is normal within the first few days postoperatively. Hypoactive bowel sounds in all four quadrants can indicate ileus, which is a possible complication following abdominal surgery, but it is not an immediate concern and can be monitored unless other symptoms arise.

Choice A: A temperature of 37.2°C (99°F) is within the normal range and does not require reporting.

Choice B: Serosanguineous drainage at the incision site is normal within the first few days postoperatively.

Choice D: Hypoactive bowel sounds in all four quadrants can indicate ileus, which is a possible complication following abdominal surgery, but it is not an immediate concern and can be monitored unless other symptoms arise.

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Naxlex Comprehensive Predictor Exams

The nurse caring for a client reviews the medical record and determines the client is at risk for developing a potassium deficit because of which situation?

Correct Answer is D

Explanation

A nurse is caring for a client who is 1 day postoperative following an appendectomy. Which of the following findings should the nurse report?

Correct Answer is C

Explanation

A nurse is collecting data from a female client during an initial health assessment. Which of the following findings should the nurse identify as a risk factor for osteoporosis?

A nurse is reinforcing discharge teaching with a client regarding selfadministration of regular insulin. What instruction should the nurse include?

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A nurse is contributing to the plan of care for a client who has heart failure. Which of the following actions should the nurse include in the plan?

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A nurse is reviewing laboratory values of a client who has severe dyspnea. Which of the following laboratory values indicates heart failure?

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