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 C

Explanation

The correct answer is c. Apply a moist saline dressing to the area.

Choice A reason: Obtaining a set of vital signs is important, but it is not the immediate priority in this situation. The vital signs will not address the protruding organs directly.

Choice B reason: Flexing the client’s knees and hips may provide comfort but does not directly address the issue of the open incision and protruding organs.

Choice C reason: Applying a moist saline dressing to the area is the correct action. It helps to protect the protruding organs by keeping them moist and reduces the risk of organ damage or infection. This is the priority action to keep the organs moist and reduce the risk of tissue damage until surgical repair can be done.

Choice D reason: Elevating the head of the client’s bed 20° may be part of the overall care plan, but it is not the immediate priority when dealing with protruding organs from an open abdominal incision.

A. Sildenafil B. Metformin C. Omeprazole D. Atorvastatin

Correct Answer is A

Explanation

The nurse should instruct the client to avoid taking medications for erectile dysfunction, such as sildenafil, within 24 hours of taking nitroglycerin due to the risk of severe hypotension.

Reasons why the other options are not answers:

Option B: Metformin is not contraindicated with nitroglycerin.

Option C: Omeprazole is not contraindicated with nitroglycerin.

Option D: Atorvastatin is not contraindicated with nitroglycerin.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 4 hr postoperative following an abdominal surgery and notes that the client's abdominal incision is open and the internal organs are protruding. After contacting the rapid response team, which of the following actions should the nurse take next?

Correct Answer is C

Explanation

A nurse is obtaining a medication history from a client who is to start taking nitroglycerin for chest discomfort with activity. Which of the following medications should the nurse instruct the client to avoid taking within 24 hr of using nitroglycerin?

Correct Answer is A

Explanation

A nurse is collecting admission history data from a client who is in a semi-private room. Which of the following data is the priority for the nurse to address?

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 reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include?

A nurse in a provider's office is reinforcing teaching about disease prevention with an older adult client. Which of the following immunizations should the nurse recommend to the client?

A nurse is monitoring a client who is undergoing a blood transfusion of packed RBCs. The nurse should recognize that which of the following findings indicates fluid overload?

A nurse in an urgent care facility is collecting data from a client who was stung by a wasp. Which of the following findings indicates the client is experiencing anaphylaxis?

A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?