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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Free Nursing Study Resources

Correct Answer is D

Explanation

The correct answer is choice D. The nurse should identify an oral temperature of 39°C (102.2°F) as the priority finding in a client who is postoperative following a total thyroidectomy for hyperthyroidism. An elevated temperature can indicate infection, which is a risk after surgery. The nurse should report this finding to the provider immediately.

Choices A, B, and C are incorrect because moderate amount of serosanguineous drainage on dressings, serum calcium level 9.2 mg/dL, and report of a sore throat, respectively, are expected findings after a total thyroidectomy and do not require immediate action.

A. Oropharyngeal airway B. Water-soluble lubricant C. Yankauer catheter D. Sterile gloves E. Sterile gloves

Correct Answer is C

Explanation

Yankauer catheter. A Yankauer catheter is a suction device used for oral suctioning. It is important for this client to have access to a Yankauer catheter for safe and effective suctioning of secretions from the mouth.

Option A is incorrect because an Oropharyngeal airway is used to maintain or open the airway.

Option B is incorrect because the water-soluble lubricant is used for lubricating the suction catheter during suctioning.

Option D is incorrect because sterile gloves are not routinely needed for suctioning.

Reasons why the other options are not answered: Option A: An oropharyngeal airway is not used for suctioning but is used to maintain an open airway in an unconscious patient. Option B: Water-soluble lubricant is used for lubricating the suction catheter during suctioning. Option D: Sterile gloves are not routinely needed for suctioning.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a total thyroidectomy for hyperthyroidism. Which of the following findings should the nurse identify as the priority?

Correct Answer is D

Explanation

A nurse is assisting with discharge teaching for a client who requires oropharyngeal suctioning at home. The nurse should ensure that which of the following equipment is available for use at home?

Correct Answer is C

Explanation

A nurse is caring for a client who has just had a central venous catheter placed via the right subclavian vein. Which of the following actions should the nurse take?

Exhibit 1 Exhibit 2 Graphic Results Temperature 37.9°C (100.2° F) Heart rate 90/min Exhibit 3 Respiratory rate 20/min Blood pressure 140/76 mm Hg A nurse is reviewing the medical record of a client who had a left-sided stroke. Which of the following findings should the nurse expect?

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A nurse is collecting data from a client who is experiencing opioid toxicity. Which of the following findings should the nurse expect?