The nurse must give a client an intramuscular injection of a medication which is very irritating to the subcutaneous tissues. To attempt to reduce irritation of the tissues, which action should the nurse take?

Use a small gauge needle

Use the Z-track method

Administer at a 45-degree angle

Apply ice to the injection site

Answer and Explanation

The Correct Answer is B

Choice A rationale: Using a small gauge needle may reduce pain but does not specifically address tissue irritation.

Choice B rationale: The Z-track method is used to reduce irritation and prevent leakage of irritating medications into the subcutaneous tissues.

Choice C rationale: Administering at a 45-degree angle is a common angle for intramuscular injections but does not specifically address tissue irritation.

Choice D rationale: Applying ice to the injection site is not a standard practice for reducing tissue irritation with intramuscular injections.

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Correct Answer is D

Explanation

Choice A rationale: Placing the client in reverse Trendelenburg position is not the first priority; protecting the wound is more critical.

Choice B rationale: Administering IV antibiotics STAT is not the first priority in the presence of evisceration.

Choice C rationale: Using sterile gloves to replace the protruding parts is not the first intervention; covering the wound takes precedence.

Choice D rationale: Applying a sterile normal saline dressing is the first priority to cover and protect the exposed abdominal contents.

A. giving too much responsibility to the assistive personnel. B. a high degree of trust in delegates. C. a need for perfectionism and control D. that nurses usually have the time to do things themselves

Correct Answer is C

Explanation

Choice A rationale: Under-delegation is not related to giving too much responsibility to assistive personnel; it is about appropriate delegation based on the nurse's assessment of the situation.

Choice B rationale: Trust in delegates is essential, and under-delegation is more likely related to a lack of trust or confidence in delegation.

Choice C rationale: Under-delegation can occur due to a nurse's need for perfectionism and control, leading to a reluctance to delegate tasks to others.

Choice D rationale: Nurses often have heavy workloads, and under-delegation may be a result of feeling there is not enough time to delegate effectively.

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The nurse must give a client an intramuscular injection of a medication which is very irritating to the subcutaneous tissues. To attempt to reduce irritation of the tissues, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse enters a client's room to find that his abdominal wound has eviscerated. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

The nurse is aware that a common cause of under delegation in client care is:

Correct Answer is C

Explanation

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