Which action should a nurse perform when administering an intramuscular injection via the Z- track method?
Limit the total volume of the injection to 1 milliliter.
Leave the needle in place for at least 10 seconds before removing it to trap the medication in the muscle.
Use a 1 inch, 23 gauge needle to prevent tissue trauma.
Administer the medication rapidly to disperse it into the muscle.
The Correct Answer is B
Leave the needle in place for at least 10 seconds before removing it to trap the medication in the muscle.
The Z-track method is a technique used to administer intramuscular injections that prevent leakage of medication into the subcutaneous tissue. The nurse should pull the skin laterally before inserting the needle, inject the medication slowly, leave the needle in place for at least 10 seconds, and release the skin after withdrawing the needle.
Choice A is wrong because the total volume of the injection is not limited to 1 milliliter in the Z-track method. The Z-track method can be used to administer up to 3 milliliters of medication depending on the site and muscle mass of the client.
Choice C is wrong because the needle size and gauge depend on the site, medication, and client characteristics, not on the Z-track method. The Z-track method can be performed with different needle sizes and gauges as long as they are appropriate for intramuscular injections.
Choice D is wrong because the nurse should not administer the medication rapidly in the Z- track method.
Rapid injection can cause pain, tissue damage, and leakage of medication into the subcutaneous tissue. The nurse should inject the medication slowly and steadily in the Z-track method.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should first assess the client’s bladder for distention by palpating the lower abdomen between the symphysis pubis and the umbilicus.
This can indicate urinary retention, which is a common postoperative complication. The nurse should also measure the bladder volume using a bladder scanner if available.
Choice B. Inform the surgeon that the client’s status is wrong because the nurse should first assess the client before notifying the surgeon.
The surgeon may order interventions based on the assessment findings.
Choice C. Increasing the client’s fluid intake is wrong because increasing fluid intake may worsen bladder distention and discomfort.
The nurse should encourage fluid intake only after ensuring adequate urinary output.
Choice D. Administering pain medication is wrong because pain medication may not be indicated for urinary retention.
Pain medication may also cause urinary retention by relaxing the bladder muscles and impairing the micturition reflex.
Normal urine output is about 30 mL per hour or 240 mL in eight hours.
The nurse should monitor the client’s intake and output and report any signs of urinary retention to the surgeon.
Urinary retention can lead to infection, bladder damage, and renal impairment if not treated promptly.
Correct Answer is D
Explanation
Insulin injection sites are rotated to prevent lipodystrophy, which is a condition where the fat tissue under the skin becomes lumpy or dented due to repeated injections.
Lipodystrophy can affect the absorption and effectiveness of insulin.
Choice A is wrong because bruising is not a common complication of insulin
injections. Bruising can occur if the needle hits a blood vessel, but this can be avoided by using a new needle each time and applying gentle pressure after the injection.
Choice B is wrong because infection is not a common complication of insulin
injections. Infection can occur if the skin is not cleaned properly before the injection or if the needle is contaminated, but this can be prevented by washing the hands and using alcohol swabs.
Choice C is wrong because bleeding is not a common complication of insulin
injections. Bleeding can occur if the needle hits a blood vessel, but this can be minimized by using a new needle each time and applying gentle pressure after the injection.
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