Nokea
The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to
- A. enhance absorption of the medication
- B. ensure that the entire dose of medication is given
- C. provide more even distribution of the drug
- D. prevent the drug from causing tissue irritation
Correct Answer: D
Rationale: prevent the drug from causing tissue irritation. Deep injection or Z-track is a special method of giving medications via the intramuscular route. Use of this technique prevents irritating or staining medications from being tracked through tissue. Use of Z-track does not affect dose, absorption, or distribution of the drug.
You may also like to solve these questions
The NA is preparing to provide care for four clients. The nurse should direct the NA to utilize contact precautions for which client?
- A. Client with influenza
- B. Client with mumps
- C. Client with gonorrhea
- D. Client with a draining abscess
Correct Answer: D
Rationale: D: A draining abscess requires contact precautions due to potential infectious drainage. A, B: These require droplet precautions. C: Gonorrhea needs standard precautions.
The charge nurse is planning a room assignment for the client with meningococcal meningitis. Which room and precautions should the nurse plan for this client?
- A. A private room with droplet precautions
- B. A private room with airborne precautions
- C. A semiprivate room with a roommate who has a similar diagnosis and standard precautions
- D. A semiprivate room with a roommate who has a similar diagnosis and contact precautions
Correct Answer: B
Rationale: B: Meningococcal meningitis requires airborne precautions and a private room due to possible airborne transmission. A, C, D: These are insufficient or inappropriate.
When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula
- A. every four to six hours
- B. continuously
- C. in a bolus
- D. every hour
Correct Answer: B
Rationale: continuously. Usually gastrostomy and jejunostomy feedings are given continuously to ensure proper absorption. However, initial feedings may be given by bolus to assess the client's tolerance to formula.
The nurse is supervising the NA caring for a group of clients with antibiotic-resistant organisms. Which observation of the NA's performance should prompt the supervising nurse to intervene?
- A. Uses an alcohol-based hand hygiene after emptying the urinary drainage bag of the client with vancomycin-resistant enterococci (VRE)
- B. Performs hand hygiene, then dons gloves to perform oral care for the client with B-lactamase-producing Klebsiella pneumoniae
- C. Uses an alcohol-based hand rub and wears gloves before and after taking the temperature of the client with penicillin G-resistant Streptococcus pneumoniae
- D. Tells visitors to use the alcohol-based hand wash when entering and leaving the room of the client with methicillin-resistant Staphylococcus aureus (MRSA)
Correct Answer: A
Rationale: A: Soap and water are required for VRE due to spore resistance to alcohol. B, C, D: These actions are appropriate for the respective organisms.
A client with pneumococcal pneumonia was started on antibiotics 16 hours ago. During the nurse's initial evening rounds the nurse notices a foul taste and smell to the client's sputum. Which one would alert the nurse to a complication?
- A. I have a sharp pain in my chest when I take a breath.'
- B. I have been coughing up foul-tasting, brown, thick sputum.'
- C. I have been sweating all day.'
- D. I feel hot off and on.'
Correct Answer: B
Rationale: Foul smelling and tasting sputum signals a risk of a lung abscess. This puts the client in grave danger since abscesses are often caused by anaerobic organisms. This client most likely would need a change of antibiotics. Sharp chest pain on inspiration called pleuritic pain is an expected finding with this type of pneumonia. The other options are expected in the initial 24 to 48 hours of therapy for infections.