Examkin

Soru

Zorluk: OrtaPharmacological Therapies

A practical nurse is preparing to administer an intramuscular injection of iron dextran using the Z-track method to an adult client. In what order should the nurse perform the following actions? Arrange the steps from first to last.

  1. 1Verify the client using two identifiers and don clean gloves.
  2. 2Cleanse the selected ventrogluteal injection site with an antimicrobial swab.
  3. 3Displace the skin and subcutaneous tissue 1 to 1.5 inches laterally.
  4. 4Insert the needle at a 90-degree angle and steadily inject the medication.
  5. 5Withdraw the needle and immediately release the displaced skin.

Cevap

The correct sequence is: verify client identity and don gloves, cleanse the site, displace the tissue laterally, insert the needle and inject, and finally withdraw the needle and release the skin.
The Z-track method is specifically used for irritating or staining medications like iron dextran. The practical nurse must first ensure safety by verifying the client's identity and donning gloves. After the site is cleansed, the skin and subcutaneous tissue are pulled laterally to offset the tissue layers. The medication is then injected at a 90-degree angle. Finally, the needle must be completely removed before releasing the skin. This specific sequence breaks the needle track and traps the medication deep in the muscle, preventing irritation or discoloration of subcutaneous tissues.

Adım Adım Çözüm

1
Verify identity and don gloves.
The correct client is confirmed and standard precautions are applied.
Ensures the 'right client' is receiving the medication and protects the nurse from bloodborne pathogens.
2
Cleanse the ventrogluteal site.
The skin over the injection site is disinfected.
Prevents the introduction of surface microorganisms into the deep muscle tissue during needle insertion.
3
Displace the skin laterally.
The subcutaneous tissue is shifted over the muscle.
Creates a zigzag tissue path that will seal the needle track once released, defining the Z-track method.
4
Insert needle and inject.
Medication is delivered into the muscle layer.
The 90-degree angle ensures intramuscular, rather than subcutaneous, delivery of the medication.
5
Withdraw needle and release skin.
The displaced tissue returns to its original anatomical position.
Traps the irritating or staining medication (like iron dextran) in the muscle and prevents it from tracking up into the subcutaneous tissue.

Anahtar Kavram

Z-track intramuscular injection administration technique
Bu soruyu puanla

Konular

Pharmacological Therapies

Bu konudan daha fazla soru