The nurse is administering an iron medication to a client via the ...

[c0205847]

The nurse is administering an iron medication to a client via the Z-track method. Which of the following are recommended guidelines/steps for this procedure? Select all answers that apply
 
  A) Use the Z-track method only in the deltoid site.
  B) Pinch the skin of the injection site to raise the site.
  C) Insert the needle, aspirate, and inject the medication.
  D) Quickly remove the needle after injecting the medication.
  E) Do not massage the injection site.
  F) Allow the skin to return to its original position slowly, while removing the needle.

Question 2

A nurse is caring for an unconscious client who has undergone a tracheostomy. What measure should the nurse take while suctioning this client?
 
  A) Place the client in a semi- or high Fowler's position.
  B) Insert the suction catheter about an inch into the trachea.
  C) Avoid applying suction when inserting the suction catheter.
  D) Suction the tube continuously for at least 30 seconds.

[lauravaras]

Answer to Question 1

C, E, F
Feedback:
Use the Z-track method only in the gluteal muscles. To administer a medication by Z-track, pull the skin of the injection site to one side. Insert the needle, aspirate, and inject the medication. Keep the skin taut and pulled to one side; wait a few seconds before withdrawing the needle. Allow the skin to return to its original position slowly, while removing the needle. As the tissues slide past each other, they close the needle track. Do not massage the injection site when using the Z-track administration method.

Answer to Question 2

C
Feedback:
The nurse should avoid applying suction when inserting the catheter; doing so may damage mucosa in the trachea and promote hypoxia. The nurse should place the unconscious client on his or her side, facing the nurse, not in a semi- or high Fowler's position, to prevent airway obstruction. The catheter should be inserted 4 to 5 inches into the trachea, not only about an inch, for proper positioning. Suctioning should not continue for longer than 10-second intervals in order to prevent the development of hypoxia.

[c0205847]

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[adf223]

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