a nurse is preparing to administer ceftriaxone im to a client which of the following actions should the nurse take
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN

1. A healthcare professional is preparing to administer ceftriaxone IM to a client. Which of the following actions should the healthcare professional take?

Correct answer: D

Rationale: Correct Answer: When administering intramuscular injections like ceftriaxone, it is essential to aspirate for blood return before injecting the medication to ensure that the needle is not in a blood vessel. Choices A and B are incorrect because ceftriaxone is typically administered using a syringe appropriate for IM injections (not a tuberculin syringe) and injected at a 90-degree angle rather than 45 degrees. Choice C is incorrect because the dorsogluteal site is no longer recommended for IM injections due to potential injury to the sciatic nerve and other structures.

2. A nurse is teaching a group of newly licensed nurses about measures to take when caring for a client who is on contact precautions. Which of the following should the nurse include in the teaching?

Correct answer: C

Rationale: The correct measure to include when caring for a client on contact precautions is to wear gloves when providing care. Gloves help prevent the spread of infection and cross-contamination. Choice A is incorrect because the protective gown should be removed before leaving the client's room to prevent the spread of pathogens. Choice B is incorrect as clients on contact precautions should be in a room with negative pressure to prevent the spread of airborne contaminants. Choice D is incorrect as wearing a mask when changing linens is not specifically required for contact precautions.

3. A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse take?

Correct answer: B

Rationale: Before inserting an indwelling urinary catheter for a female client, the nurse should apply sterile gloves before cleansing the perineal area to prevent infection. Performing perineal care before the procedure is incorrect as it should be done after catheter insertion. Placing the client in a side-lying position is not necessary for this procedure. Lubricating the catheter with petroleum jelly is not recommended as it can damage the catheter; using a water-soluble lubricant is preferred.

4. What is the best method to assess pain in a non-verbal patient?

Correct answer: A

Rationale: The correct answer is to observe for facial expressions when assessing pain in a non-verbal patient. Facial expressions can provide vital clues about the patient's pain level and discomfort. Choices B and C, observing for restlessness and sweating, can be less specific and may indicate other issues besides pain. Choice D, checking for non-verbal cues, is too broad and does not specify the crucial aspect of focusing on facial expressions.

5. A client is experiencing an acute exacerbation of Crohn's disease. Which of the following actions should the nurse take?

Correct answer: B

Rationale: During an acute exacerbation of Crohn's disease, the nurse should maintain the client on a low-residue diet. This diet helps to minimize bowel irritation by reducing the volume and frequency of stools. Choices A, C, and D are incorrect. Encouraging the client to increase dietary fiber (Choice A) and eat a high-fiber diet (Choice D) can worsen symptoms and aggravate bowel inflammation in Crohn's disease. Providing the client with frequent high-calorie snacks (Choice C) may not be appropriate during an exacerbation since high-fat foods can be harder to digest and may exacerbate symptoms.

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