A healthcare professional is teaching a new colleague about the correct administration of subcutaneous (subQ) injections. Which instruction should the healthcare professional include?
- A. Insert the needle at a 90-degree angle for subQ injections
- B. Aspirate for blood return before injecting the medication
- C. Pinch the skin before inserting the needle
- D. Massage the site after administering the injection
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway outside her room. What is the best action?
- A. Ask the family to wait in the cafeteria while the next of kin makes the necessary arrangements
- B. Provide space and privacy for the family to share their concerns about the client's discharge
- C. Ask the social worker to encourage the family to clear the hallway
- D. Explain to the family the client's need for privacy so that she can make independent decisions
Correct Answer: B
Rationale: In this situation, providing space and privacy for the family allows them to openly discuss their concerns regarding the client's discharge. It respects the family's need for support, communication, and involvement in the decision-making process, ultimately fostering a more effective and compassionate care environment.
When turning an immobile bedridden client without assistance, which action best ensures client safety?
- A. Securely grasp the client's arm and leg.
- B. Put bed rails up on the side of bed opposite from the nurse.
- C. Correctly position and use a turn sheet.
- D. Lower the head of the client's bed slowly.
Correct Answer: B
Rationale: The correct answer is to put bed rails up on the side of the bed opposite from the nurse. This action is essential to prevent the client from falling out of bed during the turning process. Since the nurse can only stand on one side of the bed, having the bed rails up on the opposite side provides an additional safety measure. Securing the client's arm and leg or lowering the head of the bed would not prevent the client from falling and may pose a risk of injury. Using a turn sheet correctly can be helpful, but ensuring the bed rails are up is a more direct safety measure in this situation.
A client is admitted with a diagnosis of right-sided heart failure. What assessment finding should the nurse anticipate?
- A. Jugular vein distention.
- B. Crackles in the lungs.
- C. Peripheral edema.
- D. Hepatomegaly.
Correct Answer: C
Rationale: In right-sided heart failure, the heart's inability to effectively pump blood to the lungs leads to fluid backup in the systemic circulation, resulting in peripheral edema (swelling in lower extremities). While jugular vein distention (A) and hepatomegaly (D) can also occur in right-sided heart failure, peripheral edema is a hallmark sign due to fluid retention. Crackles in the lungs (B) are more commonly associated with left-sided heart failure, where fluid accumulates in the lungs.
The healthcare provider is conducting an initial admission assessment for a woman who is Mexican-American and who is scheduled to deliver a baby by C-section in the next 24 hours. What should the healthcare provider include in the assessment?
- A. Provide an interpreter to convey the meaning of words and messages in translation
- B. Commend the client for her patience during a long wait in the admission process
- C. Arrange for the hospital chaplain to visit the client during her hospital stay
- D. Rely on cultural norms as the basis for providing healthcare for this client
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with malodorous green drainage. Which dressing is best for the nurse to use first?
- A. Hydrogel dressing.
- B. Exudate absorber.
- C. Wet-to-moist dressing.
- D. Transparent adhesive film.
Correct Answer: C
Rationale: The best initial dressing for a stage four pressure ulcer with necrotic tissue is a wet-to-moist dressing. This dressing helps to provide moisture, soften necrotic tissue, and prepare the wound bed for healing. It promotes autolytic debridement and can help manage malodorous drainage. Once the necrotic tissue is loosened, other advanced dressings like hydrogel or alginate may be used in the wound bed to facilitate healing.