Nokea
All of the following interventions are correct when using the Z-track method of drug injection except:
- A. Prepare the injection site with alcohol
- B. Use a needle that is at least 1" long
- C. Aspirate for blood before injection
- D. Rub the site vigorously after the injection to promote absorption
Correct Answer: D
Rationale: When using the Z-track method of drug injection, it is important to prepare the injection site with alcohol to ensure cleanliness, use a needle that is at least 1" long to reach the muscle tissue, and aspirate for blood before injection to verify correct needle placement. However, rubbing the site vigorously after the injection is not recommended as it can cause medication to leak into subcutaneous tissue, compromising the medication's intended absorption and efficacy.
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A patient presents with an exacerbation of chronic obstructive pulmonary disease (COPD) characterized by shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough. An appropriate nursing diagnosis would be:
- A. Ineffective airway clearance related to thick, tenacious secretions.
- B. Ineffective airway clearance related to dry, hacking cough.
- C. Ineffective individual coping with COPD.
- D. Pain related to immobilization of affected leg.
Correct Answer: A
Rationale: The patient's symptoms of shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough all point towards a potential airway clearance issue. This makes option A, 'Ineffective airway clearance related to thick, tenacious secretions,' the most appropriate nursing diagnosis. It directly addresses the thick secretions and suggests a potential cause of the breathing difficulty the patient is experiencing.
If a patient asks the nurse for her opinion about a particular physician and the nurse replies that the physician is incompetent, the nurse could be held liable for:
- A. Slander
- B. Libel
- C. Assault
- D. Respondent superior
Correct Answer: A
Rationale: In this scenario, if the nurse makes a false verbal statement about the physician being incompetent, it is considered slander. Slander is the act of making defamatory spoken statements or gestures. Libel, on the other hand, refers to defamatory statements that are written or published. Assault involves the threat of physical harm, and respondent superior is a legal doctrine holding an employer responsible for the actions of an employee in the course of employment.
Which of the following interventions promotes patient safety?
- A. Assess the patient's ability to ambulate and transfer from a bed to a chair
- B. Demonstrate the signal system to the patient
- C. Check to see that the patient is wearing their identification band
- D. All of the above
Correct Answer: D
Rationale: All the listed interventions are essential for promoting patient safety. Assessing the patient's ability to ambulate and transfer helps prevent falls, demonstrating the signal system ensures effective communication in emergencies, and checking the patient's identification band aids in accurate identification and treatment. By combining these interventions, healthcare providers can enhance patient safety and quality of care.
How can preserving skin integrity impact the circular chain of infection?
- A. Host
- B. Reservoir
- C. Mode of transmission
- D. Portal of entry
Correct Answer: D
Rationale: Preserving skin integrity plays a key role in breaking the chain of infection by eliminating the portal of entry for pathogens. When the skin is intact, it acts as a natural barrier that prevents pathogens from entering the body. By maintaining skin integrity through proper hygiene and wound care, the risk of infection is significantly reduced, disrupting the cycle of infection transmission.
Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?
- A. 4,500/mm³
- B. 7,000/mm³
- C. 10,000/mm³
- D. 25,000/mm³
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.