Nokea
The nurse has attended a staff education program about administering intramuscular injections. Which of the following statements by the nurse would indicate a correct understanding of the program?
- A. I will insert the needle at a 45-degree angle.
- B. I will wait 3 seconds after injecting the medication before removing the needle.
- C. I will gently massage the injection site after removing the needle.
- D. I will use my hand to displace subcutaneous tissue prior to inserting the needle.
Correct Answer: D
Rationale: Displacing subcutaneous tissue (D) via the Z-track method prevents leakage and irritation. IM injections use a 90-degree angle (A is incorrect), waiting 3 seconds (B) is not standard, and massaging (C) is avoided for some medications.
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The clinic nurse is caring for a client who had cataract surgery with intraocular lens implantation 2 days ago. Which client report requires priority intervention?
- A. Blurry vision in the affected eye
- B. Constipation
- C. Itching in the affected eye
- D. Sleeping on 2 pillows at night
Correct Answer: C
Rationale: Itching in the affected eye (C) may indicate infection or complications post-cataract surgery, requiring immediate intervention. Blurry vision (A) is expected initially, constipation (B) is unrelated, and sleeping elevated (D) is appropriate.
A child and his family were exposed to Mycobacterium tuberculosis about 2 months ago, to confirm the presence or absence of an infection, it is most important for all family members to have a
- A. Chest x-ray
- B. Blood culture
- C. Sputum culture
- D. PPD intradermal test
Correct Answer: D
Rationale: PPD intradermal test. The administration of the PPD intradermal test determines the presence of the infection with the Mycobacterium tuberculosis organism. It is effective at 3 to 6 weeks after the initial infection.
The nurse is caring for a client with increased intracranial pressure (ICP). Which statement by the unlicensed assistive personnel would require immediate intervention by the nurse?
- A. I will raise the head of the bed so it is easier to see the television.
- B. I will turn down the lights when I leave.
- C. Let me move your belongings closer so you can reach them
- D. You should do deep breathing and coughing exercises.
Correct Answer: A
Rationale: Raising the head of the bed (A) without medical guidance can alter ICP dangerously. Dimming lights (B), moving belongings (C), and breathing exercises (D) are generally safe or neutral.
The nurse is providing care to a 9-year-old client who is awaiting surgery. Which intervention is developmentally appropriate for this client's plan of care?
- A. Discuss the procedure with the client using simple diagrams with correct anatomical terminology
- B. Explore the client's perception of how the surgery will positively affect their future
- C. Focus primarily on the client's feelings and concerns regarding surgical scar appearance
- D. Provide initial education about the procedure to the client immediately before it is performed
Correct Answer: A
Rationale: Using simple diagrams with correct terminology (A) is age-appropriate for a 9-year-old, aiding understanding. Future benefits (B) are abstract, scar concerns (C) are secondary, and last-minute education (D) increases anxiety.
The morning weight for a client with emphysema indicates that the client has gained 5 pounds in less than a week, even though his oral intake has been modest. The client's weight gain may reflect which associated complication of COPD?
- A. Polycythemia
- B. Cor pulmonale
- C. Left ventricular failure
- D. Compensated acidosis
Correct Answer: B
Rationale: Rapid weight gain in a client with emphysema, despite modest intake, suggests fluid retention, which is commonly associated with cor pulmonale, a complication of COPD involving right heart failure due to lung disease. Answer A (polycythemia) is a blood disorder, not directly linked to weight gain. Answer C (left ventricular failure) is less likely in COPD compared to cor pulmonale. Answer D (compensated acidosis) does not cause weight gain.