Nokea
A 34-year-old client is receiving an IM injection of ceftriaxone (Rocephin) for a urinary tract infection. Which is correct regarding IM injections?
- A. A 1-inch-long 25-gauge needle should be used.
- B. The injection should be given at a 45-degree angle.
- C. The injection should be given at a 90-degree angle.
- D. A bleb should form on the skin's surface following injection.
Correct Answer: C
Rationale: IM injections are given at a 90-degree angle to ensure muscle penetration. A 25-gauge needle is too small, a 45-degree angle is for subcutaneous injections, and a bleb indicates intradermal injection.
You may also like to solve these questions
Which instruction should be given to the client who is fitted for a behind-the-ear hearing aid?
- A. Remove the mold and clean every week.
- B. Store the hearing aid in a warm place.
- C. Clean the lint from the hearing aid with a toothpick.
- D. Change the batteries weekly.
Correct Answer: A
Rationale: Regular cleaning of the hearing aid mold prevents wax buildup and ensures proper function.
The nurse is conducting a physical examination of a client's abdomen. Place the examination techniques listed below (Roman numerals) in the correct sequence, from first to last.
- A. Percussion
- B. Palpation
- C. Inspection
- D. Auscultation
Correct Answer: C,D,A,B
Rationale: Abdominal exam sequence: Inspection (III) first, then auscultation (IV) before percussion (I) and palpation (II) to avoid altering bowel sounds.
A client on a 72-hour psychiatric hold experiences a panic attack while getting ready for the day. The nurse should provide the following interventions ranked by priority:
- A. stay with the client until the panic attack is over
- B. incorporate physical activity into the client's daily routine
- C. instruct the client to take slow, deep breaths
- D. reduce external stimuli in the immediate area
- E. work with the client to develop coping mechanisms
Correct Answer: A,D,C,E,B
Rationale: Priority order: Stay with the client (A) for safety, reduce stimuli (D) to calm the environment, instruct deep breathing (C) to manage symptoms, develop coping mechanisms (E) for future prevention, and incorporate physical activity (B) as a long-term strategy.
The nurse on the 3-11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?
- A. Call the surgeon and ask him or her to see the client to clarify the information
- B. Explain the procedure and complications to the client
- C. Check in the physician's progress notes to see if understanding has been documented
- D. Check with the client's family to see if they understand the procedure fully
Correct Answer: A
Rationale: The surgeon is responsible for ensuring informed consent, so contacting them to clarify the procedure and complications with the client is the most appropriate action.
Which would be included in the nursing care plan of a client experiencing severe delirium tremens?
- A. Placing the client in a darkened room
- B. Keeping the closet and bathroom doors closed
- C. Administering a diuretic to decrease fluid excess
- D. Checking vital signs every 8 hours
Correct Answer: B
Rationale: Keeping closet and bathroom doors closed minimizes visual stimuli that could exacerbate hallucinations or confusion in delirium tremens, promoting a safe environment.