A healthcare professional is planning to administer an intramuscular injection to a client. What muscle should the healthcare professional choose to avoid injury?
- A. Deltoid
- B. Ventrogluteal
- C. Rectus femoris
- D. Dorsogluteal
Correct Answer: B
Rationale: The ventrogluteal muscle is the preferred site for intramuscular injections to avoid injury. Choosing the ventrogluteal site reduces the risk of injury to major nerves and blood vessels, unlike the deltoid, rectus femoris, or dorsogluteal sites. The deltoid muscle is commonly used for vaccines but has a higher risk of injury due to its proximity to the radial nerve. The rectus femoris muscle is not recommended for intramuscular injections due to its location and the risk of injury. The dorsogluteal site is also not recommended as it poses a risk of injury to the sciatic nerve and superior gluteal artery.
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A nurse is reviewing a client's health history and identifies urinary incontinence as a risk factor for pressure injuries. What should the nurse include in the plan of care?
- A. Use a heating pad for comfort
- B. Apply a barrier cream to the skin
- C. Reposition the client every 4 hours
- D. Change the client's position every 2 hours
Correct Answer: C
Rationale: The correct answer is to reposition the client every 4 hours. Repositioning the client helps prevent pressure injuries caused by urinary incontinence by relieving pressure on vulnerable areas of the skin. Choice A, using a heating pad for comfort, is not directly related to preventing pressure injuries. Choice B, applying a barrier cream to the skin, may help protect the skin but does not address the underlying cause of pressure injuries. Choice D, changing the client's position every 2 hours, is more frequent than necessary and may not be as effective in preventing pressure injuries as repositioning every 4 hours.
A healthcare professional is teaching a group of assistive personnel about the expected integumentary changes in older adults. Which change should the healthcare professional include?
- A. Increase in skin turgor
- B. Increase in subcutaneous fat
- C. Decrease in moisture levels
- D. Increase in oil production
Correct Answer: C
Rationale: The correct answer is C: Decrease in moisture levels. In older adults, there is a reduction in oil production, leading to decreased moisture levels in the skin. This change can result in dry skin and increased risk of skin issues. The other choices are incorrect because in older adults, skin turgor tends to decrease, subcutaneous fat may decrease, and oil production typically decreases rather than increases.
A nurse in an emergency department is monitoring the hydration status of a client receiving oral rehydration. What finding should the nurse intervene for?
- A. Heart rate of 80 beats per minute
- B. Heart rate of 120 beats per minute
- C. Blood pressure of 110/70 mmHg
- D. Respiratory rate of 16 breaths per minute
Correct Answer: B
Rationale: A heart rate of 120 beats per minute indicates tachycardia, which can be a sign of dehydration and requires intervention. A heart rate of 80 beats per minute is within the normal range and does not indicate dehydration. A blood pressure of 110/70 mmHg is considered normal. A respiratory rate of 16 breaths per minute is also within the normal range and does not point towards dehydration.
When teaching about safety risks for adolescents, what should the nurse emphasize?
- A. Adolescents have a decreased risk of injury
- B. Peer pressure can lead to risky behaviors
- C. Increased responsibility reduces risks
- D. Adolescents are less likely to engage in substance abuse
Correct Answer: B
Rationale: The correct answer is B: 'Peer pressure can lead to risky behaviors.' Adolescents are at an increased risk for injury due to peer pressure and the tendency to engage in high-risk behaviors. Emphasizing the impact of peer pressure on decision-making can help adolescents make safer choices. Choices A, C, and D are incorrect because adolescents actually have an increased risk of injury, increased responsibility does not always reduce risks, and many adolescents are at risk of engaging in substance abuse.
A nurse is teaching a client with diabetes mellitus about foot care. What is the most important instruction the nurse should include?
- A. Apply lotion between the toes after bathing
- B. Inspect feet daily for injuries
- C. Wear shoes only indoors
- D. Cut toenails in a rounded shape
Correct Answer: B
Rationale: Inspecting feet daily for injuries is crucial for clients with diabetes to prevent unnoticed wounds from becoming infected. This instruction is the most important as it helps in early detection and management of foot problems. Choice A is incorrect because applying lotion between the toes can lead to excessive moisture, increasing the risk of fungal infections. Choice C is wrong as wearing shoes indoors can also lead to foot issues. Choice D is incorrect because cutting toenails in a rounded shape can result in ingrown toenails, posing a risk for infection.