Nokea
A healthcare professional is preparing to administer enoxaparin to a client. Which of the following actions should the healthcare professional take?
- A. Administer the medication intramuscularly.
- B. Inject the medication into the lateral abdominal wall.
- C. Massage the injection site after administration.
- D. Discard the prefilled syringe after expelling the air bubble.
Correct Answer: B
Rationale: The correct answer is to inject the medication into the lateral abdominal wall when administering enoxaparin. This is the recommended technique to ensure proper absorption and prevent tissue damage. Choice A is incorrect because enoxaparin should be administered subcutaneously, not intramuscularly. Choice C is incorrect as massaging the injection site after administration is not recommended, as it can cause bruising and discomfort. Choice D is incorrect because the prefilled syringe should not be discarded after expelling the air bubble; it should be used for the injection.
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What is the appropriate action for a healthcare provider to take when a patient has a high fever and is disoriented?
- A. Administer acetaminophen
- B. Administer antibiotics
- C. Administer fluids
- D. Cool the patient with cold compresses
Correct Answer: C
Rationale: Administering fluids is the appropriate action for a healthcare provider to take when a patient has a high fever and is disoriented. Dehydration can worsen confusion and other symptoms in such a situation. Administering acetaminophen or cooling the patient with cold compresses may help reduce the fever but does not address the underlying issue. Administering antibiotics is not indicated for a high fever and disorientation without knowing the cause.
If a nurse administers an incorrect dose of medication, which fact related to the incident report should the nurse document in the client's medical record?
- A. Time the medication was given
- B. The client's response to the medication
- C. The dose that was administered
- D. Reason for the error
Correct Answer: A
Rationale: The correct answer is to document the time the medication was given. This is essential for understanding the sequence of events surrounding the medication error. While documenting the client's response to the medication (Choice B) is important for assessing any effects, the immediate concern should be to establish a clear timeline by documenting the time of administration. Recording the dose administered (Choice C) is also important, but in the context of understanding the incident, the time factor takes precedence. The reason for the error (Choice D) should be included in the incident report but may not be the first priority when documenting in the client's medical record.
A nurse in a mental health facility receives a change of shift report on four clients. Which of the following clients should the nurse plan to assess first?
- A. Client placed in restraints due to aggressive behavior
- B. A new client with a history of 4.5 kg weight loss in the past two months
- C. Client receiving PRN dose of haloperidol 2 hours ago for anxiety
- D. Client receiving first ECT treatment today
Correct Answer: A
Rationale: The nurse should plan to assess the client placed in restraints due to aggressive behavior first. Clients in restraints require immediate attention and frequent monitoring for safety. While weight loss, medication administration, and ECT treatment are important, the client in restraints is in a critical situation that requires immediate assessment and intervention.
What is the best position for a patient in respiratory distress?
- A. Semi-Fowler's position
- B. Trendelenburg position
- C. Prone position
- D. Supine position
Correct Answer: A
Rationale: The best position for a patient in respiratory distress is the Semi-Fowler's position. This position promotes lung expansion and eases breathing by allowing the chest to expand more fully. The Trendelenburg position (choice B) where the patient's feet are higher than the head is not recommended in respiratory distress as it may cause increased pressure on the chest and reduced lung expansion. The prone position (choice C) lying on the stomach is also not optimal for respiratory distress as it can further compromise breathing. The supine position (choice D) lying flat on the back is not ideal as it may impair breathing by restricting chest expansion.
A nurse is providing teaching to a client who has osteoporosis about preventing fractures. Which of the following instructions should the nurse include?
- A. Increase your intake of calcium-rich foods.
- B. Avoid weight-bearing exercises.
- C. Perform weight-bearing exercises regularly.
- D. Avoid taking calcium supplements.
Correct Answer: C
Rationale: The correct instruction the nurse should include is to perform weight-bearing exercises regularly. Weight-bearing exercises help maintain bone density and reduce the risk of fractures in clients with osteoporosis. Increasing intake of calcium-rich foods (Choice A) is also beneficial for bone health. Avoiding weight-bearing exercises (Choice B) is incorrect as these exercises are essential for strengthening bones. Avoiding calcium supplements (Choice D) may not be necessary if the client's dietary intake is inadequate.