Nokea
A healthcare professional is teaching a new colleague about the correct administration of subcutaneous (subQ) injections. Which instruction should the healthcare professional include?
- A. Insert the needle at a 90-degree angle for subQ injections
- B. Aspirate for blood return before injecting the medication
- C. Pinch the skin before inserting the needle
- D. Massage the site after administering the injection
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A client with a suspected kidney infection is admitted to the hospital for observation. Which action should the nurse implement to assess the client's kidney function?
- A. Monitor the client's urine output
- B. Check for abdominal tenderness
- C. Evaluate the client's fluid intake
- D. Inspect the client's skin for edema
Correct Answer: A
Rationale: Monitoring urine output is the most direct way to assess kidney function as it provides crucial information about the kidneys' ability to filter waste and produce urine. Changes in urine output can indicate potential issues with kidney function, such as decreased filtration or impaired excretion of waste products.
While changing a client's post-operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given a positive MRSA result, what is the most important action for the nurse to take?
- A. Force oral fluids
- B. Request a nutrition consult
- C. Initiate contact precautions
- D. Limit visitors to immediate family only
Correct Answer: C
Rationale: Initiating contact precautions is crucial in this situation to prevent the spread of MRSA infection. MRSA is a highly contagious bacterium that can spread through direct contact with an infected wound or by touching contaminated surfaces. By implementing contact precautions, the nurse can help contain the infection and protect other patients, healthcare workers, and visitors from being exposed to MRSA.
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?
- A. Position the client on the right side of the bed in reverse Trendelenburg.
- B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
- C. Reposition the client in the Sims' position.
- D. Raise the side rails on both sides of the bed and elevate the bed to waist level.
Correct Answer: C
Rationale: The correct position for administering a soap suds enema is the Sims' position, not the left lateral position. The Sims' position allows the enema solution to follow the anatomical course of the intestines and provides the best overall results. By repositioning the client in the Sims' position, the weight is distributed to the anterior ilium, facilitating the enema administration process.
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement?
- A. Tell the UAP to use a larger cuff at the next scheduled assessment.
- B. Reassess the client's blood pressure using a larger cuff.
- C. Have the unit educator review this procedure with the UAPs.
- D. Teach the UAP the correct technique for assessing blood pressure.
Correct Answer: B
Rationale: The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the blood pressure with the correct size cuff (B) to obtain an accurate reading. Postponing reassessment (A) could lead to inaccurate results. While (C and D) are important actions for education and quality improvement, they are not as critical as obtaining an accurate blood pressure reading in this situation.
The healthcare provider is conducting an initial admission assessment for a woman who is Mexican-American and who is scheduled to deliver a baby by C-section in the next 24 hours. What should the healthcare provider include in the assessment?
- A. Provide an interpreter to convey the meaning of words and messages in translation
- B. Commend the client for her patience during a long wait in the admission process
- C. Arrange for the hospital chaplain to visit the client during her hospital stay
- D. Rely on cultural norms as the basis for providing healthcare for this client
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.