Nokea
A new graduate nurse is administering enoxaparin to a client. Which action indicates the need for further orientation by the nurse preceptor?
- A. Discourages the client from rubbing the injection site
- B. Ejects air bubble that is in the syringe prior to administration
- C. Inserts needle and injects medication at a 90-degree angle
- D. Selects an injection site on the left lateral side of the abdomen
Correct Answer: B
Rationale: Ejecting the air bubble in an enoxaparin syringe is incorrect, as the bubble ensures complete dose delivery and prevents leakage. Other actions (A, C, D) are correct for subcutaneous administration.
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The nurse is caring for a newborn. Which of the following signs would indicate neonatal abstinence syndrome? Select all that apply.
- A. Irritability and restlessness
- B. Meconium ileus and floppy muscle tone
- C. Microcephaly and cleft palate
- D. Nasal congestion and frequent sneezing
- E. Poor feeding and loose stools
Correct Answer: A,D,E
Rationale: Neonatal abstinence syndrome includes irritability , nasal congestion and sneezing , and poor feeding with loose stools due to withdrawal. Meconium ileus and hypotonia suggest cystic fibrosis, and microcephaly and cleft palate are congenital anomalies.
The charge nurse on a cardiac unit tells you a patient is exhibiting signs of right-sided heart failure. Which of the following would not indicate right-sided heart failure?
- A. Nausea
- B. Anorexia
- C. Rapid weight gain
- D. SOB (shortness of breath)
Correct Answer: D
Rationale: Left sided heart failure exhibits signs of pulmonary compromise (SOB).
A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? Select all that apply.
- A. Perform fundal massage
- B. Document the exact time of events
- C. Flex the client's legs back against the abdomen
- D. Request immediate assistance from other nurses
- E. Apply downward pressure above the client's symphysis pubis
Correct Answer: B,C,D,E
Rationale: For shoulder dystocia: document timing for accuracy, flex legs for McRoberts maneuver, request help for additional support, and apply suprapubic pressure to dislodge the shoulder. Fundal massage is for postpartum hemorrhage.
The client is receiving a gentamicin IV. Which finding may indicate an adverse response to gentamicin?
- A. Decreased urine output
- B. Blurred vision
- C. Orange sputum
- D. Hypertension
Correct Answer: A
Rationale: Gentamicin is nephrotoxic; decreased urine output suggests kidney injury, a serious adverse effect. Other symptoms are not typically associated.
The nurse is caring for a client who had surgery yesterday. When administering omeprazole, the client asks 'What is that for? I don't take it at home.' Which reply by the nurse is most appropriate?
- A. Omeprazole helps prevent nausea by making your stomach empty faster.'
- B. Omeprazole helps prevent you from developing an ulcer due to the stress of surgery.'
- C. Omeprazole protects you from getting an infection while on antibiotics.'
- D. This medication will treat your gastroesophageal reflux disease (GERD).'
Correct Answer: B
Rationale: Omeprazole is a proton pump inhibitor used postoperatively to prevent stress ulcers due to surgical stress. It does not affect gastric emptying , prevent infections , or assume GERD without a diagnosis.