Nokea
A nurse is precepting a nursing student in the pediatrics unit. The student nurse is preparing to administer an injection to a 14-month-old infant. Which statement by the student nurse indicates a need for further teaching by the licensed nurse?
- A. I will use a needle that is 7/8 inch to 1 inch long.
- B. I will give this injection at a 90-degree angle of insertion.
- C. I will give this injection in the vastus lateralis with a 27 gauge needle.
- D. I can give this injection with a 25-gauge needle in the dorsogluteal area.
Correct Answer: D
Rationale: The dorsogluteal site is not recommended for infants due to sciatic nerve risk; the vastus lateralis is preferred.
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The RN is assigning a client to the LPN. The RN understands that the best assignment for the LPN is which client?
- A. a client receiving blood for a GI bleed
- B. a client with a PICC line requiring TPN
- C. a client who will receive enemas in preparation for a colonoscopy
- D. a client who needs preoperative teaching for bowel resection surgery
Correct Answer: C
Rationale: Administering enemas is within the LPN's scope and less complex than transfusion, TPN, or teaching.
The role of the nurse as patient advocate is accurately identified in which of these statements?
- A. Nurses evaluate only the negative outcomes of patient advocacy.
- B. Nurses provide only physical and emotional support.
- C. Advocacy practices are limited to within health care settings.
- D. Nurses work with patients, their families, other health care team members and third-party persons.
Correct Answer: D
Rationale: Nurse advocacy involves collaboration with patients, families, and others to promote client rights and well-being.
A nurse is caring for a client in the immediate post-cardiac catheterization period. Which intervention should the nurse include in the client's care?
- A. monitor vital signs every 30 minutes for the first 2 hours
- B. assess the insertion site
- C. maintain the client in a prone position
- D. keep the client NPO for 2 hours
Correct Answer: A,B
Rationale: Monitoring vital signs and assessing the insertion site are critical to detect complications like bleeding. Prone positioning is incorrect, and NPO status is not typically required post-catheterization.