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A nurse is preparing to administer an influenza immunization IM to an infant. Which of the following actions should the nurse include in the plan of care?
- A. Use a ½-Inch needle.
- B. Use a 22-gauge needle.
- C. Use the flushing technique.
- D. Use the deltoid muscle for the injection site.
Correct Answer: A
Rationale: The correct answer is A: Use a ½-Inch needle. For infants, a ½-inch needle is recommended for intramuscular (IM) injections to ensure proper administration of the vaccine into the muscle. Using a shorter needle decreases the risk of reaching the bone or causing tissue damage.
B: Using a 22-gauge needle is not specific to infants and may not be the most appropriate size for their smaller muscles.
C: The flushing technique is not relevant to the administration of the vaccine.
D: The deltoid muscle is not typically used as the injection site for infants; the vastus lateralis muscle is more commonly used due to its larger muscle mass and ease of access.
In summary, using a ½-inch needle is the correct choice for an infant receiving an IM influenza immunization to ensure safe and effective administration.
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A nurse is caring for a client who has a new prescription for penicillin G. For which of the following adverse effects should the nurse plan to monitor?
- A. Insomnia
- B. Urticaria
- C. Constipation
- D. Nocturia
Correct Answer: B
Rationale: The correct answer is B: Urticaria. Penicillin G can cause allergic reactions like urticaria (hives) due to hypersensitivity. The nurse should monitor for skin rashes, itching, and swelling. Insomnia (A), constipation (C), and nocturia (D) are not commonly associated with penicillin G. Insomnia is more related to central nervous system stimulants, constipation is not a common side effect of penicillin, and nocturia is increased nighttime urination which is not typically caused by penicillin.
A nurse is collecting data from a client who takes furosemide daily for heart failure. Which of the following laboratory values should the nurse review before administering the medication?
- A. Erythrocyte sedimentation rate
- B. Thyroxine
- C. Serum potassium
- D. Serum aspartate aminotransferase
Correct Answer: C
Rationale: The correct answer is C: Serum potassium. Furosemide is a loop diuretic that can cause potassium depletion, leading to hypokalemia. Monitoring serum potassium levels is crucial to prevent complications such as cardiac arrhythmias. Erythrocyte sedimentation rate (A) is not relevant for assessing furosemide therapy. Thyroxine (B) is a thyroid hormone and not directly affected by furosemide. Serum aspartate aminotransferase (D) is a liver enzyme and not specifically impacted by furosemide administration.
A nurse is preparing to administer 1 L of IV fluid over 6 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 167 mL/hr
Rationale: To calculate mL/hr for IV fluid administration, divide the total volume (1 L = 1000 mL) by the total time in hours (6 hr). Therefore, 1000 mL / 6 hr = 166.67 mL/hr, rounded to 167 mL/hr. This rate ensures the patient receives the correct volume over the specified time. Other choices are incorrect because they do not follow the correct calculation method or may not deliver the required volume within the specified time frame.
A nurse is talking with a client who takes NSAIDs routinely to treat osteoarthritis and has a new prescription for misoprostol. The client asks the nurse why he needs the second medication. Which of the following is an appropriate response?
- A. Misoprostol will help prevent stomach ulcers, which can develop from taking NSAIDs for a long time.
- B. Misoprostol helps protect you against the effects long-term NSAID use can have on your kidney function.
- C. Misoprostol will boost the effectiveness of the NSAIDs, so you can get the same pain relief with lower dosages.
- D. Misoprostol is a very effective antacid that will help reduce the stomach irritation you can get from NSAIDs.
Correct Answer: A
Rationale: The correct answer is A because misoprostol is often prescribed along with NSAIDs to help prevent stomach ulcers that can develop from long-term NSAID use. NSAIDs can irritate the stomach lining and increase the risk of ulcers. Misoprostol works by reducing the production of stomach acid and protecting the stomach lining. Choices B, C, and D are incorrect because misoprostol is specifically used to protect the stomach from NSAID-related ulcers, not to protect kidney function, boost NSAID effectiveness, or act as an antacid.
Vital Signs Day 1: Temperature 37.2° C (99° F), Blood pressure 124/56 mm Hg, Heart rate 66/min, Respiratory rate 16/min, Oxygen saturation 95% on room air; Day 2: Temperature 37.2° C (99° F), Heart rate 112/min, Respiratory rate 28/min, Blood pressure 148/86 mm Hg, Oxygen saturation 90% on room air; Medication Administration Record: Albuterol 2 inhalations every 4 to 6 hr PRN wheezing, Bisacodyl 10 mg suppository daily PRN constipation, Prochlorperazine 10 mg PO 3 to 4 times per day PRN nausea, Morphine 4 mg IV bolus every 4 hr PRN severe pain, Acetaminophen 325 to 650 mg every 4 to 6 hr PRN pain or temperature greater than 38.4° C (101.1° F); Nurses' Notes Day 1: Bilateral breath sounds are clear and present throughout. Client reports pain as 2 on a scale of 0 to 10. Abdomen soft, nondistended, bowel sounds hypoactive. Client has a history of asthma. Day 2: Respirations rapid and shallow. Bilateral breath sounds with scattered wheezing. Client reports pain as 8 on a scale of 0 to 10. Client reports no nausea or constipation. Abdomen soft, nondistended, bowel sounds audible.
The nurse should contribute to the plan of care by administering _______ and ______ to the client.
- A. Prochlorperazine
- B. Albuterol
- C. Morphine
- D. Bisacodyl
- E. Acetaminophen
Correct Answer: B, C
Rationale: The correct answer is B and C. Albuterol is a bronchodilator used to treat respiratory conditions like asthma, while morphine is an opioid analgesic for pain management. The nurse should administer these medications as part of the client's plan of care to address their specific health needs. Prochlorperazine (A) is an antiemetic for nausea and vomiting, not typically within a nurse's scope. Bisacodyl (D) is a laxative, Acetaminophen (E) is a pain reliever, and the remaining choices are not provided.