Nokea
A nurse is preparing to administer an intramuscular injection to a client. Which action should the nurse take to reduce the client's risk of injury?
- A. Use a 1-inch needle
- B. Select a large muscle for the injection
- C. Aspirate for blood return before injecting
- D. Massage the injection site
Correct Answer: C
Rationale: The correct answer is to aspirate for blood return before injecting. This action helps ensure that the needle is not in a blood vessel, reducing the risk of injury. Using a 1-inch needle (Choice A) is a standard length for intramuscular injections but does not directly reduce the risk of injury. Selecting a large muscle for the injection (Choice B) is important for proper medication absorption but does not directly reduce the risk of injury. Massaging the injection site (Choice D) can help with medication absorption but does not reduce the risk of injury.
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Which nursing diagnosis has the highest priority when planning care for a client in cardiogenic shock?
- A. Risk for imbalanced body temperature
- B. Excess fluid volume
- C. Fatigue
- D. Ineffective Tissue Perfusion
Correct Answer: D
Rationale: In cardiogenic shock, the priority nursing diagnosis is Ineffective Tissue Perfusion. This diagnosis indicates that the client is not receiving adequate oxygenated blood to tissues, putting vital organs at risk. Addressing ineffective tissue perfusion is crucial to prevent organ damage and ensure the client's survival. The other options, such as 'Risk for imbalanced body temperature,' 'Excess fluid volume,' and 'Fatigue,' are important but secondary to the immediate threat of inadequate tissue perfusion in cardiogenic shock.
Is it necessary to continue to strain the urine of a client with kidney stones since several stones were obtained the previous day?
- A. UAPs should follow the prescribed care without questioning it
- B. Yes, it is important to continue straining all the client's urine
- C. Measuring intake and output is equally important as straining the urine
- D. Ensuring that the client is free from pain should be the top priority
Correct Answer: B
Rationale: Yes, it is important to continue straining all urine to catch any remaining stones. Straining the urine helps in identifying any new stones that may have formed, allowing for appropriate management. While measuring intake and output is important, straining the urine is specifically necessary in this case to monitor the presence of kidney stones. Ensuring the client is free from pain is essential, but in this situation, preventing further complications related to kidney stones is a higher priority.
The nurse is assessing on the first postoperative day following thyroid surgery. Which laboratory value is most important for the nurse to monitor?
- A. Calcium
- B. Sodium
- C. Chloride
- D. Potassium
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with cirrhosis is taking lactulose (Cephulac). Which finding indicates that the lactulose is having the desired effect?
- A. Two to three soft bowel movements per day
- B. Increased serum ammonia levels
- C. Decreased white blood cell count
- D. Soft, formed stool twice a day
Correct Answer: A
Rationale: The correct answer is A: 'Two to three soft bowel movements per day.' Lactulose is prescribed to produce soft, regular bowel movements to reduce ammonia levels in clients with cirrhosis. This helps in preventing hepatic encephalopathy. Option B is incorrect because increased serum ammonia levels would indicate that lactulose is not effectively reducing ammonia levels. Option C is incorrect because lactulose does not directly affect white blood cell counts. Option D is incorrect because soft, formed stools twice a day may not be frequent enough to effectively reduce ammonia levels in clients with cirrhosis.
The nurse observes a client in a wheelchair with a vest restraint in place. What nursing intervention is most important for the nurse to implement?
- A. Assess the need for continued restraint
- B. Check the client for urinary incontinence
- C. Determine skin integrity under the vest
- D. Perform range-of-motion exercises on extremities
Correct Answer: A
Rationale: The correct answer is to assess the need for continued restraint. This is the most important nursing intervention as it ensures the client's safety and autonomy. Checking for urinary incontinence (Choice B) may be important but is not the priority in this situation. Determining skin integrity under the vest (Choice C) is essential but not as crucial as assessing the need for continued restraint. Performing range-of-motion exercises (Choice D) is important for client mobility but not the priority when a restraint is in place.