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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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A nurse is planning care for a client who is at risk for developing deep vein thrombosis (DVT). Which intervention should the nurse include in this client's plan of care?
- A. Maintain the client on bed rest
- B. Apply warm, moist compresses to the legs
- C. Encourage early ambulation
- D. Massage the legs daily
Correct Answer: C
Rationale: The correct intervention for a client at risk for developing deep vein thrombosis (DVT) is to encourage early ambulation. Early ambulation helps prevent DVT by promoting circulation, reducing stasis, and preventing blood clot formation. Maintaining the client on bed rest (Choice A) would increase the risk of DVT due to decreased mobility. Applying warm, moist compresses to the legs (Choice B) can be beneficial for other conditions but does not directly prevent DVT. Massaging the legs daily (Choice D) can dislodge a blood clot, leading to serious complications in a client at risk for DVT.
A client with a C-6 spinal injury changes to a breathing pattern of shallow respirations and dyspnea twelve hours after the causative incident. The nurse should notify the healthcare provider and implement which intervention?
- A. Place the client in reverse Trendelenburg position
- B. Prepare for intubation with an endotracheal tube
- C. Administer a pain medication to the client
- D. Instruct the client on deep breathing exercises
Correct Answer: B
Rationale: In a client with a C-6 spinal injury exhibiting shallow respirations and dyspnea, these signs could indicate respiratory compromise and potential respiratory failure. Intubation with an endotracheal tube may be necessary to secure the airway and support adequate oxygenation. Placing the client in reverse Trendelenburg position, administering pain medication, or instructing on deep breathing exercises would not directly address the urgency of the respiratory distress in this situation, making them incorrect choices.
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 chronic obstructive pulmonary disease (COPD) is receiving oxygen at 4 liters per minute via nasal cannula. The client becomes lethargic and confused. What action should the nurse take first?
- A. Decrease the oxygen flow rate
- B. Increase the oxygen flow rate
- C. Encourage the client to cough and deep breathe
- D. Monitor the client's oxygen saturation level
Correct Answer: A
Rationale: In this scenario, the priority action for the nurse is to decrease the oxygen flow rate. Clients with COPD are sensitive to high levels of oxygen and can develop oxygen toxicity, leading to symptoms like lethargy and confusion. Decreasing the oxygen flow rate helps prevent this complication. Increasing the oxygen flow rate would worsen the client's condition. Encouraging coughing and deep breathing may not address the immediate issue of oxygen toxicity. While monitoring the client's oxygen saturation level is important, taking action to address the oxygen toxicity by decreasing the flow rate is the priority in this situation.
Several clients on a telemetry unit are scheduled for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit?
- A. Learning to self-administer insulin injections after being diagnosed with diabetes mellitus
- B. Ambulatory following coronary artery bypass graft surgery performed six days ago
- C. Wearing a sling immobilizer following permanent pacemaker insertion earlier that day
- D. Experiencing syncopal episodes resulting from the dehydration caused by severe diarrhea
Correct Answer: A
Rationale: The correct answer is A because transferring a stable client who is learning self-care, such as self-administering insulin injections after being diagnosed with diabetes mellitus, provides the needed telemetry-monitored bed without compromising the client's care. Choice B should not be transferred as the client is ambulatory following surgery and does not require telemetry monitoring. Choice C should not be transferred as the client is wearing a sling immobilizer following pacemaker insertion, which requires close monitoring. Choice D should not be transferred as the client is experiencing syncopal episodes due to severe dehydration, necessitating telemetry monitoring for immediate intervention.