Nokea
A nurse is preparing to administer an intramuscular injection to an adult client. At what angle should the nurse administer the medication using the ventrogluteal site?
- A. a 45-degree angle
- B. a 60-degree angle
- C. a 75-degree angle
- D. a 90-degree angle
Correct Answer: D
Rationale: Intramuscular injections in the ventrogluteal site should be administered at a 90-degree angle. This angle ensures that the medication reaches the muscle tissue effectively. Angles less than 90 degrees can cause subcutaneous injection instead of intramuscular, leading to slower absorption of the medication. Angles greater than 90 degrees risk hitting bone or nerves, causing unnecessary pain or injury. Therefore, the correct angle for administering intramuscular injections in the ventrogluteal site is 90 degrees.
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A nurse is caring for a client receiving patient-controlled analgesia (PCA). Which of the following interventions should the nurse take while caring for this client?
- A. Advise the client to use the pump sparingly to prevent addiction
- B. Encourage the client to use the PCA before dressing changes
- C. Encourage the client's family to administer PCA while the client is sleeping
- D. Increase the client's 4-hour limit as needed
Correct Answer: B
Rationale: The correct answer is B because encouraging the client to use the PCA before dressing changes helps in managing pain proactively. Choice A is incorrect as PCA is a safe method of pain control when used appropriately, and the nurse should not suggest using it sparingly. Choice C is incorrect as only the client should operate the PCA to ensure they are in control of their pain management. Choice D is incorrect as changing the PCA limit without proper assessment and orders from the healthcare provider can lead to adverse effects.
A nurse is preparing to administer potassium chloride IV to a client. Which of the following actions should the nurse take to prevent complications?
- A. Administer the medication by IV bolus over 2 minutes
- B. Infuse the medication slowly using an IV pump
- C. Add the medication to an IV solution of D5W
- D. Dilute the medication in 5 mL of sterile water
Correct Answer: B
Rationale: The correct action to prevent complications when administering potassium chloride IV is to infuse the medication slowly using an IV pump. Rapid administration of potassium chloride can lead to complications such as hyperkalemia and cardiac arrest. Options A, C, and D are incorrect as they do not promote the safe administration of potassium chloride. Administering the medication by IV bolus over 2 minutes is too rapid and can cause adverse effects. Adding the medication to an IV solution of D5W or diluting it in sterile water may not control the rate of administration, increasing the risk of complications.
A nurse is preparing to administer morphine sulfate 2 mg IV bolus. Available is morphine sulfate 10 mg/mL. How many mL should the nurse administer per dose?
- A. 0.2 mL
- B. 0.4 mL
- C. 0.6 mL
- D. 0.8 mL
Correct Answer: A
Rationale: The nurse should administer 0.2 mL of morphine sulfate. To calculate this, divide the desired dose (2 mg) by the concentration of the available solution (10 mg/mL). 2 mg / 10 mg/mL = 0.2 mL. Therefore, the nurse should administer 0.2 mL of morphine sulfate. Choices B, C, and D are incorrect as they do not reflect the accurate calculation based on the provided concentration and desired dose.
A nurse is caring for a client receiving theophylline for chronic obstructive pulmonary disease (COPD). Which of the following client findings indicates the need for immediate intervention?
- A. Productive cough
- B. Drowsiness
- C. Vomiting
- D. Polyuria
Correct Answer: D
Rationale: Polyuria is a sign of theophylline toxicity and requires immediate intervention. Theophylline toxicity can lead to serious complications, and polyuria is a concerning symptom that indicates the need for urgent medical attention. Productive cough, drowsiness, and vomiting are common side effects of theophylline but are not typically indicative of immediate life-threatening issues like polyuria in the context of theophylline toxicity.
A client has been prescribed lisinopril. Which of the following medication interactions should the nurse instruct this client about?
- A. Potassium supplements
- B. Ciprofloxacin
- C. Escitalopram
- D. Magnesium supplements
Correct Answer: A
Rationale: The correct answer is A: Potassium supplements. Clients taking lisinopril should avoid potassium supplements and potassium-sparing diuretics due to the risk of hyperkalemia. This interaction can lead to dangerously high levels of potassium in the blood, which can be harmful. Choice B, Ciprofloxacin, is not typically associated with a significant interaction with lisinopril. Choice C, Escitalopram, is an antidepressant and does not have a known significant interaction with lisinopril regarding potassium levels. Choice D, Magnesium supplements, are generally safe to take with lisinopril and do not pose a significant risk of hyperkalemia.