Nokea
A nurse is preparing to administer an intramuscular injection. Which of the following sites is most appropriate for an adult patient?
- A. Deltoid
- B. Vastus lateralis
- C. Dorsogluteal
- D. Ventrogluteal sites
Correct Answer: D
Rationale: The ventrogluteal site is safest for IM injections in adults, minimizing nerve or vessel damage. Deltoid and vastus lateralis are alternatives but less preferred, and dorsogluteal is avoided due to sciatic nerve risk.
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A nurse is caring for a patient with diabetes mellitus who is scheduled for surgery. Which of the following is the most important preoperative assessment?
- A. Blood glucose level.
- B. Electrolyte levels.
- C. Complete blood count (CBC).
- D. Urinalysis.
Correct Answer: A
Rationale: Blood glucose control is critical preoperatively in diabetes to prevent complications like wound infections or ketoacidosis. Electrolytes, CBC, and urinalysis are important but secondary, as glucose directly impacts surgical outcomes.
The nurse is performing an assessment of the motor function in a client with a head injury. The best technique is
- A. touching the trapezius muscle or arm firmly
- B. pinching any body part
- C. shaking a limb vigorously
- D. rubbing the sternum
Correct Answer: D
Rationale: rubbing the sternum. The purpose is to assess the non-responsive client's reaction to a painful stimulus after less noxious methods have been tried.
You're filling in as a substitute school nurse. When an 11-year-old child with an earache and sore throat reports to the nurse's office, you inspect the tympanic membrane using an otoscope.
Which color suggests a normal eardrum?
- A. Red
- B. White
- C. Gray
- D. Yellowish
Correct Answer: C
Rationale: A normal eardrum appears pearly gray.
The intent of the Patient Self Determination Act (PSDA) of 1990 is to:
- A. enhance personal control over legal care decisions.
- B. encourage medical treatment decision making prior to need.
- C. give one federal standard for living wills and durable powers of attorney.
- D. emphasize client education.
Correct Answer: B
Rationale: The PSDA promotes advance decision-making for medical care, encouraging clients to plan before a crisis. It does not set a federal standard or focus solely on legal control or education. Coordinated Care
A young female patient comes to the physician because she has been experiencing fatigue and double vision. The physician suspects myasthenia gravis.
When obtaining information from the patient, the nurse would expect her to report that:
- A. Her level of fatigue has been constant.
- B. The longer she rests the weaker she feels.
- C. Her strength increases with progressive activity.
- D. The symptoms seem more severe in the evening.
Correct Answer: D
Rationale: Myasthenia gravis symptoms worsen with activity and are more severe in the evening due to muscle fatigue.