Nokea
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
- A. Administer the medication with the needle at a 45 degree angle.
- B. Administer the medication into the client's non-dominant arm
- C. Pull the client's skin laterally or downward prior to administration
- D. Massage the injection site after administration
Correct Answer: A
Rationale: Administer the medication with the needle at a 45 degree angle. Subcutaneous injections should be inserted at 45 to 90 degree angles. Enoxaparin is given in the abdomen, and the Z-track method is for IM injections. Massaging the site of an anticoagulant will increase bruising.
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Which condition is a risk factor for pulmonary embolism?
- A. Dehydration
- B. Hypotension
- C. Bradycardia
- D. Fever
Correct Answer: A
Rationale: Dehydration increases blood viscosity, promoting clot formation and pulmonary embolism risk, more than hypotension, bradycardia, or fever.
When planning care,for which client should the nurse include close observation for a decreased or absent cough reflex?
- A. The client with a nasal fracture
- B. The client with impairment of vagus nerve conduction
- C. The client with a sinus infection
- D. The client with reduction in respiratory membrane conduction
Correct Answer: B
Rationale: The cough reflex relies on vagus nerve (cranial nerve X) conduction to the medulla. Impairment of vagus nerve function (B) such as from spinal cord injury or CNS depression can decrease or eliminate the cough reflex increasing risks of aspiration and respiratory infections requiring close monitoring. Nasal fractures (A) and sinus infections (C) do not typically affect the cough reflex. Reduced respiratory membrane conduction (D) impacts gas exchange
A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, 'What would happen if I arrived at the emergency department and I had difficulty breathing?' Which of the following responses should the nurse make?
- A. We would consult the person appointed by your health care proxy to make decisions
- B. We would give you oxygen through a tube in your nose
- C. You would give you oxygen through a tube in your nose.
- D. We would insert a breathing tube while we evaluate your condition
Correct Answer: B
Rationale: We would give you oxygen through a tube in your nose. Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula.
The nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?
- A. Alginate
- B. Gauze
- C. Transparent
- D. Hydrocolloid
Correct Answer: D
Rationale: Hydrocolloid promotes healing in stage 2 by creating a moist wound bed. Alginate dressings are for stage 3 and 4 injuries to absorb drainage, moist gauze is for stage 4 or unstageable dressing that need debridement, transparent dressings are for stage 1 to prevent further friction.
A client is diagnosed with congestive heart failure. The nurse should assess the client for which conditions that can alter this clients respiratory function?
- A. Conditions that affect the airway.
- B. Conditions that affect transport.
- C. Conditions that affect the movement of air.
- D. Conditions that affect diffusion.
Correct Answer: B
Rationale: Congestive heart failure (CHF) reduces cardiac output impairing oxygen transport (B) from lungs to tissues and $\mathrm{CO} 2$ return affecting respiratory function. Airway conditions (A) air movement (C) and diffusion (D) are less directly impacted by CHF making B the primary concern for assessing respiratory alterations.