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A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching?
- A. Stir the needle to 15° before administration.
- B. Aspire the syringe prior to administration.
- C. Administer the medication to the abdomen.
- D. Massage the site following the injection.
Correct Answer: C
Rationale: Correct Answer: C - Administer the medication to the abdomen.
Rationale: Heparin is typically administered subcutaneously. The abdomen has a larger subcutaneous tissue area compared to other sites, allowing for better absorption and reducing the risk of tissue damage. Administering heparin in the abdomen also minimizes the risk of hitting blood vessels and nerves. It is important to rotate injection sites to prevent tissue damage and ensure consistent absorption.
Summary of other choices:
A: Stirring the needle to a specific angle is unnecessary and can increase the risk of needle breakage or improper administration.
B: Aspiration is not required for subcutaneous injections as it may cause unnecessary tissue trauma.
D: Massaging the site after injection can lead to bruising and discomfort.
E, F, G: Choices left blank as they are not relevant to the administration of heparin.
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A nurse is assessing a client with heart failure. The client reports increasing shortness of breath, fatigue, and weakness. Which of the following findings in the assessment should the nurse identify as most concerning?
- A. Weak pulses with +2 dependent edema in lower extremities.
- B. Slightly labored respirations at rest.
- C. Wheezes and crackles in the chest.
- D. Reports productive cough during the overnight hours.
Correct Answer: C
Rationale: The correct answer is C: Wheezes and crackles in the chest. This finding is most concerning in a client with heart failure as it indicates potential fluid overload in the lungs, leading to impaired gas exchange and worsening respiratory status. Wheezes suggest bronchoconstriction, while crackles indicate fluid accumulation in the alveoli, both of which can exacerbate shortness of breath. Weak pulses with dependent edema (choice A) are expected in heart failure but do not directly point to acute decompensation. Slightly labored respirations at rest (choice B) may be common in heart failure but do not indicate immediate deterioration. Reports of a productive cough (choice D) can be a sign of fluid retention but are less urgent compared to wheezes and crackles.
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?
- A. Biofeedback
- B. Aloe
- C. Reflexology
- D. Acupuncture
Correct Answer: D
Rationale: The correct answer is D: Acupuncture. Herpes zoster, also known as shingles, is a viral infection that affects the nerves and causes a painful rash. Acupuncture involves inserting thin needles into specific points on the body to alleviate pain and promote healing. However, in the case of herpes zoster, the skin lesions and nerve involvement increase the risk of spreading the virus through acupuncture needles, leading to potential complications. Therefore, acupuncture is contraindicated in clients with herpes zoster to prevent the spread of the virus.
A: Biofeedback, B: Aloe, and C: Reflexology are not contraindicated for clients with herpes zoster. Biofeedback is a non-invasive technique that helps individuals control physiological processes such as reducing stress and managing pain. Aloe is a natural plant extract commonly used for its anti-inflammatory and soothing properties, which can be beneficial for skin irritations caused by herpes zoster. Reflexology is a therapeutic technique that involves applying pressure to
A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?
- A. Use the complete name of the medication magnesium sulfate.
- B. Distinguish the space between the numerical dose and the unit of measure.
- C. Write the letter U when noting the dosage of insulin.
- D. Use the abbreviation SC when indicating an injection.
Correct Answer: A
Rationale: The correct answer is A: Use the complete name of the medication magnesium sulfate. This is important because using the complete name of the medication helps prevent medication errors and ensures clarity in communication. It also follows best practices for medication safety.
Choice B is incorrect because while distinguishing the space between the numerical dose and the unit of measure is important for clarity, it is not as critical as using the complete name of the medication.
Choice C is incorrect because when noting the dosage of insulin, it is important to use the unit "units" rather than the letter "U" for accuracy and clarity.
Choice D is incorrect because the correct abbreviation for indicating a subcutaneous injection is "SQ" or "subQ," not "SC."
Overall, using the complete name of the medication is the most crucial aspect in medication documentation to ensure patient safety and prevent errors.
The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
- A. Wear an N95 mask when caring for the client.
- B. Place a container for soiled linens inside the client's room.
- C. Place the client in a negative airflow room.
- D. Remove mask after exiting the client's room.
- E. Wear a sterile water-resistant gown if within 3 feet of the client.
Correct Answer: A, B, C, E
Rationale: The correct interventions for placing a client on isolation precautions include A, B, C, and E. A) Wearing an N95 mask is crucial for airborne precautions. B) Placing a container for soiled linens inside the room prevents contamination. C) A negative airflow room helps contain airborne pathogens. E) Wearing a sterile water-resistant gown within close proximity to the client prevents transmission. D is incorrect as the mask should be removed inside the client's room. Choices F and G are likely blank options or not relevant to isolation precautions.
A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?
- A. A lesion with uniform pigmentation
- B. New appearance of petechiae
- C. A mole with an asymmetrical appearance
- D. The presence of a papule
Correct Answer: C
Rationale: The correct answer is C: A mole with an asymmetrical appearance. This is indicative of a potential skin malignancy such as melanoma. The asymmetry suggests irregular growth patterns, which can be a sign of cancerous cells. Other choices, such as A (lesion with uniform pigmentation), B (petechiae), and D (presence of a papule) are not specific indicators of skin malignancy. Lesions with uniform pigmentation are more likely to be benign. Petechiae are tiny red spots due to bleeding under the skin and are not typically associated with skin cancer. Papules are small raised bumps that can have various causes, not necessarily cancerous. Therefore, choice C is the most concerning finding for skin cancer based on asymmetry, prompting further evaluation and possible biopsy.