Nokea
A physician orders vitamin B12 for a client with pernicious anemia. Which site is appropriate for the nurse to administer vitamin B12? Select all that apply.
- A. Deltoid.
- B. Greater femur trochanter.
- C. Acromion muscle.
- D. Ventrogluteal.
- E. Upper back.
- F. Dorsogluteal.
Correct Answer: A,D,F
Rationale: Vitamin B12 is administered intramuscularly, and appropriate sites include the deltoid, ventrogluteal, and dorsogluteal muscles, as these provide adequate muscle mass for absorption. The greater femur trochanter and acromion muscle are not standard injection sites, and the upper back is not suitable for intramuscular injections.
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The nurse is to administer Polycillin (ampicillin) 500 mg orally to a client with a ruptured appendix. The nurse checks the capsule in the client's medication box which is located inside of the client's room. The dosage of the medication is not labeled, but the nurse recognizes the color and shape of the capsule. The nurse should next:
- A. Administer the medication to maintain blood levels of the drug.
- B. Ask another registered nurse to verify that the capsule is ampicillin.
- C. Contact the pharmacy to bring a properly labeled medication.
- D. Adjust the unit manager to report the problem.
Correct Answer: C
Rationale: Contacting the pharmacy to bring a properly labeled medication ensures safe administration, as recognizing the capsule's color and shape is insufficient for verification. Administering without confirmation or relying on another nurse risks error, and reporting to the manager delays care. CN: Safety and infection control; CL: Synthesize
A client with renal calculi has a stent placed. The nurse should teach:
- A. Report blood in urine.
- B. Avoid all activity.
- C. Remove the stent at home.
- D. Expect no discomfort.
Correct Answer: A
Rationale: Blood in urine may indicate stent issues, requiring medical attention.
Immediately after a lumbar laminectomy, the nurse administers ondansetron hydrochloride (Zofran) to the client as ordered. The nurse determines that the drug is effective when which of the following is controlled?
- A. Muscle spasms.
- B. Nausea.
- C. Shivering.
- D. Dry mouth.
Correct Answer: B
Rationale: Ondansetron is an antiemetic, effective when nausea is controlled.
The client who has undergone a bilateral adrenalectomy is ready to return home. She tells the nurse that she is concerned about persistent body changes and the fact that her moods are still so unpredictable. She says, 'I thought surgery was supposed to fix all that.' The nurse should tell the client that:
- A. The body changes are permanent and the client will not be the same as before this condition.'
- B. The body and mood will gradually return to normal.'
- C. The physical changes are permanent, but the mood swings will disappear.'
- D. The physical changes are temporary, but the mood swings are permanent.'
Correct Answer: B
Rationale: Post-adrenalectomy, with proper hormone replacement, physical changes and mood swings gradually resolve as hormone levels normalize.
As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which of the following statements by the client indicates she understands her current ability?
- A. I will be able to have sexual intercourse until the urinary catheter is removed.'
- B. I can participate in sexual activity but might not experience orgasm.'
- C. I can't have sexual intercourse because it causes hypertension, but other sexual activity is okay.'
- D. I should be able to participate in sexual activity, but I will be infertile.'
Correct Answer: B
Rationale: Quadriplegia may impair sensation and orgasm but does not preclude sexual activity, which the client correctly understands.