Nokea
A student nurse is preparing to administer the hepatitis B vaccine to a newborn. Which statement by the student nurse requires the preceptor to provide further teaching?
- A. A 5/8-inch, 25-gauge needle is appropriate for intramuscular injection in newborns.
- B. I will clean the injection site with an antiseptic swab before administration.
- C. I will draw the medication into a 1-mL syringe.
- D. The medication should be administered into the deltoid muscle.
Correct Answer: D
Rationale: The deltoid muscle is not developed enough in newborns for intramuscular injections. The hepatitis B vaccine should be administered in the anterolateral thigh.
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A student nurse is caring for a client with iron deficiency anemia who is newly prescribed ferrous sulfate. Which action by the student nurse requires the supervising nurse to intervene?
- A. Encourages the client to drink extra fluids while taking ferrous sulfate
- B. Offers the client orange juice for administration of ferrous sulfate
- C. Plans to administer ferrous sulfate one hour before breakfast
- D. Prepares to administer a prescribed calcium supplement with ferrous sulfate
Correct Answer: D
Rationale: Calcium inhibits iron absorption, so administering ferrous sulfate with a calcium supplement reduces its effectiveness, requiring intervention.
The nurse is collecting data from a client with heart failure. The nurse notes that the client is agitated, has crackles bilaterally, and is reporting dyspnea and anxiety. The nurse should place the client in
- A. modified Trendelenburg position
- B. high Fowler position
- C. left Sims position
- D. supine position
Correct Answer: B
Rationale: High Fowler position optimizes lung expansion and reduces preload, alleviating dyspnea and crackles in acute heart failure exacerbation.
In reviewing the assessment data of a client suspected of having diabetes insipidus, the nurse expects which of the following after a water deprivation test?
- A. Increased edema and weight gain
- B. Unchanged urine specific gravity
- C. Rapid protein secretion
- D. Decreased blood potassium
Correct Answer: B
Rationale: Unchanged urine specific gravity. When fluids are restricted, the client continues to excrete large amounts of dilute urine. This finding supports the diagnosis. Normally, urine is more concentrated with reduced fluid intake.
A client with acquired immunodeficiency syndrome has a T cell count of 180 . The medication frequently used for the client with T cell counts less than 200 is:
- A. Garamycin (gentamicin)
- B. Zovirax (acyclovir)
- C. Pentam (pentamidine)
- D. Immune globulin
Correct Answer: C
Rationale: Pentamidine is used for Pneumocystis prophylaxis in AIDS patients with T-cell counts <200. Gentamicin is an antibiotic, acyclovir treats herpes, and immune globulin is not specific.
The nurse is caring for a preschool-age child whose grandparent died 3 days ago. Which intervention is inappropriate?
- A. Assign the same nurses and caregivers to the child each day
- B. Avoid mentioning the loved one's death in the child's presence
- C. Explain the importance of being with the child to the parents
- D. Schedule time each day for age-appropriate play
Correct Answer: B
Rationale: Avoiding discussion of the grandparent's death may confuse the child or hinder grieving. Open, age-appropriate communication supports emotional processing.