Nokea
An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to
- A. administer the medication in 2 separate injections
- B. give the medication in the dorsal gluteal site
- C. call to get a smaller volume ordered
- D. check with pharmacy for a liquid form of the medication
Correct Answer: A
Rationale: administer the medication in 2 separate injections. Intramuscular injections should not exceed a volume of 1 ml for small children. Medication doses exceeding this volume should be split into 2 separate injections of 1.0 ml each. In adults the maximum intramuscular injection volume is 5 ml per site.
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A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be to
- A. cover the areas with dry sterile dressings
- B. assess for dyspnea or stridor
- C. initiate intravenous therapy
- D. administer pain medication
Correct Answer: B
Rationale: assess for dyspnea or stridor. Due to the location of the burns, the client is at risk for developing upper airway edema and subsequent respiratory distress.
The nurse is using chlorhexidine to cleanse a vein site prior to inserting an IV catheter. While pressing the activated applicator on the skin, what should the nurse do next?
- A. Scrub the skin back and forth for 30 seconds.
- B. Scrub the skin in a circular motion for 10 seconds.
- C. Scrub until the solution is visually wet on the vein.
- D. Scrub until the skin appears to be dark brown in color.
Correct Answer: A
Rationale: A: Back-and-forth scrubbing for 30 seconds ensures effective antisepsis. B: Circular motion and 10 seconds are inadequate. C: Visual wetness is insufficient. D: Chlorhexidine is clear, causing no discoloration.
The nurse is caring for a client with clinical depression who is receiving a monoamine oxidase inhibitor (MAOI). When providing instructions about precautions with this medication, which action should the nurse stress to the client as important?
- A. Avoid chocolate and cheese
- B. Take frequent naps
- C. Take the medication with milk
- D. Avoid walking without assistance
Correct Answer: A
Rationale: Avoid chocolate and cheese. Foods high in tryptophan, tyramine, and caffeine, such as chocolate, wine, and cheese may precipitate hypertensive crisis.
The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention?
- A. Pallor
- B. Increased temperature
- C. Dyspnea
- D. Involuntary muscle spasms
Correct Answer: C
Rationale: Dyspnea. Clients having the insertion of a central venous catheter are at risk for tension pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this complication.
During a health promotion seminar, the nurse plans to discuss ways to prevent food poisoning. What information should the nurse plan to address?
- A. Keep all meat together during the preparation, cooking, and serving processes.
- B. Drink natural unpasteurized milk because it contains less harmful chemicals.
- C. Wash fruits and vegetables thoroughly, especially those that will be eaten raw.
- D. Ensure that ground beef patties are cooked to a temperature of 125°F (51.7°C).
Correct Answer: C
Rationale: C: Thorough washing of raw produce removes bacteria, preventing food poisoning. A: Meats should be separated to avoid cross-contamination. B: Unpasteurized milk carries infection risks. D: Ground beef must reach 160°F to kill pathogens.