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Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include:
- A. A ham and Swiss cheese sandwich on whole wheat bread
- B. Mashed potatoes and broiled chicken
- C. A tossed salad with oil and vinegar and olives
- D. Chicken bouillon
Correct Answer: B
Rationale: The correct answer is B: Mashed potatoes and broiled chicken. Both mashed potatoes and broiled chicken are typically low in sodium content, making them suitable choices for a 500-mg low sodium diet. The other options, such as a ham and Swiss cheese sandwich on whole wheat bread, a tossed salad with oil and vinegar and olives, and chicken bouillon, may contain higher amounts of sodium and are not typically recommended for a low sodium diet.
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A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patient's skin. The most appropriate nursing action would be to:
- A. Withhold the medication and notify the physician
- B. Administer the medication and notify the physician
- C. Administer the medication with an antihistamine
- D. Apply corn starch soaks to the rash
Correct Answer: A
Rationale: In this scenario, the appearance of a rash after administering penicillin, even in a patient with no known allergies, is concerning for a potential allergic reaction. The appropriate action for the nurse to take is to withhold the medication and notify the physician. This precaution is necessary to prevent further administration of a medication that may be causing an adverse reaction, as allergic reactions can range from mild to severe and require immediate intervention.
All of the following interventions are correct when using the Z-track method of drug injection except:
- A. Prepare the injection site with alcohol
- B. Use a needle that is at least 1" long
- C. Aspirate for blood before injection
- D. Rub the site vigorously after the injection to promote absorption
Correct Answer: D
Rationale: When using the Z-track method of drug injection, it is important to prepare the injection site with alcohol to ensure cleanliness, use a needle that is at least 1" long to reach the muscle tissue, and aspirate for blood before injection to verify correct needle placement. However, rubbing the site vigorously after the injection is not recommended as it can cause medication to leak into subcutaneous tissue, compromising the medication's intended absorption and efficacy.
When is sterile technique used?
- A. During strict isolation procedures
- B. After terminal disinfection is performed
- C. For invasive procedures
- D. When protective isolation is necessary
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What is the appropriate needle gauge for intradermal injection?
- A. 20G
- B. 22G
- C. 25G
- D. 26G
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which of the following signs and symptoms would the nurse expect to find when assessing an Asian patient for postoperative pain following abdominal surgery?
- A. Decreased blood pressure and heart rate and shallow respirations
- B. Quiet crying
- C. Immobility, diaphoresis, and avoidance of deep breathing or coughing
- D. Changing position every 2 hours
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.