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How should a healthcare professional administer a subcutaneous injection?
- A. Insert the needle at a 45-degree angle
- B. Insert the needle at a 90-degree angle
- C. Use a Z-track method
- D. Insert the needle at a 15-degree angle
Correct Answer: A
Rationale: The correct technique for administering subcutaneous injections is to insert the needle at a 45-degree angle. This angle ensures that the medication is delivered into the subcutaneous tissue, which is located just below the skin. Inserting the needle at a 90-degree angle is more appropriate for intramuscular injections, while using a Z-track method is specific to intramuscular injections to prevent leakage of medication into the subcutaneous tissue. Inserting the needle at a 15-degree angle would not reach the subcutaneous tissue effectively.
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What is the best intervention for a patient with a suspected pulmonary embolism?
- A. Administer oxygen
- B. Administer anticoagulants
- C. Reposition the patient
- D. Administer bronchodilators
Correct Answer: A
Rationale: Administering oxygen is the best intervention for a patient with a suspected pulmonary embolism because it helps alleviate respiratory distress and improve oxygenation. Oxygen therapy is crucial to ensure adequate oxygen levels in the blood due to the obstruction in the pulmonary circulation caused by the embolism. Administering anticoagulants (choice B) is a treatment for confirmed pulmonary embolism rather than a suspected case. Repositioning the patient (choice C) or administering bronchodilators (choice D) would not directly address the underlying issue of impaired gas exchange and oxygen delivery associated with pulmonary embolism.
A nurse is assessing a client who is receiving enteral feedings through a nasogastric tube. Which of the following findings requires immediate intervention?
- A. Aspirating 100 mL of gastric residual
- B. Gastric pH of 4
- C. Auscultating crackles in the lung bases
- D. Checking residual every 6 hours
Correct Answer: C
Rationale: Auscultating crackles in the lung bases indicates fluid in the lungs, which can be a sign of aspiration pneumonia or pulmonary edema and requires immediate intervention to prevent respiratory distress. Aspirating 100 mL of gastric residual is within the acceptable range and does not require immediate intervention. A gastric pH of 4 is normal for gastric contents. Checking residual every 6 hours is a routine nursing intervention and does not indicate an urgent issue like pulmonary complications.
A nurse is providing teaching to a client who has osteoporosis about preventing fractures. Which of the following instructions should the nurse include?
- A. Increase your intake of calcium-rich foods.
- B. Avoid weight-bearing exercises.
- C. Perform weight-bearing exercises regularly.
- D. Avoid taking calcium supplements.
Correct Answer: C
Rationale: The correct instruction the nurse should include is to perform weight-bearing exercises regularly. Weight-bearing exercises help maintain bone density and reduce the risk of fractures in clients with osteoporosis. Increasing intake of calcium-rich foods (Choice A) is also beneficial for bone health. Avoiding weight-bearing exercises (Choice B) is incorrect as these exercises are essential for strengthening bones. Avoiding calcium supplements (Choice D) may not be necessary if the client's dietary intake is inadequate.
What is the most appropriate action when a patient is experiencing confusion after surgery?
- A. Administer oxygen
- B. Reposition the patient
- C. Administer IV fluids
- D. Perform a neurological exam
Correct Answer: A
Rationale: Administering oxygen is the most appropriate action when a patient is experiencing confusion after surgery because it helps alleviate hypoxia, which may be causing the patient's confusion. Repositioning the patient would not directly address the potential hypoxia issue. Administering IV fluids may be necessary for hydration or other reasons but is not the initial priority in addressing confusion post-surgery. Performing a neurological exam may be important later on to assess the patient's neurological status but should not be the first action taken when confusion is present.
What is the best method to manage fluid overload in a patient with heart failure?
- A. Administer diuretics
- B. Provide oral fluids
- C. Increase fluid intake
- D. Provide chest physiotherapy
Correct Answer: A
Rationale: Administering diuretics is the best method to manage fluid overload in a patient with heart failure. Diuretics help to remove excess fluid from the body by increasing urine output, thus reducing the fluid volume in the bloodstream and tissues. Providing oral fluids (choice B) or increasing fluid intake (choice C) would exacerbate the fluid overload rather than managing it. Chest physiotherapy (choice D) is not indicated for managing fluid overload in heart failure; it is more commonly used for conditions affecting the lungs or airways.