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The employee health nurse is observing a student nurse administer a PPD tuberculin test to a new employee. Which behavior would warrant immediate intervention by the employee health nurse?
- A. The student nurse inserts the needle at a 45-degree angle.
- B. The student nurse cleanses the forearm with alcohol.
- C. The student nurse circles the injection site with ink.
- D. The student nurse instructs the employee to return in three (3) days.
Correct Answer: A
Rationale: PPD tests require a 10–15-degree angle for intradermal injection to form a wheal; 45 degrees is incorrect and warrants intervention. Other actions are standard.
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The nurse is preparing to administer the morning dose of digoxin, a cardiac glycoside, to a client diagnosed with congestive heart failure. Which data would indicate the medication is effective?
- A. The apical heart rate is 72 beats per minute.
- B. The client denies having any anorexia or nausea.
- C. The client's blood pressure is 120/80 mm Hg.
- D. The client's lungs sounds are clear bilaterally.
Correct Answer: D
Rationale: Clear lung sounds indicate reduced fluid overload in CHF, a sign of digoxin’s effectiveness in improving cardiac output. HR, nausea, or BP are less specific.
The nurse is caring for an elderly client who is eight (8) hours postoperative hip replacement and is reporting incisional pain. Which intervention is priority for this client?
- A. Assist the client to sit in the bedside chair.
- B. Initiate pain medication at the lowest dose.
- C. Assess the client's pupil size and accommodation.
- D. Monitor the client's urinary output hourly.
Correct Answer: B
Rationale: Pain management is the priority post-op to promote recovery and comfort; lowest dose minimizes side effects in the elderly. Sitting, pupil assessment, or urine output are secondary.
The client in the emergency department requires sutures for a laceration on the left leg. Which information is most pertinent prior to suturing the wound?
- A. The client tells the nurse she has never had sutures.
- B. The spouse refuses to leave the room during suturing.
- C. The client shares she is scared of needles.
- D. The client reports hives after having dental surgery.
Correct Answer: D
Rationale: Hives post-dental surgery suggest a possible local anesthetic allergy, critical to know before suturing to avoid anaphylaxis.
The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?
- A. Blanch nail beds for color and refill
- B. Assess for post-operative arrhythmias
- C. Auscultate for pulmonary congestion
- D. Monitor equality of peripheral pulses
Correct Answer: B
Rationale: Assess for post-operative arrhythmias. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.
A 10-month-old child has been diagnosed as having acute otitis media. The pediatrician prescribed amoxicillin suspension. What instructions should the nurse give the child's mother?
- A. When your child's temperature has been normal for two days, discontinue the medicine.
- B. Discard any unused medication.
- C. If your child has symptoms of an ear infection again, start giving her the leftover medication.
- D. Give your child all of the medication in the bottle.
Correct Answer: B
Rationale: The nurse should instruct to discard unused medication to prevent misuse. The full course should be completed, but the bottle is only good for two weeks.