Nokea
The healthcare provider prescribes ear drops to an adult client with an ear infection.Which exacting should the nurse follow?
- A. Swab and shake bottle before administering the drops.
- B. Administer the drops with the head tilted upright.
- C. Lower the edge of the dropper into the canal of the ear.
- D. Keep the patient in supine position to administer the drops
Correct Answer: D
Rationale: When administering ear drops to an adult client with an ear infection, the nurse should keep the patient in a supine position to administer the drops. This position allows the medication to flow into the ear canal and reach the site of infection.
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The nurse is preparing to administer Tylenol to a client admitted with urination issues who also has difficulty sleeping (OSA).Which interaction is most important for the nurse to implement before leaving the client?
- A. Elevate the head of the bed to a 45-degree angle
- B. Apply the client's positive airway pressure device
- C. Lift and lock the side rails in place
- D. Remove dentures or other oral appliances
Correct Answer: B
Rationale: The client has difficulty sleeping due to obstructive sleep apnea (OSA), and using a positive airway pressure device can help keep their airway open and prevent dangerous pauses in breathing while they sleep.
The nurse observes the skin over a client's greater trochanter, as seen in the picture with pressure sores.What actions should the nurse implement?
- A. Instruct the unlicensed assistive personnel to frequently offer oral fluids.
- B. Prepare to implement a pressure redistribution mattress.
- C. Explain to the client that the wound needs debridement.
- D. Obtain hemoglobin of the side to check for anemia and sensitivity.
Correct Answer: B
Rationale: Pressure redistribution is an important part of preventing and treating pressure sores.
The nurse is preparing to give an emergency sedative injection to an agitated client.Which action by the nurse is inappropriate?
- A. Placing a client in restraints without having a healthcare provider's order.
- B. Administering the medication to a client behind a closed curtain.
- C. Enlisting security personnel to assist with restraining the client.
- D. Informing a client that the medication being administered is a sedative.
Correct Answer: A
Rationale: Placing a client in restraints without having a healthcare provider's order is inappropriate for a nurse to do.
The nurse is teaching a client how to self-administer subcutaneous heparin injections.Which instruction should the nurse include?
- A. Inject in abdominal area at least 2 inches from the umbilicus.
- B. Rotate injections between the abdomen and gluteal areas.
- C. Massage the injection site to increase absorption.
- D. Expel the air in the prefilled syringe prior to injection.
Correct Answer: A
Rationale: Inject in abdominal area at least 2 inches from the umbilicus. When administering subcutaneous heparin injections, it is important to choose an injection site on either your tummy or outer areas of your left or right thigh. Your tummy is usually best as the injection site and it is important that you change the site each time.
What's the priority intervention for a patient with persistent STIs and risky behaviors?
- A. Recommend consistent use of latex condoms.
- B. Discuss the purpose of annual infection screening.
- C. Some infections may have no initial symptoms.
- D. Advise that alcohol intake may lead to risky behaviors.
Correct Answer: A
Rationale: The priority intervention for a patient with persistent STIs and risky behaviors is to recommend consistent use of latex condoms. According to the USPSTF, behavioral counseling is recommended for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs).