Nokea
The LPN is preparing to administer an injection of vitamin K to the newborn. The nurse should administer the injection in the:
- A. Rectus femoris muscle
- B. Vastus lateralis muscle
- C. Deltoid muscle
- D. Dorsogluteal muscle
Correct Answer: B
Rationale: The vastus lateralis muscle is the preferred site for vitamin K injection in newborns, offering a large, safe muscle mass away from nerves and vessels, standard for intramuscular prophylaxis against hemorrhagic disease. Rectus femoris is smaller, deltoid underdeveloped, and dorsogluteal risky near sciatic nerve. Nurses use this site for efficacy and safety, teaching parents its purpose in clotting support.
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Which of the following assessment finding is typical of extracellular fluid loss?
- A. Distended jugular veins
- B. Elevated hematocrit level
- C. Rapid thready pulse
- D. Increased serum sodium level
Correct Answer: C
Rationale: Extracellular fluid loss (e.g., dehydration) reduces blood volume, causing a rapid, thready pulse as the heart compensates for hypovolemia. Distended jugular veins suggest fluid overload, not loss. Elevated hematocrit reflects hemoconcentration, but pulse is a more immediate sign. Increased sodium occurs with water loss, not always fluid volume. Nurses monitor pulse to detect early shock, guiding fluid replacement to restore circulation and prevent organ damage.
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: Mashed potatoes and broiled chicken are low in sodium, unlike ham, olives, or bouillon.
Mr. Gary uses acupuncture along with his meds. This is an example of?
- A. Complementary therapy
- B. Alternative therapy
- C. Therapeutic touch
- D. Health promotion
Correct Answer: A
Rationale: Acupuncture with meds is complementary therapy (A) with conventional, per definition. Alternative (B) replaces, touch (C) hands, promotion (D) well-being not combo-specific. A fits integrated use, making it correct.
Which of the following is considered as an example of intentional tort?
- A. Malpractice
- B. Negligence
- C. Breach of duty
- D. False imprisonment
Correct Answer: D
Rationale: False imprisonment, an intentional tort, involves deliberately restricting someone's freedom, like restraining a competent patient against their will. Malpractice and negligence are unintentional torts, stemming from carelessness or failure to meet standards, not intent. Breach of duty is a negligence component, not a standalone tort. In nursing, intentional torts require purposeful action, and false imprisonment risks legal liability, emphasizing patient rights and consent in care delivery.
The nurse checked Mr. Gary's dose to prevent an overdose. This is an example of?
- A. Nonmaleficence
- B. Beneficence
- C. Fidelity
- D. Veracity
Correct Answer: A
Rationale: Checking dose to prevent overdose is nonmaleficence (A) avoiding harm, per ethics. Beneficence (B) does good, fidelity (C) keeps promises, veracity (D) tells truth not harm-specific. A fits the nurse's focus on safety, ensuring no adverse effects occur, aligning with nonmaleficence's protective principle, making it correct.