Nokea
The nurse administered an intramuscular injection to an adult. How should the nurse dispose of the needle and syringe?
- A. Immediately place syringe and needle in the disposal container.
- B. Recap the needle and place syringe and needle in the disposal container.
- C. Separate the syringe and the needle and place in the appropriate disposal containers.
- D. Recap the needle and cut the syringe before placing in disposal container.
Correct Answer: A
Rationale: Immediately placing the needle and syringe in a sharps container prevents needlestick injuries. Recapping or separating risks exposure, and cutting is unsafe.
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The incidence of Sickle Cell Anemia is higher among black American babies.
The symptoms of sickle cell anemia are not evident until later during infancy because
- A. The baby is fed with milk formula, which is rich in ironbfb.
- B. The infant has a much higher RBC count than children and adult.
- C. Maternal iron is depleted later in infancy.
- D. Infants have more body fluids than any age group.
Correct Answer: C
Rationale: High levels of fetal hemoglobin prevent sickling of red blood cells. The newborn has from 44% to 89% fetal hemoglobin, but this rapidly decreases during the first year, making symptoms evident later.
A young female patient comes to the physician because she has been experiencing fatigue and double vision. The physician suspects myasthenia gravis.
When obtaining information from the patient, the nurse would expect her to report that:
- A. Her level of fatigue has been constant.
- B. The longer she rests the weaker she feels.
- C. Her strength increases with progressive activity.
- D. The symptoms seem more severe in the evening.
Correct Answer: D
Rationale: Myasthenia gravis symptoms worsen with activity and are more severe in the evening due to muscle fatigue.
Which client is at highest risk for developing a pressure ulcer?
- A. 23 year-old in traction for fractured femur
- B. 72 year-old with peripheral vascular disease, who is unable to walk without assistance
- C. 75 year-old with left sided paresthesia who is incontinent of urine and stool
- D. 30 year-old who is comatose following a ruptured aneurysm
Correct Answer: C
Rationale: 75 year-old with left sided paresthesia who is incontinent of urine and stool. Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.
The patient with DM has flu.
Which nursing action is more appropriate?
- A. Frequent monitoring of blood glucose.
- B. Expected increase in the patient insulin requirement.
- C. Implement respiratory isolation.
- D. Monitor the patient's respiratory status frequently.
Correct Answer: A
Rationale: Flu can disrupt glucose control, making frequent monitoring critical.
The nurse is assessing a client with a history of asthma who presents with decreased breath sounds and prolonged expiration. The nurse should prioritize which of the following actions?
- A. Administer a bronchodilator as ordered.
- B. Encourage the client to cough and deep breathe.
- C. Obtain a chest X-ray.
- D. Position the client supine.
Correct Answer: A
Rationale: Decreased breath sounds and prolonged expiration indicate an asthma exacerbation with bronchoconstriction, requiring a bronchodilator to open airways. Coughing (B) is ineffective during an attack, X-rays (C) are diagnostic, and supine positioning (D) worsens breathing.