Nokea
The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site demonstrates which of the following?
- A. No swelling.
- B. Tissue pallor.
- C. Evidence of a bleb.
- D. Erythema.
Correct Answer: C
Rationale: A bleb (small wheal) at the injection site indicates correct intradermal technique, as the medication is deposited just under the skin.
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The nurse is caring for a client who has just undergone a colectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Monitor for signs of bowel perforation.
- B. Encourage early ambulation.
- C. Administer oral fluids immediately.
- D. Keep the client on bed rest for 48 hours.
Correct Answer: B
Rationale: Encouraging early ambulation post-colectomy prevents complications like ileus and deep vein thrombosis.
The nurse is caring for a client who has just had a mastectomy. Which exercise should the nurse assist the client in doing during the first 24 hours after surgery?
- A. Hand wall climbing
- B. Pendulum arm swings
- C. Elbow flexion and extension
- D. Shoulder abduction and external rotation
Correct Answer: C
Rationale: During the first 24 hours after surgery, the client is assisted to move the fingers and hands, and to flex and extend the elbow. The client may also use the arm for self-care provided that she does not raise the arm above shoulder level or abduct the shoulder. The exercises identified in the remaining options are done once surgical drains are removed and wound healing is well established.
A client's 12:00 noon blood glucose concentration was inaccurately documented as 310 instead of 130. This error was not noticed until 1:00 p.m. The nurse administered the sliding scale insulin for a blood glucose of 310 instead of 130. What should the nurse do first?
- A. Notify the physician.
- B. Assess for hypoglycemia.
- C. Consult with the clinical pharmacist.
- D. Call the charge nurse.
Correct Answer: B
Rationale: Administering insulin for a falsely high glucose level risks hypoglycemia, so assessing for symptoms (e.g., shakiness, sweating) is the priority.
Which federal law is most closely associated with the highly restrictive 'need to know'?
- A. The Patient Self Determination Act
- B. The Mental Health Parity Act
- C. The Health Insurance Portability and Accountability Act
- D. The Americans with Disabilities Act of 1990
Correct Answer: C
Rationale: The Health Insurance Portability and Accountability Act (HIPAA) enforces the 'need to know' principle, restricting access to protected health information to only those who require it for their job functions.
You will be providing nursing care prior to, during and after electroconvulsive therapy for your client who is severely depressed. Which of the following is an appropriate nursing intervention for this client?
- A. Maintain the client with NPO status for at least 4 hours prior to this procedure.
- B. Teach the client about the fact that they may experience muscle flaccidity.
- C. Teach the client about the fact that they may have a headache after the ECT.
- D. Maintain the client on continuous hemodynamic monitoring after the ECT.
Correct Answer: C
Rationale: Headache is a common side effect of ECT, and educating the client about this prepares them for post-procedure expectations.