Nokea
The nurse has attended a staff education program about administering intramuscular injections. Which of the following statements by the nurse would indicate a correct understanding of the program?
- A. I will insert the needle at a 45-degree angle.
- B. I will wait 3 seconds after injecting the medication before removing the needle.
- C. I will gently massage the injection site after removing the needle.
- D. I will use my hand to displace subcutaneous tissue prior to inserting the needle.
Correct Answer: D
Rationale: Displacing subcutaneous tissue (D) via the Z-track method prevents leakage and irritation. IM injections use a 90-degree angle (A is incorrect), waiting 3 seconds (B) is not standard, and massaging (C) is avoided for some medications.
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The nurse admits a 2 year-old child who has had a seizure. Which of the following statement by the child's parent would be important in determining the etiology of the seizure?
- A. He has been taking long naps for a week.'
- B. He has had an ear infection for the past 2 days.'
- C. He has been eating more red meat lately.'
- D. He seems to be going to the bathroom more frequently.'
Correct Answer: B
Rationale: He has had an ear infection for the past 2 days.' Contributing factors to seizures in children include those such as age (more common in first 2 years), infections (late infancy and early childhood), fatigue, not eating properly and excessive fluid intake or fluid retention.
The nurse assesses a client who has been re-admitted to the psychiatric inpatient unit for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment?
- A. Stressors in the home
- B. Medication compliance
- C. Exposure to hot temperatures
- D. Alcohol use
Correct Answer: B
Rationale: Medication compliance. Ensuring adherence to fluphenazine is critical for symptom management in schizophrenia.
A 62-year-old client admitted to the telemetry unit after an acute myocardial infarction 3 days ago reports that the left calf is very tender and warm to the touch. Which nursing intervention is the priority?
- A. Asking the client how long the leg has been tender and warm
- B. Checking the electrocardiogram for ectopic beats
- C. Obtaining vital signs, including pulse oximetry
- D. Performing a neurovascular check on the lower extremities
Correct Answer: D
Rationale: Tenderness and warmth suggest deep vein thrombosis, so a neurovascular check (D) is the priority to assess for complications. History (A), ECG (B), and vitals (C) are secondary.
A client who had bowel surgery is to be NPO for several days. The nurse anticipates that the client will have an order for:
- A. diet therapy.
- B. enteral nutrition.
- C. parenteral nutrition.
- D. nasogastric tube feedings.
Correct Answer: C
Rationale: Parenteral nutrition provides nutrients intravenously for clients NPO post-bowel surgery, bypassing the gastrointestinal tract.
Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test? Select all that apply.
- A. Avoid the arm on the affected side after a mastectomy
- B. Do not make further attempts to draw blood if unsuccessful on first 2 attempts
- C. If necessary to use an arm with IV infusing, draw proximal to infusion point
- D. Insert the needle bevel up at a 15-degree angle to the skin
- E. Obtain a finger capillary specimen from the middle of the finger pad
Correct Answer: A,B,C
Rationale: Avoiding the mastectomy side (A), limiting attempts to two (B), and drawing proximal to an IV (C) are correct. A 15-degree angle (D) is for IVs, not phlebotomy, and capillary samples avoid the finger pad center (E).