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 is caring for an older adult client who is confused and has a high risk for falls. The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the restroom. Which nursing interventions are appropriate when caring for this client? Select all that apply.
- A. Ensuring bed alarm remains activated
- B. Initiating an hourly rounding schedule
- C. Inserting an indwelling urinary catheter
- D. Moving client to a room close to the nurses' station
- E. Raising all side rails of the client's bed
Correct Answer: A,B,D
Rationale: Bed alarms (A), hourly rounding (B), and proximity to the nurses' station (D) enhance safety and monitoring. Catheters (C) increase infection risk and are not first-line, and raising all side rails (E) is a restraint and unsafe.
The nurse prepares to insert an indwelling urinary catheter in a client who is disoriented to time, place, and person and cannot follow directions or commands. Which intervention is most important when inserting the urinary catheter?
- A. Ensure the client understands the procedure prior to implementation
- B. Maintain a sterile field and keep the urinary catheter sterile
- C. Place the catheter supply kit between the client's legs in the center of the bed
- D. Throw swabs used to clean the perineum directly into the biohazard bin
Correct Answer: B
Rationale: Maintaining a sterile field (B) is critical to prevent infection, especially in a disoriented client. Explaining the procedure (A) is ideal but not feasible, kit placement (C) is secondary, and swab disposal (D) follows insertion.
The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility?
- A. Genital herpes and HIV
- B. Gonorrhea and chlamydia
- C. Human papillomavirus and syphilis
- D. Yeast and trichomoniasis
Correct Answer: B
Rationale: Gonorrhea and chlamydia (B) are bacterial infections that commonly cause pelvic inflammatory disease and infertility if untreated. Other options are less associated with these outcomes.
A woman who had a tuberculosis test three days ago reports to the nurse to have the test read. Which finding, if present, indicates a positive result and a need for referral and follow-up?
- A. A red area 12 mm in diameter
- B. A raised area 10 mm in diameter
- C. Itching at the injection site
- D. A rash on the arm near the test site
Correct Answer: B
Rationale: A raised (indurated) area >10 mm indicates a positive TB skin test, requiring follow-up for potential latent or active TB.
The nurse is planning care for an 11-year-old child with attention deficit hyperactivity disorder who is hospitalized for surgical treatment of a fractured femur. What is the priority nursing action?
- A. Create a structured and consistent environment with a daily schedule
- B. Give the child a written schedule of activities
- C. Provide a verbal explanation of what to expect during hospitalization
- D. Restrict visitors while the child is hospitalized
Correct Answer: A
Rationale: A structured environment (A) supports ADHD management by reducing overstimulation and providing predictability, critical for a hospitalized child. Written schedules (B) and verbal explanations (C) are secondary, and restricting visitors (D) is unnecessary.