Nokea
The nurse has reinforced education at a conference on intramuscular (IM) injections. Which of the following statements by the participant would indicate a correct understanding of the teaching?
- A. "1 mL is the maximum volume in a single site for small children and older infants."
- B. "Depress the plunger as the needle is being inserted into the client's skin to minimize discomfort."
- C. "Insert the needle quickly using a dart-like motion at a 60-degree angle."
- D. "Injecting in the ventrogluteal muscle is more painful than the vastus lateralis."
Correct Answer: A
Rationale: The maximum volume for IM injections in small children and older infants is 1 mL to prevent tissue damage; other options contain incorrect techniques or assumptions.
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A client is to receive peritoneal dialysis. To prepare for the procedure, the nurse should?
- A. Assess the dialysis access for a bruit and thrill.
- B. Insert an indwelling urinary catheter and drain all urine from the bladder.
- C. Ask the client to turn toward the left side.
- D. Warm the solution in the warmer.
Correct Answer: D
Rationale: Warming the dialysis solution prevents discomfort and promotes effective dialysis by relaxing abdominal muscles.
In providing care to the client with leukemia who has developed thrombocytopenia, the nurse assesses the most common sites for bleeding. Which of the following is not a common site?
- A. Biliary system.
- B. Gastrointestinal tract.
- C. Brain and meninges.
- D. Pulmonary system.
Correct Answer: A
Rationale: Thrombocytopenia in leukemia increases bleeding risk in the gastrointestinal tract, brain/meninges, and pulmonary system due to mucosal surfaces and vascularity. The biliary system is not a common site for bleeding.
The nurse notes that the sterile, occlusive dressing on the central catheter insertion site of a client receiving total parenteral nutrition (TPN) is moist. The client is breathing easily with no abnormal breath sounds. The nurse should do the following in order of what priority from first to last?
- A. Change dressing per institutional policy.
- B. Culture drainage at insertion site.
- C. Notify physician.
- D. Position rolled towel under client's back, parallel to the spine.
Correct Answer: C,B,A,D
Rationale: The priority is to notify the physician (C) due to potential infection indicated by a moist dressing, followed by culturing drainage (B) to identify the organism, changing the dressing (A) to maintain sterility, and positioning a towel (D), which is unrelated to the immediate issue. CN: Pharmacological and parenteral therapies; CL: Synthesize
A client with jaundice has pruritis and states that he has areas of irritation from scratching. What measures can the nurse discuss to prevent skin breakdown? Select all that apply.
- A. Avoid lotions containing calamine.
- B. Take baking soda baths.
- C. Keep nails short and clean.
- D. Rub with knuckles instead of nails.
- E. Massage skin with alcohol.
- F. Increase sodium intake in diet.
Correct Answer: B,C,D
Rationale: Baking soda baths (B), short nails (C), and rubbing with knuckles (D) reduce itching and prevent skin breakdown. Calamine (A) is helpful, not avoided. Alcohol (E) dries skin, worsening irritation. Sodium (F) is unrelated.
After surgery for gastric cancer, a client is scheduled to undergo radiation therapy. It will be most important for the nurse to include information about which of the following in the client's teaching plan?
- A. Nutritional intake.
- B. Management of alopecia.
- C. Exercise and activity levels.
- D. Access to community resources.
Correct Answer: A
Rationale: Radiation therapy can affect appetite and digestion, making nutritional intake a priority in the teaching plan to maintain the client's strength and recovery. The other options are less critical.