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. "Aspiration before injection of IM medications is no longer universally recommended."
- B. "The deltoid muscle provides slower absorption rates than gluteal sites."
- C. "To ease a client's anxiety, inform the client that an IM injection will not hurt."
- D. "The dorsogluteal muscle is recommended as a site for IM injections."
Correct Answer: A
Rationale: Aspiration is not universally recommended for IM injections due to lack of evidence supporting its necessity.
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The nurse should teach the client who is receiving warfarin sodium that:
- A. Partial thromboplastin time values determine the dosage of warfarin sodium.
- B. Protamine sulfate is used to reverse the effects of warfarin sodium.
- C. International Normalized Ratio (INR) is used to assess effectiveness.
- D. Warfarin sodium will facilitate clotting of the blood.
Correct Answer: C
Rationale: INR monitors warfarin's anticoagulant effectiveness, guiding dosage adjustments to prevent clotting or bleeding.
What should the nurse teach a client about stoma care?
- A. Clean with hydrogen peroxide.
- B. Measure stoma size weekly.
- C. Apply adhesive remover.
- D. Change pouch every day.
Correct Answer: B
Rationale: Measuring stoma size weekly ensures proper appliance fit as swelling subsides.
A nurse is planning care for a client who underwent a percutaneous needle biopsy of the kidney. What should the nurse plan to do immediately after the biopsy? Select all that apply.
- A. Assess the biopsy site.
- B. Take vital signs every hour.
- C. Assess urine for hematuria.
- D. Place the client in a prone position.
- E. Assess the client for chest pain.
Correct Answer: A,C,D
Rationale: Assessing the biopsy site, urine for hematuria, and placing the client prone help monitor for bleeding and promote hemostasis post-biopsy.
The nurse finds the client who has had an ileostomy crying. The client explains to the nurse, 'I'm upset because I know I won't be able to have children now that I have an ileostomy.' Which of the following would be the best response for the nurse?
- A. Many women with an ileostomy can still have children; let's discuss your concerns with your doctor.
- B. Having an ileostomy does prevent pregnancy, but you can explore adoption.
- C. This is a common feeling; would you like to talk more about it?
- D. I'll RAW arrange for a counselor to discuss your fertility options.
Correct Answer: A
Rationale: The nurse should reassure the client that many women with ileostomies can still have children and offer to discuss this with the doctor, addressing the misconception directly. The other options either reinforce the misconception, avoid the concern, or defer without providing immediate support. CN: Psychosocial adaptation; CL: Synthesize
Following a thoracotomy, the client has severe pain. Which of the following strategies for pain management will be most effective for this client?
- A. Repositioning the client immediately after administering pain medication.
- B. Reassessing the client 30 minutes after administering pain medication.
- C. Verbally reassuring the client after administering pain medication.
- D. Readjusting the pain medication dosage as needed according to the client's condition.
Correct Answer: D
Rationale: Readjusting pain medication dosage based on the client's condition ensures adequate pain control, critical for recovery. Repositioning, reassessing, and reassurance are supportive but less effective alone.