Nokea
The nurse holds the gauze pledget against an I.M. injection site while removing the needle from the muscle. This technique helps to:
- A. Seal off the track left by the needle in the tissue.
- B. Speed the spread of the medication in the tissue.
- C. Avoid the discomfort of the needle pulling on the skin.
- D. Prevent organisms from entering the body through the skin puncture.
Correct Answer: A
Rationale: Holding gauze against the injection site prevents medication leakage along the needle track, ensuring proper drug absorption.
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A 6-year-old client is diagnosed with attention deficit hyperactivity disorder (ADHD). When asking this client to complete a task, what techniques should the nurse use to communicate most effectively with him?
- A. Obtain eye contact before speaking, use simple language, and have him repeat what was said. Praise him if he completes the task.
- B. Fully explain to the client the actions required of him, offer verbal praise and a food reward for task completion.
- C. Explain to the client what he is to do, the consequences if he does not comply, and follow through with praise or consequences as appropriate.
- D. Demonstrate to the client what he is to do, have him imitate the nurse's actions, and give a food reward if he completes the task.
Correct Answer: A
Rationale: Clear, simple instructions with eye contact and repetition enhance communication for a child with ADHD, and praise reinforces positive behavior.
A client with a history of liver failure is admitted with hepatic encephalopathy. The nurse should monitor the client for which of the following?
- A. Asterixis.
- B. Hypotension.
- C. Polyuria.
- D. Bradycardia.
Correct Answer: A
Rationale: Asterixis (flapping tremor) is a hallmark sign of hepatic encephalopathy due to ammonia buildup.
The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the chart A. The nurse compares these findings to the Apgar score obtained at birth, as determined by the findings in the chart B. What should the nurse do next?
- A. Notify the neonatologist on call.
- B. Continue to assess the neonate.
- C. Apply an oxygen mask.
- D. Rub the neonate’s extremities.
Correct Answer: B
Rationale: The neonate’s Apgar score has been improving since birth. (The birth score is 6; the current score is 9.) The nurse should continue to assess the neonate. There is no indication that oxygen is
needed since the color is improving, and stimulating the baby is not necessary as the he is now fl exing his extremities.
A 19-year-old G1 P0 is being discharged home after hospitalization for hyperemesis gravidarum and is being referred to home health care. The nurse should develop a discharge plan that includes which of the following? Select all that apply.
- A. Refer client to a nutritionist for the following day.
- B. Ensure that the client has a prescription for an antiemetic.
- C. Ask the health care provider (HCP) for an anxiolytic prescription.
- D. Encourage return to normal routine when client feels ready.
- E. Coordinate follow-up appointment with provider in 6 weeks.
- F. Discuss plan of care and discharge instructions with client.
Correct Answer: A, B, D, F
Rationale: For hyperemesis gravidarum, a nutritionist referral, antiemetic prescription, gradual return to routine, and discussing discharge instructions are essential. Anxiolytics may not be indicated, and a 6-week follow-up is too delayed.
A client with a diagnosis of Parkinson's disease is prescribed pramipexole (Mirapex). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Drowsiness.
- C. Weight gain.
- D. Hyperglycemia.
Correct Answer: B
Rationale: Pramipexole, a dopamine agonist, commonly causes drowsiness, which the nurse should monitor in Parkinson's clients.