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The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?
- A. Ensure bevel of the needle is pointing up.
- B. Massage the site gently after injection.
- C. Hold the syringe perpendicular to the skin.
- D. Select upper arm as the injection site.
Correct Answer: A
Rationale: Bevel up ensures proper delivery.
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The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?
- A. Verify placement of pulse oximeter.
- B. Increase the oxygen to 3 L/minute.
- C. Remove nasal cannula.
- D. Switch to a non-rebreather mask.
Correct Answer: A
Rationale: Verifying placement ensures accurate readings.
The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?
- A. Self-care deficit.
- B. Impaired physical mobility.
- C. Risk for infection.
- D. Risk for impaired skin integrity.
Correct Answer: D
Rationale: Neuropathy increases skin breakdown risk.
What times should the nurse measure vital signs? Select all that apply.
- A. 1500
- B. 1600
- C. 1800
- D. 1000
- E. 1200
Correct Answer: A,B,C,D,E,F,G
Rationale: Context-dependent; typically every 4 hours.
The nurse is viewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client’s plan of care? Select all that apply.
- A. Encourage increased fluid intake and measure urinary output every 8 hours.
- B. Provide comfort measures such as topical warm application and tactile massage.
- C. Determine client’s objective measure of pain using a numerical pain scale.
- D. Assist the client to ambulate as much as possible during waking hours.
- E. Implement a 24-hour schedule of routine administration of prescribed analgesics.
Correct Answer: B,C,E
Rationale: Comfort, assessment, and analgesics manage pain.
An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep?
- A. Ask the healthcare provider for a mild sedative for bedtime.
- B. Take an afternoon nap to make up for missed sleep.
- C. Drink a mixture of warm water, whiskey, and honey at bedtime.
- D. Establish a regular time for going to bed and getting up.
- E. Avoid drinking caffeinated beverages late in the day.
Correct Answer: D,E
Rationale: Regular schedule and avoiding caffeine improve sleep.