Nokea
The nurse is observing a nursing student prepare to give an intramuscular (IM) injection in a client's deltoid. Which action by the student requires follow-up?
- A. Depresses the plunger of the syringe during the insertion of the needle
- B. Locates the injection site 3 finger widths below the acromion process
- C. Positions the client either lying or sitting position
- D. Dons clean gloves before administering the injection
Correct Answer: A
Rationale: Depressing the plunger during needle insertion can cause medication to leak into subcutaneous tissue, leading to improper administration and potential tissue damage.
You may also like to solve these questions
The American Heart Association (AHA) guidelines urge greater availability of automated external defibrillators (AEDs) and people trained to use them. AEDs are used in cardiac arrest situations for:
- A. Early defibrillation in cases of atrial fibrillation.
- B. Cardiovascular placement.
- C. Early defibrillation in cases of ventricular fibrillation.
- D. None of the above
Correct Answer: C
Rationale: AEDs are used for early defibrillation in ventricular fibrillation or pulseless ventricular tachycardia, as these are shockable rhythms that can be corrected to restore cardiac function.
The nurse is caring for a client with herpes simplex virus who is experiencing an outbreak. Which medication does the nurse anticipate that the primary healthcare provider (PHCP) will prescribe?
- A. Metronidazole
- B. Acyclovir
- C. Imiquimod
- D. Fluconazole
Correct Answer: B
Rationale: Acyclovir is an antiviral medication used to treat herpes simplex virus (HSV) infections. Choice A (metronidazole) is used for bacterial and parasitic infections, Choice C (antibiotic) is for topical treatment of genital warts, and Choice D (fluconazole) is an antifungal for yeast infections.
A nurse is assessing a 42-year-old client who has been receiving chemotherapy. The client has a platelet count of 22,000 cells/mm³ and has petechiae on the lower extremities. The nurse should advise the client to:
- A. Increase the amount of iron in the client's diet.
- B. Apply lotion to the lower extremities.
- C. Elevate the legs.
- D. Consult the oncologist.
Correct Answer: D
Rationale: A platelet count of 22,000/mm³ with petechiae indicates severe thrombocytopenia, requiring urgent consultation with the oncologist for potential platelet transfusion or treatment adjustment.
Three weeks after the client has had an ileostomy, the nurse is following up with instruction about using a skin barrier around the stoma at all times. The client has been applying the skin barrier correctly when:
- A. There is no odor from the stoma.
- B. The client is adequately hydrated.
- C. There is no skin irritation around the stoma.
- D. The client only changes the ostomy pouch once a day.
Correct Answer: C
Rationale: Correct application of a skin barrier is indicated by no skin irritation around the stoma, as the barrier protects the peristomal skin. Odor, hydration, and pouch change frequency are not direct indicators of proper barrier use. CN: Physiological adaptation; CL: Evaluate
The nurse uses a Doppler ultrasound device to assess the client's lower extremities. In addition, the nurse calculates the ankle-brachial index to estimate stenosis of the:
- A. Arteries
- B. Aorta
- C. Carotid
- D. Veins
Correct Answer: A
Rationale: The ankle-brachial index (ABI) measures the ratio of ankle to brachial systolic blood pressure to assess arterial stenosis in the lower extremities. A low ABI indicates arterial narrowing, typical in PVD. It does not assess the aorta, carotid, or veins.