Nokea
The nurse is precepting a newly hired nurse administering an intramuscular injection to an adult. Which action by the newly hired nurse requires follow-up?
- A. Prepares to administer the medication in the dorsogluteal.
- B. Prepares to insert the needle at a 90-degree angle.
- C. Uses isopropyl alcohol to clean the area prior to injection.
- D. Washes their hands before and after the procedure.
Correct Answer: A
Rationale: The dorsogluteal site is not recommended due to the risk of sciatic nerve injury.
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After surgery for head and neck cancer, a client has a permanent tracheostomy. The nurse should teach the client and family about the importance of:
- A. Providing tracheostomy site care.
- B. Addressing the psychosocial issues related to tracheostomy.
- C. Observing for early signs and symptoms of skin breakdown around the tracheostomy site.
- D. Using humidifiers to prevent thick, tenacious secretions.
Correct Answer: A,C,D
Rationale: Tracheostomy site care (A), monitoring for skin breakdown (C), and using humidifiers (D) are critical to prevent infection, maintain skin integrity, and keep secretions manageable.
A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, 'Why can't I stop talking about these things? I know those days are gone forever.' Which of the following responses by the nurse conveys the best understanding of the client's behavior?
- A. Be patient. It takes time to adjust to such a massive loss.'
- B. I will be sure to tell the team that reviewing the past is a form of denial. We have to help you focus on today.'
- C. Reviewing your losses is a way to help you work through your grief and loss.'
- D. It's a simple escape mechanism to go back and live again in happier times.'
Correct Answer: C
Rationale: Reflecting on past activities is part of grieving, helping the client process the loss of function.
The nurse is planning care for a client with a femoral fracture who is in balanced suspension traction. Which of the following would the nurse be least likely to include in the plan of care?
- A. Use of a fracture bedpan.
- B. Checks for redness over the ischial tuberosity.
- C. Elevation of the head of bed no more than 25 degrees.
- D. Personal hygiene with a complete bed bath.
Correct Answer: C
Rationale: Elevating the head of the bed beyond 25 degrees can disrupt traction alignment, making it least appropriate.
A nurse is assessing a client with heart failure. The nurse should assess the client based on which compensatory mechanisms that are activated in the presence of heart failure? Select all that apply.
- A. Sympathetic nervous system activation.
- B. Renin-angiotensin-aldosterone system activation.
- C. Myocardial hypertrophy.
- D. Natriuretic peptide release.
- E. Ventricular dilation.
Correct Answer: A,B,C,D,E
Rationale: Heart failure activates the sympathetic nervous system (A), renin-angiotensin-aldosterone system (B), myocardial hypertrophy (C), natriuretic peptide release (D), and ventricular dilation (E) to compensate for reduced cardiac output.
The nurse is caring for a client with a fractured pelvis in pelvic traction. Which activity is contraindicated?
- A. Log rolling to change positions.
- B. Deep breathing exercises.
- C. Using a trapeze for repositioning.
- D. Applying moisturizer to the skin.
Correct Answer: A
Rationale: Log rolling is contraindicated in pelvic traction to maintain alignment and prevent displacement.