Nokea
The nurse is preparing an injection of IM haloperidol from a glass ampule. Which of the following actions by the nurse are appropriate? Select all that apply.
- A. Attaches an 18-gauge injection needle to a syringe for withdrawal of medication
- B. Breaks the ampule neck away from the nurse's body to prevent injury from the glass
- C. Disposes of the empty glass ampule in a sharps container
- D. Injects air into the glass ampule prior to withdrawing the medication
- E. Rests and steadies the needle on the ampule's outer rim to withdraw medication
Correct Answer: B,C
Rationale: Breaking the ampule away from the body (B) and disposing in a sharps container (C) are safe practices. An 18-gauge needle (A) is too large, injecting air (D) is unnecessary, and resting the needle on the rim (E) risks contamination.
You may also like to solve these questions
The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse?
- A. I think you or your partner needs to stay with the child while in the hospital.'
- B. Oh, that is expected, so I would just ignore the behavior.'
- C. Perhaps you could gradually leave for short periods.'
- D. You should leave quickly to minimize the child's distress.'
Correct Answer: C
Rationale: Gradually increasing the time of separation can help the child adjust to the mother's absence, reducing anxiety and screaming over time.
A client has many delusions. As the nurse helps the client prepare for breakfast the client comments 'Don't waste good food on me. I'm dying from this disease I have.' The appropriate response would be
- A. You need some nutritious food to help you regain your weight.'
- B. None of the laboratory reports show that you have any physical disease.'
- C. Try to eat a little bit, breakfast is the most important meal of the day.'
- D. I know you believe that you have an incurable disease.'
Correct Answer: D
Rationale: This response does not challenge the client’s delusional system and thus forms an alliance by providing reassurance of desire to help the client.
The nurse is caring for a 10-year-old client with sickle cell disease who is experiencing an episode of acute pain. Which of the following diversional activities would be appropriate for the nurse to offer the client?
- A. putting together a puzzle in the activity room
- B. reading an age-appropriate book
- C. walking down the unit hallways
- D. playing with finger puppets
Correct Answer: B
Rationale: Reading a book (B) is a calm, stationary activity suitable for pain management. Puzzles (A) may require movement, walking (C) could worsen pain, and puppets (D) may be too childish for a 10-year-old.
The nurse is planning care for an 11-year-old child with attention deficit hyperactivity disorder who is hospitalized for surgical treatment of a fractured femur. What is the priority nursing action?
- A. Create a structured and consistent environment with a daily schedule
- B. Give the child a written schedule of activities
- C. Provide a verbal explanation of what to expect during hospitalization
- D. Restrict visitors while the child is hospitalized
Correct Answer: A
Rationale: A structured environment (A) supports ADHD management by reducing overstimulation and providing predictability, critical for a hospitalized child. Written schedules (B) and verbal explanations (C) are secondary, and restricting visitors (D) is unnecessary.
The nurse is providing care to a 9-year-old client who is awaiting surgery. Which intervention is developmentally appropriate for this client's plan of care?
- A. Discuss the procedure with the client using simple diagrams with correct anatomical terminology
- B. Explore the client's perception of how the surgery will positively affect their future
- C. Focus primarily on the client's feelings and concerns regarding surgical scar appearance
- D. Provide initial education about the procedure to the client immediately before it is performed
Correct Answer: A
Rationale: Using simple diagrams with correct terminology (A) is age-appropriate for a 9-year-old, aiding understanding. Future benefits (B) are abstract, scar concerns (C) are secondary, and last-minute education (D) increases anxiety.