Nokea
The nurse is preparing to administer a measles, mumps, and rubella (MMR) vaccine to a 15-month-old. Where should the nurse administer the injection?
- A. Deltoid muscle
- B. Vastus lateralis muscle
- C. Gluteal muscle
- D. Subcutaneous tissue of the abdomen
Correct Answer: B
Rationale: The vastus lateralis is the preferred site for intramuscular vaccines like MMR in toddlers due to adequate muscle mass and low risk of nerve damage.
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Which of the following is NOT a procedure to reduce risks associated with invasive surgeries?
- A. Surgical site marking
- B. A time out
- C. Medication reconciliation
- D. A neutral zone for sharps
Correct Answer: C
Rationale: Medication reconciliation ensures accurate medication lists but is not specific to reducing surgical risks, unlike site marking, time out, and neutral zones for sharps.
The nurse is caring for a client with a history of atrial fibrillation who is prescribed vernakalant (Brinavess). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Bradycardia.
- C. Liver toxicity.
- D. Weight gain.
Correct Answer: B
Rationale: Vernakalant can cause bradycardia, requiring close monitoring of heart rate.
The nurse is assessing a client with suspected appendicitis. Which test should the nurse perform to confirm the diagnosis?
- A. Rovsing's sign
- B. Murphy's sign
- C. Psoas sign
- D. Both A and C
Correct Answer: D
Rationale: Rovsing's sign (pain in the right lower quadrant with left-sided pressure) and psoas sign (pain with leg extension) support an appendicitis diagnosis.
Which type of legal consent is indirectly given by the client by the very nature of their voluntary acute care hospitalization?
- A. An opt out consent
- B. An implicit consent
- C. An explicit consent
- D. No consent at all is given
Correct Answer: B
Rationale: Implicit consent is given by the client's voluntary admission to an acute care facility, implying agreement to routine treatments and procedures necessary for their care, unless explicitly refused.
An infant with increased intracranial pressure (ICP) on a regular diet vomits while eating dinner. Which of the following should the nurse do next?
- A. Put the child on nothing-by-mouth (NPO) status.
- B. Call to report this event to the physician.
- C. Wait a few minutes, then refeed the child.
- D. Administer the prescribed antiemetic.
Correct Answer: B
Rationale: Vomiting in an infant with increased ICP may indicate worsening pressure, requiring immediate physician notification.