Nokea
The nurse is preparing to administer an injection of haloperidol decanoate (Haldol D).
- A. What is the most appropriate action for the nurse when administering haloperidol decanoate IM?
- B. Massage the injection site.
- C. Give deep IM in a large muscle mass.
- D. Use a 2 inch 25 gauge needle.
- E. Administer the medication in divided doses.
Correct Answer: B
Rationale: Haloperidol decanoate is highly irritating to subcutaneous tissue, requiring deep IM injection into a large muscle mass to ensure proper absorption and minimize irritation. Massaging the site, using a small-gauge needle, or dividing doses is inappropriate.
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The nurse is admitting a client to the unit from the postoperative recovery area after abdominal exploratory surgery.
After determining the client's vital signs, which of the following activities should the nurse perform next?
- A. Position the client on her left side, supported with pillows.
- B. Check the chart and determine the status of the fluid balance from surgery.
- C. Check the client's abdominal dressing for any evidence of bleeding.
- D. Monitor the incision and pulmonary status for the presence of infection.
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) implementation, complete assessment first (2) assessment, determine what is happening to the patient now (3) correct-assessment, dressing should be checked on admission to the room and frequently for the next several hours (4) inappropriate assessment, it is too soon for infection to occur secondary to surgery
A client arrives in the emergency department after a radiologic accident at a local factory. The first action of the nurse would be to
- A. begin decontamination procedures for the client
- B. ensure physiologic stability of the client
- C. wrap the client in blankets to minimize staff contamination
- D. double bag the client's contaminated clothing
Correct Answer: B
Rationale: The nurse must initially assist in stabilizing the patient prior to performing the other tasks related to radiologic contamination.
A client is being discharged following insertion of a permanent set pacemaker. A client with a permanent set pacemaker should be taught:
- A. To keep a loose dressing over the insertion site at all times
- B. That the pacemaker will function continuously at a set rate
- C. That increases in activity will require adjustments in the pacemaker setting
- D. That he will have to modify his lifestyle to allow for afternoon rest periods
Correct Answer: C
Rationale: Modern pacemakers adjust their rate based on activity (rate-responsive pacing), so the client should understand that increased activity may require pacemaker adjustments.
While giving care to a 2 year-old client, the nurse should remember that the toddler's tendency to say 'no' to almost everything is an indication of what psychosocial skill?
- A. Stubborn behavior
- B. Rejection of parents
- C. Frustration with adults
- D. Assertion of control
Correct Answer: D
Rationale: Assertion of control. Negativity is a normal behavior in toddlers. The nurse must be aware that this behavior is an important sign of the child's progress from dependency to autonomy and independence.
The nurse is teaching a woman the normal changes of pregnancy. Which statement by the woman indicates correct understanding?
- A. There is decreased oxygen consumption during pregnancy.'
- B. There is an increased rate of peristalsis in the GI tract.'
- C. I will have a 50% increase in blood volume.'
- D. My metabolic rate will decrease.'
Correct Answer: C
Rationale: Pregnancy increases blood volume by about 50% to support fetal circulation, a correct understanding. Oxygen consumption and metabolic rate increase, and peristalsis slows.