The nurse is preparing to administer an intramuscular (IM) injection to a neonate. Which gauge and size needle should the nurse use to administer the medication?
- A. 19 gauge, 1 1/2" (3.8 cm) needle
- B. 18 gauge, 1" (2.5 cm) needle
- C. 20 gauge, 1" (2.5 cm) needle
- D. 25 gauge, 5/8" (1.6 cm) needle
Correct Answer: D
Rationale: A 25-gauge, 5/8" needle is appropriate for neonates due to their small muscle mass and thin subcutaneous tissue, minimizing trauma.
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A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should:
- A. Institute range-of-motion (ROM) exercise every 4 hours.
- B. Massage the abdomen once a shift.
- C. Use an alternating air pressure mattress.
- D. Elevate the lower extremities.
Correct Answer: C
Rationale: An alternating air pressure mattress (C) prevents pressure ulcers in clients with edema. ROM exercises (A) and elevation (D) are helpful but secondary. Abdominal massage (B) is not indicated.
Which of the following is an appropriate expected outcome for a client recovering from a total laryngectomy? The client will:
- A. Regain the ability to taste and smell food.
- B. Demonstrate appropriate care of the gastrostomy tube.
- C. Communicate feelings about body image changes.
- D. Demonstrate sterile suctioning technique for stoma care.
Correct Answer: C
Rationale: Communicating feelings about body image changes is an appropriate psychosocial outcome post-laryngectomy, addressing adaptation to altered appearance. Taste and smell may be impaired long-term. Gastrostomy tubes are not always required. Sterile suctioning is a nursing task, not a client outcome.
The client tells the preoperative nurse that she cannot hear without her hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response?
- A. Explain to the client that it is policy not to take personal items to surgery because they may be lost or broken.
- B. Tell the client that she will bring the hearing aid to the postanesthesia care unit so that she can have it as soon as she wakes up.
- C. Explain to the client that she will have a premedication that will make her sleep before she goes to surgery and she won't need to hear.
- D. Call the surgery unit to explain the client's concern and ask if she can wear her hearing aid to surgery.
Correct Answer: D
Rationale: Calling the surgery unit to discuss the client's need for a hearing aid ensures her communication needs are addressed while adhering to surgical safety protocols. This action balances patient advocacy with policy considerations.
The nurse is planning care for a client with severe postoperative pain. There is an order for 10 mg MSO4. Which of the following should the nurse do first?
- A. Obtain an intravenous infusion system.
- B. Prepare the medication for administration.
- C. Contact the Pharmacy Department.
- D. Contact the physician that ordered the medication.
Correct Answer: A
Rationale: MSO4 (morphine sulfate) is typically given IV for severe pain. Obtaining an IV infusion system ensures the medication can be administered safely and effectively.
A client with Raynaud's phenomenon is prescribed diltiazem (Cardizem). An expected outcome is:
- A. Decreased heart rate
- B. A return to normal sinus rhythm
- C. Reduced episodes of finger numbness
- D. Increased SpO2
Correct Answer: C
Rationale: Diltiazem, a calcium channel blocker, reduces vasospasm in Raynaud's by promoting vasodilation, decreasing episodes of finger numbness. It may lower heart rate or affect rhythm, but these are not primary goals, and SpO2 is not directly improved.
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