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The nurse is preparing to give a subcutaneous injection to an elderly, emaciated client. Which needle length and angle should the nurse plan to use to administer the injection safely?
- A. A 3/8-inch needle at a 90-degree angle.
- B. A 3/8-inch needle at a 45-degree angle.
- C. A 1/2-inch needle at a 15-degree angle.
- D. A 5/8-inch needle at a 90-degree angle.
Correct Answer: B
Rationale: For an emaciated client, a 3/8-inch needle at a 45-degree angle ensures subcutaneous delivery without hitting muscle or bone.
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The nurse providing care to a client with a leg fracture ensures that which intervention is first implemented before the fracture is reduced in the casting room?
- A. Obtaining an anesthesia consent
- B. Administering an opioid analgesic
- C. Notifying the operating room staff
- D. Obtaining an informed consent for treatment
Correct Answer: D
Rationale: Before a fracture is reduced, an informed consent for treatment is needed. The nurse should reinforce explanations according to the client's needs and ability to understand. Administration of anesthesia would only be done in the operating room for open reduction of fractures. Closed reductions may be done in the emergency department without anesthesia. An analgesic would be administered as prescribed because the procedure is painful, but the informed consent form must be obtained before administering the medication.
The nurse is assessing a client with a suspected hip fracture. Which of the following findings is most likely to be present?
- A. External rotation of the affected leg.
- B. Increased range of motion in the hip.
- C. Absence of pain on weight-bearing.
- D. Symmetrical leg lengths.
Correct Answer: A
Rationale: External rotation of the affected leg is a common sign of a hip fracture due to muscle and bone displacement.
The nurse is preparing to start an I.V. infusion. Before inserting the needle into a vein, the nurse should apply a tourniquet to the client's arm to accomplish which of the following?
- A. Distend the veins.
- B. Stabilize the veins.
- C. Immobilize the arm.
- D. Occlude arterial circulation.
Correct Answer: A
Rationale: A tourniquet distends veins by restricting venous return, making them easier to access for I.V. insertion.
A client with a history of chronic lymphocytic leukemia is prescribed prednisone. The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia.
- B. Weight gain.
- C. Hypotension.
- D. Hair loss.
Correct Answer: B
Rationale: Prednisone, a corticosteroid, commonly causes weight gain due to fluid retention and increased appetite.
Your client is receiving brachytherapy. What nursing intervention should you implement for this client?
- A. Exclude pregnant visitors from the client's room.
- B. Place the client in a negative pressure room.
- C. Have all visitors wear protective masks and boots.
- D. All of the above
Correct Answer: A
Rationale: Brachytherapy involves internal radiation, posing a risk to pregnant individuals due to radiation exposure. Excluding pregnant visitors minimizes this risk.