Nokea
The nurse is teaching a client how to self-administer subcutaneous heparin injections.Which instruction should the nurse include?
- A. Inject in abdominal area at least 2 inches from the umbilicus.
- B. Rotate injections between the abdomen and gluteal areas.
- C. Massage the injection site to increase absorption.
- D. Expel the air in the prefilled syringe prior to injection.
Correct Answer: A
Rationale: Inject in abdominal area at least 2 inches from the umbilicus. When administering subcutaneous heparin injections, it is important to choose an injection site on either your tummy or outer areas of your left or right thigh. Your tummy is usually best as the injection site and it is important that you change the site each time.
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The nurse observes a new employee, an uncertified nursing assistant (UAP), checking the temperature using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer.Which action should the nurse implement?
- A. Remind the UAP to locate the thermometer before gently inserting the ear.
- B. Demonstrate the correct technique for pulling the client's auricle up and back.
- C. Advise the UAP to hold the thermometer securely in place to obtain the measurement.
- D. Use positive reinforcement to affirm that the procedure being performed correctly.
Correct Answer: D
Rationale: The UAP is correctly pulling the client's auricle up and back and preparing to insert the thermometer.
An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert and requests that no heroic measures be implemented if her breathing stops.What actions should the nurse take first?
- A. Obtain a do not resuscitate prescription.
- B. Set up a family conference to discuss the client's wishes.
- C. Discuss with the client her meaning of heroic measures.
- D. Consult the palliative care team about the client's care.
Correct Answer: C
Rationale: The nurse should first discuss with the client her meaning of heroic measures. This will help the nurse to understand the client's wishes and preferences for her care.
Which response by the nurse is most therapeutic?
- A. Tell me about the visit with your significant other.
- B. I can see that you are feeling lonely.
- C. Would you like to talk for a while?
- D. What did you enjoy about your visit tonight?
Correct Answer: C
Rationale: This response shows that the nurse is willing to listen and provide support to the client. It also allows the client to decide if they want to talk and share their feelings.
The nurse is planning to provide mouth care to an unconscious client.Which statement is accurate for implementing mouth care to this client?
- A. Brushing an unconscious client's teeth should be avoided.
- B. Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client.
- C. Unconscious clients need less frequent mouth care than conscious clients.
- D. Positioning the unconscious client upright is the best method because they are not eating or drinking.
Correct Answer: B
Rationale: Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client. When mouth care is provided, an unconscious patient is placed in the side-lying position because this prevents secretions from pooling at the back of the oral cavity, lowering the risk of aspiration.
A client arrives at the emergency department (ED) with severe right upper quadrant pain.To assess the quality of the client's pain, which approach should the nurse use?
- A. Ask the client to describe the pain.
- B. Provide a numeric pain scale.
- C. Identify effective pain relief measures.
- D. Observe body language and movement.
Correct Answer: A
Rationale: To assess the quality of the client's pain, the nurse should ask the client to describe the pain. This will help the nurse to understand the characteristics of the pain and how it is affecting the client.