Nokea
The nurse is to administer an IM injection to a 6-month-old child. What is the most appropriate site to use?
- A. Vastus lateralis
- B. Dorsal gluteal
- C. Ventral gluteal
- D. Iliac crest
Correct Answer: A
Rationale: Infants and small children do not have enough muscle in the gluteal area to use that site. The vastus lateralis is the appropriate site. The iliac crest is a site used for SC injections, not IM.
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A 67-year-old client is to be discharged from the hospital. The client is taking digoxin and furosemide daily. Which instruction is most essential for the nurse to give this client?
- A. Take your medicine early in the day.
- B. Be sure to drink orange juice and eat bananas or melons every day.
- C. Avoid foods that are high in sodium.
- D. Drink plenty of milk.
Correct Answer: B
Rationale: Furosemide causes potassium loss; orange juice, bananas, and melons are potassium-rich, preventing hypokalemia.
The client diagnosed with Parkinson's disease is taking levodopa (L-dopa) and is experiencing an 'on/off' effect. Which action should the nurse take regarding this medication?
- A. Document the occurrence and take no action.
- B. Request the HCP to increase the dose of medication.
- C. Discuss the client's imminent death as a result of this complication.
- D. Explain this is a desired effect of the medication.
Correct Answer: A
Rationale: The on/off effect is a known levodopa issue; documenting monitors progression without immediate action. Increasing dose, death discussions, or calling it desired are incorrect.
A toddler who has swallowed several adult aspirin is admitted to the emergency room. When admitted, the child is breathing but is difficult to arouse. What is the immediate priority of care?
- A. Administration of syrup of ipecac
- B. Cardiopulmonary resuscitation
- C. Ventilatory support
- D. Gastric lavage
Correct Answer: D
Rationale: Gastric lavage is the priority to remove aspirin from the stomach, preventing further absorption, given the child is breathing but unresponsive.
The client is complaining of incisional pain. Which intervention should the nurse implement first?
- A. Administer the pain medication STAT.
- B. Determine when the last pain medication was given.
- C. Assess the client's pulse and blood pressure.
- D. Teach the client distraction techniques to address pain.
Correct Answer: B
Rationale: Determining the last dose ensures safe timing and avoids overdose, the first step in pain management per nursing process.
A client is receiving erythromycin 500 mg IV every 6 hours to treat a pneumonia. Which of the following is the most common side effect of the medication?
- A. Blurred vision
- B. Nausea and vomiting
- C. Severe headache
- D. Insomnia
Correct Answer: B
Rationale: Nausea and vomiting. Nausea is a common side-effect of erythromycin in both oral and intravenous forms.