Nokea
The nurse plans on administering a medication using the Z-track intramuscular technique. The nurse knows the following steps are required during the procedure. Select all that apply.
- A. Draw 0.2-0.5 cc of air after aspirating the prescribed medication.
- B. Use the vastus lateralis muscle.
- C. Replace the needle used for medication withdrawal with a new one prior to injection.
- D. Insert the needle at 45-degree angle.
Correct Answer: A,C
Rationale: Z-track requires an air lock (A) to seal medication and a new needle (C) to prevent tracking. The needle is inserted at 90 degrees, not 45 (D), and various muscles can be used (B is not mandatory).
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Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives?
- A. Weight gain should be reported to the physician.
- B. An alternate method of birth control is needed when taking antibiotics.
- C. If the client misses one or more pills, two pills should be taken per day for 1 week.
- D. Changes in the menstrual flow should be reported to the physician.
Correct Answer: B
Rationale: Antibiotics can reduce the effectiveness of oral contraceptives, necessitating an alternate method.
A client with psychotic depression is receiving haloperidol (Haldol). Which of the following adverse effects is associated with haloperidol?
- A. Akathisia
- B. Cataracts
- C. Diaphoresis
- D. Polyuria
Correct Answer: A
Rationale: Akathisia, a movement disorder characterized by restlessness, is a common extrapyramidal side effect of haloperidol.
The nurse is preparing to deliver an infusion of vancomycin through a client's peripherally inserted central catheter (PICC). Shortly after the infusion begins the IV pumps beeps, indicating a blockage. How should the nurse proceed? Select all that apply.
- A. start a peripheral IV in the opposite limb
- B. notify the PICC nurse if unable to clear the blockage
- C. use a 5 mL syringe to flush the PICC with sterile saline
- D. ask the client to raise and lower the arm or cough
- E. attempt to flush the line by aggressively pushing heparin to clear the blockage
- F. use a 10 mL syringe to gently flush the PICC with sterile saline or tPA as ordered
Correct Answer: B, D, F
Rationale: Notifying the PICC nurse, repositioning the arm, and gently flushing with a 10 mL syringe (saline or tPA as ordered) are appropriate. Aggressive flushing or small syringes risk damage, and a peripheral IV is unnecessary.
A client recently started on hemodialysis wants to know how the dialysis will take the place of his kidneys. The nurse's response is based on the knowledge that hemodialysis works by:
- A. Passing water through a dialyzing membrane
- B. Eliminating plasma proteins from the blood
- C. Lowering the pH by removing nonvolatile acids
- D. Filtering waste through a dialyzing membrane
Correct Answer: D
Rationale: Hemodialysis filters waste products and excess fluids through a dialyzing membrane, mimicking kidney function.
The nurse is caring for a client with bipolar disorder. The client has been manipulating some of the staff and other clients in order to get her way. Which actions by the nurse are appropriate in managing this client? Select all that apply.
- A. giving support when the client exhibits positive behaviors
- B. setting clear limits and communicating expected behaviors
- C. role playing with the client to demonstrate appropriate behaviors
- D. treating the client more like a friend in order to show respect for her as a person
- E. giving the client small gifts, such as extra dessert, in order to encourage appropriate behavior
Correct Answer: A,B,C
Rationale: Appropriate actions include reinforcing positive behaviors (A), setting clear limits (B), and role-playing (C) to promote appropriate interactions. Treating as a friend (D) or giving gifts (E) blurs boundaries and encourages manipulation.