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What is the appropriate needle gauge for intradermal injection?
- A. 20G
- B. 22G
- C. 25G
- D. 26G
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures the hourly urine output. When should she notify the physician?
- A. Less than 30 ml/hour
- B. 64 ml in 2 hours
- C. 90 ml in 3 hours
- D. 125 ml in 4 hours
Correct Answer: A
Rationale: Notifying the physician is necessary when the urine output is less than 30 ml/hour as it indicates impaired kidney function. Adequate urine output is essential for monitoring kidney function, and a urine output less than 30 ml/hour could suggest potential renal issues that require medical attention.
During a Romberg test, the patient is asked to assume which position?
- A. Sitting
- B. Standing
- C. Genupectoral
- D. Trendelenburg
Correct Answer: B
Rationale: During a Romberg test, the patient is asked to stand with feet together and arms at the sides. The test evaluates proprioception and vestibular function by assessing the patient's ability to maintain balance with eyes closed. Asking the patient to stand helps to detect any balance issues or disturbances in the absence of visual input.
A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patient's skin. The most appropriate nursing action would be to:
- A. Withhold the medication and notify the physician
- B. Administer the medication and notify the physician
- C. Administer the medication with an antihistamine
- D. Apply corn starch soaks to the rash
Correct Answer: A
Rationale: In this scenario, the appearance of a rash after administering penicillin, even in a patient with no known allergies, is concerning for a potential allergic reaction. The appropriate action for the nurse to take is to withhold the medication and notify the physician. This precaution is necessary to prevent further administration of a medication that may be causing an adverse reaction, as allergic reactions can range from mild to severe and require immediate intervention.
After routine patient contact, how long should hand washing last at least?
- A. 30 seconds
- B. 1 minute
- C. 2 minutes
- D. 3 minutes
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
How can preserving skin integrity impact the circular chain of infection?
- A. Host
- B. Reservoir
- C. Mode of transmission
- D. Portal of entry
Correct Answer: D
Rationale: Preserving skin integrity plays a key role in breaking the chain of infection by eliminating the portal of entry for pathogens. When the skin is intact, it acts as a natural barrier that prevents pathogens from entering the body. By maintaining skin integrity through proper hygiene and wound care, the risk of infection is significantly reduced, disrupting the cycle of infection transmission.