Nokea
When administering an IM injection to a 5-month-old infant, which of the following injection sites should be used?
- A. Deltoid
- B. Ventrogluteal
- C. Vastus lateralis
- D. Dorsogluteal
Correct Answer: C
Rationale: For infants and young children, the vastus lateralis muscle located over the anterior thigh is the preferred site for intramuscular injections. This site is chosen for its large muscle mass and reduced risk of injury to major nerves and blood vessels. Infants have less developed muscle structures, making the vastus lateralis a safer and more effective site for injections compared to other sites like the deltoid, ventrogluteal, or dorsogluteal. Using the correct injection site is essential to prevent complications and ensure the proper absorption of the medication.
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Which intervention should the nurse implement to prevent contractures in a patient who is immobile?
- A. Encouraging frequent changes in position
- B. Applying heat packs to stiff joints
- C. Administering muscle relaxants
- D. Using soft restraints to immobilize the extremities
Correct Answer: A
Rationale: Frequent position changes prevent contractures in immobile patients by keeping joints mobile and reducing muscle shortening risks. Heat or relaxants offer relief but don't address root immobility, and restraints worsen stiffness. Nurses use this to maintain range of motion, ensuring flexibility and function, a proactive measure against permanent musculoskeletal damage in prolonged stillness.
During postoperative teaching following a hip arthroplasty, which instruction should the nurse include?
- A. Avoid lying on your operative side.
- B. Cross your legs at the ankles only.
- C. Place a pillow between your legs when turning.
- D. Avoid bending your hip more than 120 degrees.
Correct Answer: C
Rationale: The correct instruction for the nurse to include during postoperative teaching following a hip arthroplasty is to 'Place a pillow between your legs when turning.' Placing a pillow between the legs when turning is crucial as it helps prevent dislocation of the hip prosthesis. This position aids in maintaining proper alignment and stability, thereby reducing the risk of complications after hip arthroplasty surgery. Choices A, B, and D are incorrect because they do not directly address the specific action needed to protect the hip prosthesis and prevent complications.
A client with chronic kidney disease is being educated by a nurse about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should limit my intake of protein to prevent overworking my kidneys.
- B. I should increase my intake of potassium-rich foods.
- C. I should increase my intake of phosphorus-rich foods.
- D. I should increase my intake of calcium-rich foods.
Correct Answer: A
Rationale: The correct answer is A. In chronic kidney disease, limiting protein intake is crucial to prevent overworking the kidneys. Excessive protein consumption can lead to the accumulation of metabolic waste products that the kidneys struggle to process, worsening kidney function. Therefore, by recognizing the need to restrict protein intake, the client demonstrates an understanding of the dietary management required for their condition. Choices B, C, and D are incorrect. Increasing intake of potassium-rich foods (Choice B) is not recommended in chronic kidney disease as it can lead to hyperkalemia. Similarly, increasing intake of phosphorus-rich foods (Choice C) is not advised because impaired kidneys struggle to excrete phosphorus, leading to elevated levels in the blood. Lastly, increasing intake of calcium-rich foods (Choice D) may not be necessary unless there is a specific deficiency or requirement, as calcium balance is often disrupted in chronic kidney disease.
A client with hyperkalemia is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of potassium-rich foods.
- B. I should decrease my intake of potassium-rich foods.
- C. I should increase my intake of sodium-rich foods.
- D. I should decrease my intake of sodium-rich foods.
Correct Answer: B
Rationale: Correct! Hyperkalemia is a condition characterized by high levels of potassium in the blood. To manage hyperkalemia, it is essential to decrease the intake of potassium-rich foods since excess potassium can worsen the condition. By understanding the need to decrease potassium-rich foods, the client shows comprehension of the dietary management required for hyperkalemia. Choice A is incorrect because increasing potassium-rich foods would exacerbate hyperkalemia. Choice C is incorrect since increasing sodium-rich foods is unrelated to managing hyperkalemia and could potentially lead to other health issues. Choice D is incorrect as decreasing sodium-rich foods is not the primary focus when managing hyperkalemia.
When caring for a client with a spinal cord injury, the nurse continually monitors this client for which medical emergency?
- A. Hemorrhage
- B. Hypovolemic shock
- C. Gastrointestinal atony
- D. Autonomic hyperreflexia
Correct Answer: D
Rationale: Autonomic hyperreflexia (D) is a medical emergency in spinal cord injury (SCI) above T6, causing severe hypertension from unopposed sympathetic response. Hemorrhage (A) or shock (B) requires trauma context. GI atony (C) is chronic, not emergent. D is correct. Rationale: Hyperreflexia, triggered by stimuli like bladder distension, can lead to stroke or death if untreated, requiring urgent monitoring and intervention, per SCI emergency protocols, unlike less acute complications.