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When giving an intramuscular injection to an infant, which of the following sites is preferred?
- A. Ventrogluteal region
- B. Deltoid
- C. Vastus lateralis
- D. Dorsogluteal region
Correct Answer: C
Rationale: The correct answer is the Vastus lateralis when giving an intramuscular injection to an infant. The Vastus lateralis muscle, located in the thigh, is the preferred site for infants as it has a larger muscle mass and is well-developed, making it suitable for injections. The Ventrogluteal region and Dorsogluteal region are not recommended for infants due to their smaller muscle mass and potential risk of damaging nearby structures. The Deltoid muscle is typically used for older children and adults, not infants.
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In a client with asthma who develops respiratory acidosis, what should the nurse expect the client's serum potassium level to be?
- A. normal
- B. elevated
- C. low
- D. unrelated to the pH
Correct Answer: B
Rationale: In respiratory acidosis, the serum potassium level is expected to be elevated. This occurs because potassium shifts from cells into the bloodstream as a compensatory mechanism to maintain acid-base balance. Choices A, C, and D are incorrect. A normal potassium level is not expected in respiratory acidosis. A low potassium level is more commonly associated with alkalosis, not acidosis. The potassium level is indeed related to pH changes in respiratory acidosis, leading to the expected elevation.
Which physiologic mechanism best describes the function of the sodium-potassium pump?
- A. active transport
- B. diffusion
- C. filtration
- D. osmosis
Correct Answer: A
Rationale: Active transport is the correct answer as it accurately describes the process involved in the sodium-potassium pump. The pump utilizes energy to move ions against their concentration gradient, maintaining cellular concentrations. Diffusion (choice B) is a passive process where substances move from an area of higher concentration to lower concentration. Filtration (choice C) involves the movement of solutes based on pressure gradients. Osmosis (choice D) is the movement of water across a semipermeable membrane.
Paula is a 32-year-old woman seeking evaluation and treatment for major depressive symptoms. A major nursing priority during the assessment process includes which of the following?
- A. meaning of current stressors
- B. possibility of self-harm
- C. motivation to participate in treatment
- D. presence of alcohol or other drug use
Correct Answer: B
Rationale: The correct answer is to consider the possibility of self-harm during the assessment process. This is crucial because unless the client is first assessed for self-harm or suicide potential, the necessary degree of vigilance in the client's environment may not be observed. While understanding the meaning of current stressors is important for treatment planning, ensuring the client's safety takes precedence. Motivation to participate in treatment and the presence of alcohol or other drug use are also important aspects to assess but ensuring the client's safety is the top priority in this scenario.
A nurse has been ordered to set up Buck's traction on a patient's lower extremity due to a femur fracture. Which of the following applies to Buck's traction?
- A. A weight greater than 10 lbs. should be used.
- B. The line of pull is upward at an angle.
- C. The line of pull is straight
- D. A weight greater than 20 lbs. should be used.
Correct Answer: C
Rationale: The correct answer is that the line of pull is straight for Buck's traction. This type of traction is applied to maintain alignment and immobilization of fractures, typically involving the lower extremities. A straight line of pull helps to provide the necessary countertraction to keep the fractured bone in proper alignment. Choices A and D are incorrect because Buck's traction commonly uses a weight range between 5-10 lbs, and using a weight greater than 10 or 20 lbs would not be appropriate or safe. Choice B is incorrect as well since the line of pull for Buck's traction is straight, not upward at an angle.
During a petit mal seizure in the clinic, what should be the highest priority?
- A. Provide a safe environment free of obstructions in the immediate area
- B. Call a code
- C. Contact the patient's physician
- D. Prevent excessive movement of the extremities
Correct Answer: A
Rationale: During a petit mal seizure, the highest priority is to provide a safe environment free of obstructions in the immediate area. This action aims to prevent injuries to the patient during the seizure. While calling a code or contacting the patient's physician may be necessary at some point, immediate safety measures take precedence. Preventing excessive movement of the extremities is relevant but ensuring a safe environment is crucial to avoid harm during the seizure.