Nokea
When taking blood pressure at the brachial artery, the nurse should place the client's arm in which position?
- A. Slightly above the level of the heart
- B. At the level of the heart
- C. At a level of comfort for the client
- D. Below the level of the heart
Correct Answer: B
Rationale: When taking blood pressure at the brachial artery, it is crucial to place the client's arm at the level of the heart to ensure accurate measurement. Placing the arm above or below the heart level can lead to incorrect readings. Option A, placing the arm slightly above the heart level, would result in falsely lower blood pressure readings as gravity would assist in a lower value. Option C, placing the arm at a level of comfort for the client, may not align with the standardized technique required for accurate blood pressure assessment. Option D, placing the arm below the level of the heart, would likely yield falsely higher blood pressure readings due to increased hydrostatic pressure pushing the blood against gravity.
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A client with a history of asthma is experiencing wheezing and shortness of breath. What is the priority nursing intervention?
- A. Administer a bronchodilator as prescribed
- B. Encourage the client to drink fluids
- C. Place the client in an upright position
- D. Assess the client's peak flow rate
Correct Answer: A
Rationale: Administering a bronchodilator as prescribed is the priority nursing intervention for a client experiencing wheezing and shortness of breath due to asthma. Bronchodilators help relieve bronchoconstriction, allowing better airflow and improving breathing. Encouraging the client to drink fluids may be beneficial in certain situations, but it is not the priority when the client is in respiratory distress. Placing the client in an upright position, not supine, can facilitate easier breathing by allowing the chest to expand fully. While assessing the client's peak flow rate is important in asthma management, in this acute situation, the priority is to provide immediate relief by administering the bronchodilator.
The nurse is preparing to administer a subcutaneous injection of heparin. What is the correct angle of insertion?
- A. 15 degrees
- B. 30 degrees
- C. 45 degrees
- D. 90 degrees
Correct Answer: C
Rationale: The correct angle of insertion for a subcutaneous injection, such as heparin, is 45 degrees. This angle is appropriate as it helps to ensure proper delivery of the medication into the subcutaneous tissue. Option A (15 degrees) is too shallow for a subcutaneous injection and may result in the medication being deposited into the muscle. Option B (30 degrees) is also too shallow for subcutaneous injections. Option D (90 degrees) is used for intramuscular injections, not subcutaneous injections.
A client with type 1 diabetes is experiencing symptoms of hypoglycemia. What is the nurse's priority intervention?
- A. Administer glucagon intramuscularly
- B. Provide a complex carbohydrate snack
- C. Administer 50% dextrose intravenously
- D. Give 15 grams of a fast-acting carbohydrate
Correct Answer: D
Rationale: The priority intervention for a client with type 1 diabetes experiencing symptoms of hypoglycemia is to give 15 grams of a fast-acting carbohydrate. In a hypoglycemic state, the priority is to quickly raise the blood glucose level. Administering glucagon intramuscularly (Choice A) is reserved for severe hypoglycemia when the client is unable to take oral carbohydrates. Providing a complex carbohydrate snack (Choice B) is beneficial after the initial treatment of hypoglycemia to prevent recurrence. Administering 50% dextrose intravenously (Choice C) is a more invasive intervention typically done in a hospital setting for severe cases.
When inserting an indwelling urinary catheter in a female client and urine flows into the tubing, what is the next action?
- A. Document the color and clarity of the urine
- B. Insert the catheter an additional inch
- C. Ask the client to breathe deeply and slowly exhale
- D. Inflate the balloon with 5 mL of sterile water
Correct Answer: D
Rationale: When urine flows into the tubing during the insertion of an indwelling urinary catheter, it confirms proper catheter placement. The next step should be to inflate the balloon with the specified amount of sterile water to secure the catheter in place. Documenting the color and clarity of the urine (choice A) is important for assessment but not the immediate next action. Inserting the catheter further (choice B) without securing it could cause harm. Asking the client to breathe deeply (choice C) is not relevant to this situation.
A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy protocol that includes methotrexate, an antimetabolite. Which information should the nurse provide the parents about caring for their child?
- A. Use sunblock or protective clothing when outdoors.
- B. Include the child in regular outings with the family.
- C. Obtain any childhood vaccinations that are not up-to-date.
- D. Use diluted commercial mouthwash for mouth care.
Correct Answer: A
Rationale: The correct answer is to use sunblock or protective clothing when outdoors. Methotrexate can cause photosensitivity, making the child more prone to sunburns and skin damage. Therefore, advising the parents to protect their child's skin from direct sunlight exposure is crucial. Choice B is incorrect because exposing the child to direct sunlight without protection can worsen the photosensitivity caused by methotrexate. Choice C is incorrect as obtaining vaccinations is generally avoided during chemotherapy due to the child's compromised immune system. Choice D is incorrect as commercial mouthwash may contain alcohol, which can be irritating to the child's oral mucosa, especially during chemotherapy.