Nokea
When the nurse alternates injection sites on the client's upper arms, how far apart should the injections be spaced?
- A. 1/4'' (0.6 cm)
- B. 1/2'' (1.3 cm)
- C. 1'' (2.5 cm)
- D. 2'' (5 cm)
Correct Answer: C
Rationale: Injections should be spaced 1'' apart to prevent tissue irritation and ensure proper drug absorption.
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The nurse observes a coworker acting erratically. The clients assigned to this coworker don’t seem to get relief when pain medications are administered. Which action should the nurse implement?
- A. Try to help the coworker by confronting the coworker with the nurse’s suspicions.
- B. Tell the coworker that the nurse will give all narcotic medications from now on.
- C. Report the nurse’s suspicions to the nurse’s supervisor or the facility’s peer review.
- D. Do nothing until the nurse can prove the coworker has been using drugs.
Correct Answer: C
Rationale: Erratic behavior and ineffective pain relief suggest possible drug diversion. Reporting to the supervisor or peer review (C) ensures proper investigation while protecting patients. Confronting (A) may escalate, taking over medications (B) doesn’t address the issue, and waiting for proof (D) risks harm.
The nurse is admitting the client for rule-out encephalitis. Which interventions should the nurse assess to support the diagnosis of encephalitis? Select all that apply.
- A. Determine if the client has recently received any immunizations.
- B. Ask the client if he or she has had a cold in the last week.
- C. Check to see if the client has active herpes simplex 1.
- D. Find out if the client has traveled to the Great Lakes region.
- E. Assess for exposure to soil with fungal spores.
Correct Answer: C
Rationale: Encephalitis is often viral, with herpes simplex virus (HSV-1, C) a common cause, supporting the diagnosis. Recent immunizations (A), colds (B), travel (D), and fungal exposure (E) are less directly linked to encephalitis.
Which intervention should the nurse implement to decrease increased intracranial pressure (ICP) for a client on a ventilator? Select all that apply.
- A. Position the client with the head of the bed up 30 degrees.
- B. Cluster activities of care.
- C. Suction the client every three (3) hours.
- D. Administer soapsuds enemas until clear.
- E. Place the client in Trendelenburg position.
Correct Answer: A
Rationale: HOB at 30 degrees (A) promotes venous drainage, reducing ICP. Clustering activities (B) increases ICP, suctioning every 3 hours (C) is excessive, enemas (D) are irrelevant, and Trendelenburg (E) worsens ICP.
The client diagnosed with Parkinson’s disease (PD) is being admitted with a fever and patchy infiltrates in the lung fields on the chest x-ray. Which clinical manifestations of PD would explain these assessment data?
- A. Masklike facies and shuffling gait.
- B. Difficulty swallowing and immobility.
- C. Pill rolling of fingers and flat affect.
- D. Lack of arm swing and bradykinesia.
Correct Answer: B
Rationale: Difficulty swallowing and immobility (B) in PD increase aspiration risk, leading to pneumonia, which presents as fever and lung infiltrates. Other manifestations are less directly related to pulmonary complications.
The charge nurse is making assignments. Which client should be assigned to the new graduate nurse?
- A. The client diagnosed with aseptic meningitis who is complaining of a headache and the light bothering his eyes.
- B. The client diagnosed with Parkinson’s disease who fell during the night and is complaining of difficulty walking.
- C. The client diagnosed with a cerebrovascular accident whose vital signs are P 60, R 14, and BP 198/68.
- D. The client diagnosed with a brain tumor who has a new complaint of seeing spots before the eyes.
Correct Answer: A
Rationale: Aseptic meningitis with headache and photophobia (A) is a stable condition suitable for a new graduate, requiring basic symptom management. Parkinson’s with a fall (B) needs fall risk assessment, CVA with high BP (C) requires experienced intervention, and brain tumor with visual changes (D) suggests progression needing expertise.