Nokea
Which action is included in the accurate procedure for administering heparin sodium subcutaneously?
- A. Injecting the medication via an infusion device
- B. Massaging the injection site after administration
- C. Injecting the medication 1 inch from the umbilicus
- D. Avoiding aspiration before administration of the medication
Correct Answer: D
Rationale: Aspiration before administration of heparin sodium, an anticoagulant, should be avoided. Heparin administered by the subcutaneous route does not require an infusion device. The injection site is above the iliac crest or in the abdominal fat layer. It is injected at least 2 inches from the umbilicus. After administration, the needle is withdrawn, pressure is applied to the injection site, but the site is not massaged. Injection sites are rotated.
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While assisting the physician with an amniocentesis on a multigravid client at 38 weeks' gestation, the nurse observes that the fluid is very cloudy and thick. The nurse interprets this finding as indicating which of the following?
- A. Intrauterine infection.
- B. Fetal meconium staining.
- C. Erythroblastosis fetalis.
- D. Normal amniotic fluid.
Correct Answer: B
Rationale: Cloudy, thick amniotic fluid often indicates meconium staining, suggesting fetal distress, which requires further evaluation.
An adult client has bacterial conjunctivitis. What should the nurse teach him to do? Select all that apply.
- A. Use warm saline soaks four times per day to remove crusting.
- B. Apply topical antibiotic without touching the tip of the tube to his eye.
- C. Wash his hands after touching his eyes.
- D. Avoid touching his eyes.
- E. Observe isolation procedures and confine himself to his bedroom until the redness in the eye disappears.
Correct Answer: A,B,C,D
Rationale: Warm saline soaks, careful antibiotic application, hand washing, and avoiding eye contact prevent spread and promote healing. Isolation is unnecessary unless specified.
You are working in a community pediatric health clinic. Which expected life transition should you apply into your practice for these pediatric clients as you are caring for pediatric clients of all ages?
- A. Pregnancy
- B. Puberty
- C. Childhood immunizations
- D. Separation anxiety
Correct Answer: B
Rationale: Puberty is a significant life transition for pediatric clients, particularly adolescents, and is relevant across the age range in a pediatric clinic. It involves physical, emotional, and social changes that nurses should consider in their practice.
A client with emphysema is receiving continuous oxygen therapy. Depressed ventilation is likely to occur unless the nurse ensures that the oxygen is administered in which of the following ways?
- A. Cooled.
- B. Humidified.
- C. At a low flow rate.
- D. Through nasal cannula.
Correct Answer: C
Rationale: Low flow rate oxygen prevents CO2 retention in emphysema clients, reducing the risk of depressed ventilation.
Sertraline is prescribed for a client in the treatment of depression. Before administering the medication, the nurse reviews the client's record and consults with the primary health care provider when which finding is noted?
- A. Prescribed phenelzine sulfate
- B. A history of diabetes mellitus
- C. A history of myocardial infarction
- D. A history of irritable bowel syndrome
Correct Answer: A
Rationale: Sertraline is a serotonin reuptake inhibitor. Serious potentially fatal reactions may occur if sertraline is administered concurrently with a monoamine oxidase inhibitor (MAOI). Phenelzine sulfate is an MAOI. MAOIs should be stopped at least 14 days before sertraline therapy. Sertraline should also be stopped at least 14 days before MAOI therapy. The remaining options are not concerns associated with the administration of this medication.