Nokea
Which of the following techniques for administering the Mantoux test is correct?
- A. Hold the needle and syringe almost parallel to the client's skin.
- B. Pinch the skin when inserting the needle.
- C. Aspirate before injecting the medication.
- D. Massage the site after injecting the medication.
Correct Answer: A
Rationale: The Mantoux test requires intradermal injection, with the needle held almost parallel to the skin to form a wheal. Pinching, aspirating, or massaging disrupts the test's accuracy.
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The nurse is teaching a caregiver how to administer an injection of enoxaparin. Which statement, if made by the caregiver, would require further teaching?
- A. "I will give this injection in the abdomen."
- B. "I should give this injection at a 30 degree angle."
- C. "Acetaminophen is safe while taking this medication for any aches or pains."
- D. "A soft toothbrush should be used while taking this medicine."
Correct Answer: B
Rationale: Enoxaparin is administered subcutaneously at a 90-degree angle, not 30 degrees, to ensure proper absorption.
A client with acute renal failure has a potassium level of 6.5 mEq/L. The nurse should prepare for:
- A. IV insulin and glucose.
- B. Oral potassium supplements.
- C. Fluid restriction.
- D. Diuretic administration.
Correct Answer: A
Rationale: Insulin and glucose shift potassium into cells, treating hyperkalemia.
The nurse has attended a staff development conference regarding patient-controlled analgesia. Which of the following statements by the nurse indicates effective understanding?
- A. A client may be prescribed a loading dose before they are able to activate their own prescribed dosage.
- B. PCAs are not recommended for individuals with acute pain.
- C. PCAs decrease the need for a client to have pain assessments.
- D. When a client receives a PCA via a continuous basal rate, it decreases their risk for adverse effects.
Correct Answer: A
Rationale: A loading dose is often used in PCA to achieve initial pain control before the patient begins self-administering doses. PCAs are suitable for acute pain, do not eliminate the need for pain assessments, and continuous basal rates may increase adverse effect risks.
A client with allergic rhinitis is instructed on the correct technique for using an intranasal inhaler. Which the patient is the client should demonstrate to the nurse that the client understands the instructions?
- A. I should limit the use of the inhaler to early morning and bedtime use.
- B. It is important to not shake the canister because that can damage the spray device.
- C. I should hold one nostril closed while I insert the spray into the other nostril.
- D. The inhaler tip is inserted into the nostril and pointed toward the inside nostril wall.
Correct Answer: C
Rationale: Holding one nostril closed while spraying into the other ensures proper delivery of the medication to the nasal mucosa. Limiting use to specific times is not typically required unless specified by the prescriber. Shaking the canister is often necessary for some inhalers to mix the medication. Pointing the inhaler toward the inner nostril wall is incorrect; it should be directed upward and slightly outward.
The nurse is developing a discharge plan for a client who had a phacoemulsification procedure. Which of the following should the nurse include? Select all that apply.
- A. Teach the client how to instill eye drops.
- B. Instruct the client not to lie on the affected side.
- C. Remind the client that a reduction of vision is normal.
- D. Provide the client with an eye patch for the affected eye.
- E. Educate the client to avoid bending at the waist.
Correct Answer: A,B,D,E
Rationale: Post-phacoemulsification care includes teaching eye drop instillation, avoiding lying on the affected side, using an eye patch for protection, and avoiding bending to prevent pressure increase. Reduced vision is not normal and requires evaluation.