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Which of the following techniques is correct when administering a subcutaneous injection?
- A. Use a 1-inch needle for injection.
- B. Insert the needle at a 45-degree angle to the skin.
- C. Spread the skin tightly at the injection site.
- D. Draw 0.2 mL of air into the syringe before administration.
Correct Answer: B
Rationale: A subcutaneous injection is correctly administered at a 45-degree angle (or 90 degrees for obese patients) using a 5/8-inch needle, pinching the skin, without an air bubble.
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A client is scheduled for a creatinine clearance test. Which one of the following preparations is appropriate for the nurse to make?
- A. Instruct the client about the need to collect urine for 24 hours.
- B. Prepare to insert an indwelling urethral catheter.
- C. Provide the client with a sterile urine collection container.
- D. Instruct the client to force fluids to 3,000 mL/day.
Correct Answer: A
Rationale: A creatinine clearance test requires a 24-hour urine collection to assess kidney function accurately, making this the appropriate preparation.
Which of the following would be most important for the nurse to include in the teaching plan for a client who is taking phenelzine (Nardil)?
- A. Eating a normal amount of salt in the diet.
- B. Drinking 10 to 12 glasses of water each day.
- C. Allowing 10 days to achieve therapeutic effects.
- D. Avoiding foods high in tyramine.
Correct Answer: D
Rationale: Phenelzine, an MAOI, requires avoiding tyramine-rich foods to prevent hypertensive crisis.
The nurse is teaching a client with a new diagnosis of asthma about the use of a peak flow meter. Which of the following instructions is most important?
- A. Use the meter once a week.
- B. Record the highest of three readings.
- C. Clean the meter with soap daily.
- D. Use the meter only during an asthma attack.
Correct Answer: B
Rationale: Recording the highest of three readings provides an accurate measure of peak expiratory flow to monitor asthma control.
A client with a spinal cord injury is at risk for autonomic dysreflexia. Which symptom should the nurse monitor for?
- A. Bradycardia.
- B. Hypotension.
- C. Severe headache.
- D. Increased urine output.
Correct Answer: C
Rationale: Severe headache is a key sign of autonomic dysreflexia, often triggered by bladder or bowel issues.
The nurse is caring for a client with a closed head injury. Which finding indicates increasing intracranial pressure?
- A. Widening pulse pressure
- B. Tachycardia
- C. Hyperthermia
- D. Hypotension
Correct Answer: A
Rationale: Widening pulse pressure (e.g., increasing systolic with stable diastolic) is a sign of increasing intracranial pressure, part of Cushing's triad.