Nokea
Which position would most help to decrease a client's discomfort when the client's spouse injects vitamin B12 using the ventrogluteal site?
- A. Lying on the side with legs extended.
- B. Lying on the abdomen with toes pointed inward.
- C. Leaning over the edge of a low table with hips flexed.
- D. Standing upright with the feet one shoulder-width apart.
Correct Answer: B
Rationale: The ventrogluteal site is best accessed when the client lies on their abdomen with toes pointed inward, as this position relaxes the gluteal muscles and minimizes discomfort during injection. The other positions do not optimally relax the muscle or provide access to the ventrogluteal site.
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The nurse is caring for a client with a fractured pelvis in pelvic traction. Which activity is contraindicated?
- A. Log rolling to change positions.
- B. Deep breathing exercises.
- C. Using a trapeze for repositioning.
- D. Applying moisturizer to the skin.
Correct Answer: A
Rationale: Log rolling is contraindicated in pelvic traction to maintain alignment and prevent displacement.
A severe acute respiratory syndrome (SARS) epidemic is suspected in a community of 10,000 people. As clients with SARS are admitted to the hospital, what type of precautions should the nurse institute?
- A. Historic precautions.
- B. Hand-washing precautions.
- C. Reverse isolation.
- D. Standard precautions.
Correct Answer: D
Rationale: SARS requires standard precautions plus airborne and contact precautions, but standard precautions are the baseline for all patients to prevent transmission.
Assessment of the diabetic client for common complications should include examination of the:
- A. Abdomen.
- B. Lymph glands.
- C. Pharynx.
- D. Eyes.
Correct Answer: D
Rationale: Diabetic retinopathy, a common complication, requires regular eye examinations to detect and prevent vision loss.
The nurse is suctioning a client who had a laryngectomy. What is the maximum amount of time the nurse should suction the client?
- A. 10 seconds.
- B. 15 seconds.
- C. 25 seconds.
- D. 30 seconds.
Correct Answer: B
Rationale: Suctioning for no more than 15 seconds prevents hypoxia and trauma to the airway. Longer durations risk oxygen deprivation.
The rate at which I.V. fluids are infused is based on the burn client's:
- A. I.V. and body surface area (BSA) burned.
- B. Total body weight and BSA burned.
- C. Total BSA and BSA burned.
- D. Height and weight and BSA burned.
Correct Answer: B
Rationale: The Parkland Formula uses total body weight and percentage of BSA burned to calculate fluid requirements, ensuring adequate resuscitation based on burn severity.