Nokea
Which site or technique would you expect to use to administer ferrous sulfate?
- A. A subcutaneous injection site
- B. The PQRST technique
- C. The Z track technique
- D. The sublingual site
Correct Answer: C
Rationale: The Z-track technique is used for ferrous sulfate IM injections to prevent leakage and skin staining.
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Which of the following is true with regard to delegation of client care responsibilities? Select all that apply.
- A. The nurse must know the nursing model that underlies care at the institution.
- B. The nurse delegates in accordance with demands on his/her time.
- C. The nurse validates with the non-RN caregiver that he/she has performed the same activity before.
- D. The nurse retains the right to determine which tasks are delegated.
- E. The nurse must account that the task has been delegated and to whom.
Correct Answer: A, C, D, E
Rationale: Delegation involves understanding the care model, validating caregiver competency, determining tasks, and documenting delegation, but not delegating based solely on time demands.
A child with a diagnosis of sickle cell disease is admitted to the hospital for treatment of vaso-occlusive pain crisis. The nurse should plan for which interventions in the care of the client? Select all that apply.
- A. Increase fluid intake.
- B. Administer oxygen.
- C. Administer meperidine.
- D. Perform frequent pain assessment.
- E. Administer intravenous (IV) fluids.
Correct Answer: A,B,D,E
Rationale: Management of the severe pain that occurs with vaso-occlusive crisis includes frequent pain assessment and the use of strong opioid analgesics, such as morphine sulfate and hydromorphone. Fluids are necessary to promote hydration, so options related to the delivery of fluids are appropriate. Oxygen is administered to increase tissue perfusion. Meperidine is contraindicated because of its side effects and increased risk of seizures after as few as 2 doses.
A 6-month-old infant is admitted with a diagnosis of bacterial meningitis. The nurse should expect to observe which of the following symptoms?
- A. Positive Babinski reflex.
- B. High-pitched cry.
- C. Hypothermia.
- D. Kernig's sign.
Correct Answer: B
Rationale: A high-pitched cry is a common symptom of bacterial meningitis in infants, indicating neurological irritation.
The nurse is assessing a client with a suspected gastrointestinal bleed. Which of the following findings is most indicative of this condition?
- A. Bright red stools.
- B. Hypotension.
- C. Fever.
- D. Abdominal distension.
Correct Answer: B
Rationale: Hypotension is a critical sign of a gastrointestinal bleed due to significant blood loss.
A couple has completed testing and is a candidate for in vitro fertilization. The nurse is reviewing the procedure with them and realizes that further instruction is needed when the woman states:
- A. One of the greatest risks is multiple pregnancies.'
- B. I will need to redefine how I view my job if I do become pregnant.'
- C. The fertilization procedure can be done anytime during my cycle.'
- D. We can use our own eggs and sperm or someone else's.'
Correct Answer: C
Rationale: IVF requires precise timing with the menstrual cycle, so the statement about performing it anytime indicates a need for further instruction.