Nursing Elites

1. A nurse is preparing to administer a blood transfusion. What is the first action?

• A. Administer the blood through an IV push
• B. Verify the client's blood type before starting the transfusion
• C. Warm the blood to body temperature before administration
• D. Ensure the client eats before starting the transfusion

Correct answer: B

Rationale: The correct first action when preparing to administer a blood transfusion is to verify the client's blood type before starting the transfusion. This step is crucial to prevent transfusion reactions and complications. Option A is incorrect because blood transfusions should not be administered through an IV push due to the risk of rapid infusion and adverse reactions. Option C is incorrect because blood should be transfused at room temperature, not body temperature. Option D is incorrect because it is not necessary for the client to eat before a blood transfusion.

2. A nurse is reinforcing teaching about cane use for a client with left-leg weakness. What should the nurse instruct the client to do?

• A. Use the cane on the weak side
• B. Maintain two points of support on the ground at all times
• C. Advance the cane 30 to 45 cm with each step
• D. Advance the cane and the strong leg simultaneously

Correct answer: B

Rationale: The correct answer is B: Maintain two points of support on the ground at all times. When using a cane for left-leg weakness, the client should hold the cane in the right hand and advance the cane and the weak leg simultaneously. This technique provides the necessary support and stability. Option A is incorrect because the cane should be used on the side opposite the weakness to provide support. Option C is incorrect as advancing the cane too far with each step may cause the client to lose balance. Option D is incorrect because advancing the cane and the strong leg simultaneously does not provide the needed support for the weakened leg.

3. What are the nursing responsibilities when administering intravenous (IV) antibiotics?

• A. Verify the antibiotic dosage and check for allergies
• B. Administer the medication without verification
• C. Do not check for allergies or dosage
• D. Ensure the patient is allergic to antibiotics

Correct answer: A

Rationale: When administering IV antibiotics, it is essential for the nurse to verify the antibiotic dosage and check for any allergies the patient may have. This is crucial to ensure that the correct medication is being given at the proper dose and to prevent potential adverse reactions. Choice B is incorrect because administering medication without verification can lead to errors. Choice C is incorrect as it goes against safe medication administration practices. Choice D is incorrect as the focus should be on checking if the patient has allergies to antibiotics, not ensuring the patient is allergic to them.

4. A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse take?

• A. Use the Z-track method to administer the medication.
• B. Use a 1.5-inch needle to administer the medication.
• C. Use the deltoid muscle for the injection.
• D. Administer the injection at a 90° angle.

Correct answer: A

Rationale: The Z-track method should be used to administer IM injections in obese clients to prevent medication from leaking into subcutaneous tissue. Using a longer needle (1.5 inches) ensures that the medication reaches the muscle mass adequately. Choice C is incorrect because the deltoid muscle is not ideal for IM injections in obese clients due to inadequate muscle mass. Administering the injection at a 90° angle (perpendicular to the skin) is recommended for IM injections to ensure proper delivery into the muscle.

5. What is the proper technique for administering an intramuscular (IM) injection?

• A. Locate the injection site and insert at 90 degrees
• B. Insert needle at a 45-degree angle
• C. Massage the site after injection
• D. Insert needle at a 15-degree angle

Correct answer: A

Rationale: The correct technique for administering an intramuscular (IM) injection is to locate the injection site and insert the needle at a 90-degree angle. This angle ensures that the medication is delivered into the muscle for proper absorption. Choice B is incorrect because a 45-degree angle is typically used for subcutaneous injections, not intramuscular. Choice C is incorrect as massaging the site after an injection can cause the medication to disperse unevenly. Choice D is incorrect as a 15-degree angle would not reach the muscle layer effectively for an IM injection.

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