a nurse is preparing to administer an intramuscular im injection to a client which of the following actions should the nurse take
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Nursing Elites

ATI LPN

LPN Fundamentals of Nursing

1. A healthcare professional is preparing to administer an intramuscular (IM) injection to a client. Which of the following actions should the healthcare professional take?

Correct answer: C

Rationale: Aspirating before injecting the medication is a crucial step in IM injections to check for blood return, ensuring that the needle is not in a blood vessel. This technique helps prevent accidental intravascular injection of the medication, reducing the risk of complications such as inadvertent intravenous administration of the substance.

2. A client has a pressure ulcer. Which of the following findings indicates healing of the ulcer?

Correct answer: B

Rationale: When a pressure ulcer is healing, there is a decrease in its size as the tissue repair progresses. This reduction in size is a positive indication of the healing process. An increase in drainage, presence of foul odor, or reddened wound edges are typically signs of infection or lack of improvement. Therefore, the correct answer is a decrease in size.

3. A client is receiving discharge teaching after a total hip arthroplasty. Which of the following instructions should be included?

Correct answer: B

Rationale: To prevent dislocation of the hip prosthesis, the client should avoid bending their hips more than 90 degrees. Excessive bending at the hips can increase the risk of hip dislocation, which is a significant concern following total hip arthroplasty. Sitting with crossed legs at the ankles (choice A) can also increase the risk of hip dislocation and should be avoided. Sitting in a low-seated chair (choice C) can make it more challenging for the client to stand up safely. Twisting the body when standing up (choice D) can also strain the hip joint and increase the risk of dislocation. Therefore, the correct instruction to include during discharge teaching is to avoid bending the hips more than 90 degrees.

4. When assessing a client with chronic pain, which of the following is the most reliable indicator of the client's pain?

Correct answer: B

Rationale: The client's self-report of pain is the most reliable indicator of pain. Pain is a subjective experience, and the client's self-report provides direct insight into their perception of pain intensity, quality, and impact on daily life. Vital signs, body language, and medical history can offer additional information but may not accurately reflect the client's actual pain experience. Therefore, relying on the client's self-report ensures a more accurate assessment of their pain and helps in tailoring appropriate interventions and treatment plans.

5. During an admission interview, a nurse is assessing a client's personal identity. Which of the following questions should the nurse ask?

Correct answer: B

Rationale: When assessing personal identity, it is important to ask questions that prompt clients to describe themselves. Question B, 'How would you describe yourself?' is the most appropriate as it allows the client to share their own perceptions and characteristics, aiding in understanding their personal identity. Choices A, C, and D are more focused on specific personal details such as marital status, employment status, and parental status, which do not directly contribute to understanding personal identity.

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