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

ATI RN

ATI Comprehensive Exit Exam

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

Correct answer: C

Rationale: The correct answer is C: 'Use a Z-track technique to administer the injection.' When administering IM injections, using a Z-track technique helps prevent medication from leaking into subcutaneous tissues. This technique involves pulling the skin laterally, injecting the medication deeply into the muscle, and then releasing the skin. Choice A is incorrect because massaging the injection site after administering the medication can lead to increased blood flow and potential leakage of the medication. Choice B is incorrect as the needle should typically be inserted at a 90° angle for IM injections to ensure proper delivery into the muscle. Choice D is incorrect as aspirating for blood before injecting the medication is not routinely recommended for IM injections.

2. A client with heart failure is receiving furosemide. Which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: A weight loss of 1.1 kg (2.5 lb) in 24 hours may indicate dehydration or fluid imbalance, which should be reported. This rapid weight loss could be a sign of excessive diuresis, potentially leading to hypovolemia or electrolyte imbalances. Monitoring weight changes is crucial in clients with heart failure receiving diuretics. The other findings are within normal ranges and expected in a client receiving furosemide for heart failure. A heart rate of 80/min, a potassium level of 3.8 mEq/L, and a urine output of 60 mL/hr are generally acceptable in this scenario.

3. A healthcare provider is teaching a client who has a new diagnosis of hypertension about dietary management. Which of the following foods should the healthcare provider instruct the client to avoid?

Correct answer: C

Rationale: The correct answer is C. Bacon is high in sodium, which can elevate blood pressure levels. Clients with hypertension should avoid high-sodium foods like bacon to help manage their blood pressure. Choices A, B, and D are healthier options compared to bacon and can be included in a balanced diet for someone with hypertension. Bananas are a good source of potassium, which can help in managing blood pressure. Carrots are low in sodium and high in fiber, making them a heart-healthy choice. Chicken breast is a lean protein option that is beneficial for individuals with hypertension.

4. A client who has a new prescription for levothyroxine is receiving teaching from a nurse. Which statement by the client indicates an understanding of the teaching?

Correct answer: D

Rationale: The correct answer is D: "I will take this medication in the morning before breakfast." Levothyroxine should be taken in the morning before breakfast to improve absorption and effectiveness. Choice A is incorrect because the duration of levothyroxine therapy is usually long-term and not limited to 3 months. Choice B is incorrect because levothyroxine should not be taken with antacids as they may decrease its absorption. Choice C is incorrect because there is no need to avoid foods that contain iodine while taking levothyroxine.

5. What is the priority nursing intervention for a patient experiencing a myocardial infarction?

Correct answer: A

Rationale: The correct answer is to administer aspirin. Administering aspirin is a priority nursing intervention for a patient experiencing a myocardial infarction because it helps reduce the risk of further clot formation. Aspirin is a common medication given during the early stages of a heart attack to prevent additional clotting. Administering nitroglycerin may also be indicated to help relieve chest pain by dilating blood vessels, but aspirin takes precedence due to its role in preventing clot progression. Administering morphine is not typically the first intervention in myocardial infarction as it can mask symptoms and delay other critical treatments. Surgery is not an immediate priority in the initial management of a myocardial infarction.

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