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 stage 1 pressure ulcer on the right heel. Which of the following interventions should the nurse include in the plan?

Correct answer: C

Rationale: Applying a transparent dressing over the heel is beneficial as it can protect the ulcer from friction and shear, and allow for continuous observation of the wound. This intervention promotes healing and prevents further damage to the skin. Choice A is incorrect because applying heat can increase the risk of tissue damage and should be avoided. Choice B is incorrect as changing the dressing every 12 hours may disrupt the wound healing process and is not necessary for a stage 1 pressure ulcer. Choice D is incorrect because using a water pressure mattress is not a specific intervention for a stage 1 pressure ulcer on the heel.

3. During tracheostomy care, what action should a healthcare professional take?

Correct answer: D

Rationale: Changing tracheostomy ties if they are wet is essential to prevent infection and maintain skin integrity. Wet ties can harbor bacteria, increasing the risk of skin breakdown and other complications. Regularly changing wet ties promotes cleanliness, reduces the likelihood of complications, and ensures optimal care for the client with a tracheostomy.

4. A client with hyperlipidemia is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B. In hyperlipidemia management, decreasing the intake of foods high in cholesterol is crucial to improve lipid levels and reduce the risk of cardiovascular diseases. Choices A and C are incorrect as increasing intake of saturated fats or trans fats can raise cholesterol levels, worsening the condition. Choice D is incorrect because decreasing intake of foods high in fiber is not recommended as fiber-rich foods are beneficial for heart health, which is important in managing hyperlipidemia.

5. A client has a new diagnosis of lactose intolerance and is receiving teaching from a nurse about dietary management. Which of the following statements should the nurse include in the teaching?

Correct answer: A

Rationale: The correct statement for the nurse to include in teaching a client with lactose intolerance is to avoid foods that contain lactose. Lactose intolerance results from the body's inability to digest lactose, a sugar found in dairy products. By avoiding foods containing lactose, the client can manage symptoms and prevent complications associated with lactose intolerance. Choices B, C, and D are incorrect. Increasing intake of high-fiber foods (choice B) may be beneficial for general health but is not directly related to lactose intolerance. Avoiding gluten (choice C) is necessary for individuals with celiac disease, not lactose intolerance. Increasing intake of dairy products (choice D) would worsen symptoms in individuals with lactose intolerance due to the lactose content.

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