Nursing Elites

1. All of the following interventions are correct when using the Z-track method of drug injection except:

• A. Prepare the injection site with alcohol
• B. Use a needle that is at least 1” long
• C. Aspirate for blood before injection
• D. Rub the site vigorously after the injection to promote absorption

Correct answer: D

Rationale: When using the Z-track method of drug injection, it is important to prepare the injection site with alcohol to ensure cleanliness, use a needle that is at least 1” long to reach the muscle tissue, and aspirate for blood before injection to verify correct needle placement. However, rubbing the site vigorously after the injection is not recommended as it can cause medication to leak into subcutaneous tissue, compromising the medication's intended absorption and efficacy.

2. A client is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take?

• A. Cleanse equipment before removal from the client's room.
• B. Limit the client's visitors to 30 minutes per day.
• C. Discard the client's linens in a double bag.
• D. Discard the radioactive source in a biohazard bag

Correct answer: D

Rationale: When caring for a client receiving brachytherapy, it is crucial to handle radioactive sources appropriately. Discarding the radioactive source in a biohazard bag is essential to prevent exposure to radiation. Cleaning equipment before removal, limiting client's visitors, or discarding linens in a double bag are not specific to the management of radioactive sources in brachytherapy.

3. When caring for a client who is on contact precautions, which of the following measures should the nurse include in the teaching?

• A. Remove the protective gown after leaving the client's room.
• B. Place the client in a room with negative pressure.
• C. Wear gloves when providing care to the client.
• D. Wear a mask when in the client's room.

Correct answer: C

Rationale: Contact precautions are used for clients with known or suspected infections that are spread by direct or indirect contact. The most important measure for healthcare workers when caring for a client on contact precautions is to wear gloves when providing care. This helps prevent the transmission of infectious agents between the client and the healthcare worker. Removing the protective gown after leaving the client's room, placing the client in a room with negative pressure, and wearing a mask when in the client's room are not specific to contact precautions and may not be necessary for all clients on contact precautions.

4. A client with active tuberculosis is prescribed isoniazid, rifampin, pyrazinamide, and ethambutol. Which statement by the client indicates an understanding of the teaching?

• A. I can substitute one medication for another if I run out because they all fight infection.
• B. I will wash my hands each time I cough.
• C. I am glad I don't have to have any more sputum specimens.
• D. I don't need to worry about where I go once I start taking my medications.

Correct answer: B

Rationale: The correct statement indicating understanding of tuberculosis medication regimen is 'I will wash my hands each time I cough.' This statement shows knowledge of infection control practices to prevent the spread of tuberculosis. Washing hands after coughing helps in reducing the transmission of the disease to others. The other options are incorrect. Option A is incorrect as each medication in the regimen has a specific role, and substituting one for another can compromise the effectiveness of treatment. Option C is incorrect as obtaining sputum specimens is essential for monitoring treatment response. Option D is incorrect as the client should still adhere to infection control measures and avoid exposing others to tuberculosis.

5. When preparing to administer eye drops to a school-age child, what actions should a nurse take?

• A. 52341
• B. 53241
• C. 35241
• D. 14325

Correct answer: A

Rationale: The correct sequence for administering eye drops to a school-age child is as follows: 5. Place the child in a sitting position, 2. Ask the child to look upward, 3. Pull the lower eyelid downward, 4. Instill the drops of medication, and 1. Apply pressure to the lacrimal punctum. Placing the child in a sitting position helps with stability and ease of access. Asking the child to look upward helps expose the conjunctival sac. Pulling the lower eyelid downward creates a pouch for instilling the drops. Instilling the drops of medication directly into the pouch ensures proper administration, and applying pressure to the lacrimal punctum prevents systemic absorption and promotes local action of the medication.

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