A nurse is giving iron dextran intramuscularly (IM). Why should the nurse implement the Z-track method?
a. Makes the injection less painful
b. Prevents staining of the skin
c. Prevents postinjection pain
d. Allows another injection to be given at the same location
B
The Z-track method only ensures that no iron will be staining the skin after injection. The amount of pain is the same and, after all IM injections, the needle is cleaned on withdrawal. Injections are never given at recent injection sites.
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The nurse is working with a student nurse during assessment of a 2-hour-old newborn. Which action indicates that the student nurse understands neonatal assessment? The student nurse:
1. Listens to bowel sounds then assesses the head for skull consistency, and size and tension of fontanels. 2. Checks for Ortolani's sign, then palpates femoral pulse, then assesses respiratory rate. 3. Determines skin color, then describes shape of the chest and looks at structures and flexion of the feet. 4. Counts the number of cord vessels, then assess genitals, then sclera color and eyelids.
If the patient tells the nurse, "I'm not an alcoholic. I can stop whenever I want to," what should be the nurse's most therapeutic response?
a. "Well, why don't you?" b. "Hasn't alcohol use interfered with your employment?" c. "A positive attitude like that is a good start." d. "What would you call alcoholism?"
A patient receiving a blood transfusion reports nausea and back pain 10 minutes into the transfusion. The nurse realizes the patient is experiencing which type of hypersensitivity response?
1. Type I 2. Type III 3. Type IV 4. Type II
A patient is awaiting surgery. The nurse's best rationale for assessing vital signs is to:
A. assess the patient's anxiety level. B. determine the patient's basal temperature. C. establish a baseline for vital signs comparisons. D. assess for any changes in the blood pressure and pulse.