The nurse is preparing to give an injection of iron (Imferon) to a patient with anemia. What is the rationale for using the Z-track method for injection?
a. Prevent pain at the site
b. Prevent tissue damage at the site
c. Promote absorption of the medication
d. Prevent discoloration of tissue at the site
ANS: D
Administer intramuscular iron injections by Z-track method to avoid staining the injection site. A. C. Z-track will not prevent pain or improve absorption. B. Tissue damage is not usually a problem.
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A prenatal patient asks the nurse how the baby can possibly come out through her vagina, because a vagina is not nearly as big as a baby. How does the nurse best answer this patient's question? "The vagina:
1. "Usually tears as it stretches during childbirth.". 2. "Is designed to allow a baby come through.". 3. "Changes due to pregnancy hormones, and stretches more.". 4. "Dilates and effaces in labor so the baby can get out.".
A group of students is reviewing information about the frail elderly and functional status. The students demonstrate understanding when they identify which as an instrumental activity of daily living?
A) Bathing B) Cooking C) Toileting D) Eating
The mother of a premature infant born at 32 weeks' gestation expresses the desire to breastfeed her child. An appropriate suggestion by the nurse would be:
1. "Mothers who cannot directly breastfeed should talk with and stroke their infants during gavage feedings, as this can help facilitate milk letdown." 2. "The letdown reflex is best initiated by having the baby suck at the breast." 3. "Pumping should be done no more than three times daily, making sure to empty each breast completely." 4. "You should begin pumping by six hours postpartum to ensure adequate milk production."
The nurse notes excessive swelling of the ankles and legs in a patient with a history of congestive heart failure. What would be a recommended change to this patient's care plan?
A) Reduce oxygen B) Reduce ambulation C) Encourage deep breathing D) Implement dietary changes