Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
When preparing medication from a vial for a subcutaneous injection for a client, which of the following actions should the nurse take?
A. Hold the syringe so that bubbles collect at the level of the plunger.
Choice A is wrong because holding the syringe so that bubbles collect at the level of the plunger is not necessary when preparing medication from a vial.
B. Hold the vial with the top facing upward while injecting air into the vial.
When preparing medication from a vial for subcutaneous injection for a client, the nurse should hold the vial with the top facing upward while injecting air into the vial. This is because injecting air into the vial equalizes the pressure inside and makes it easier to withdraw the medication 1.
C. Inject air into the vial with the eye of the needle immersed in the fluid.
Choice C is wrong because injecting air into the vial with the eye of the needle immersed in the fluid can contaminate the medication.
D. Hold the syringe at a 45° angle to verify dosage.
Choice D is wrong because holding the syringe at a 45° angle is not necessary when verifying dosage.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Fundamentals 2019 with NGN Proctored Exam. Take the full exam now
Full Explanation
When preparing medication from a vial for subcutaneous injection for a client, the nurse should hold the vial with the top facing upward while injecting air into the vial.
This is because injecting air into the vial equalizes the pressure inside and makes it easier to withdraw the medication 1.
Choice A is wrong because holding the syringe so that bubbles collect at the level of the plunger is not necessary when preparing medication from a vial.
Choice C is wrong because injecting air into the vial with the eye of the needle immersed in the fluid can contaminate the medication.
Choice D is wrong because holding the syringe at a 45° angle is not necessary when verifying dosage.
Similar Questions
When caring for a client who has wrist restraints after an episode of violent behavior, which of the following actions should the nurse take?
A. Tie the restraints to the side rail.
Choice A is wrong because tying the restraints to the side rail can be dangerous as it can cause injury to the client if they move suddenly.
B. Remove the restraints every 3 hr.
Choice B is wrong because removing the restraints every 3 hours is not a specific guideline and may vary depending on the facility’s policy and the client’s condition.
C. Remove one restraint at a time.
When caring for a client who has wrist restraints after an episode of violent behavior, the nurse should remove one restraint at a time. This allows the nurse to assess the client’s behavior and response to having one arm free while still maintaining some level of control and safety.
D. Secure restraints with a square knot.
Choice D is wrong because securing restraints with a square knot can make it difficult to quickly release the restraints in an emergency.
Full Explanation
When caring for a client who has wrist restraints after an episode of violent behavior, the nurse should remove one restraint at a time.
This allows the nurse to assess the client’s behavior and response to having one arm free while still maintaining some level of control and safety.
Choice A is wrong because tying the restraints to the side rail can be dangerous as it can cause injury to the client if they move suddenly.
Choice B is wrong because removing the restraints every 3 hours is not a specific guideline and may vary depending on the facility’s policy and the client’s condition.
Choice D is wrong because securing restraints with a square knot can make it difficult to quickly release the restraints in an emergency.
A client who has colon cancer and is scheduled for a colon resection with a possible colostomy tells the nurse, "I'm worried about that bag."
Which of the following is an appropriate response by the nurse?
A. "Let's wait until after the surgery to discuss your concerns about your colostomy.".
Choice A is not an appropriate response because it dismisses the client’s current concern and delays addressing it until after the surgery.
B. "You are worried about having to wear a colostomy bag?".
The nurse should respond to the client’s concern by saying “You are worried about having to wear a colostomy bag?” This response acknowledges the client’s concern and allows the client to express their feelings and concerns about the potential colostomy.
C. "The surgeon will only place the colostomy if it is necessary.".
Choice C is not an appropriate response because it does not address the client’s concern about wearing a colostomy bag.
D. "Have you ever known someone who has a colostomy?".
Choice D is not an appropriate response because it shifts the focus away from the client’s concern and onto someone else.
Full Explanation
The nurse should respond to the client’s concern by saying “You are worried about having to wear a colostomy bag?” This response acknowledges the client’s concern and allows the client to express their feelings and concerns about the potential colostomy.
Choice A is not an appropriate response because it dismisses the client’s current concern and delays addressing it until after the surgery.
Choice C is not an appropriate response because it does not address the client’s concern about wearing a colostomy bag.
Choice D is not an appropriate response because it shifts the focus away from the client’s concern and onto someone else.
When caring for a client who is receiving a warm, moist compress to relieve lower back pain, which of the following findings should indicate to the nurse that the compress has been effective?
A. The client's skin on the lower back is intact without redness.
This indicates that the compress has been effective in relieving lower back pain and has not caused any skin irritation or damage.
B. The client states that he is able to concentrate while reading.
Choice B is wrong because the ability to concentrate while reading is not directly related to the effectiveness of a warm, moist compress for relieving lower back pain.
C. The client's vital signs are within the expected reference range.
Choice C is wrong because vital signs being within the expected reference range does not necessarily indicate that the compress has been effective in relieving lower back pain.
D. The client is laughing at a television show.
Choice D is wrong because laughing at a television show does not necessarily indicate that the compress has been effective in relieving lower back pain.
Full Explanation
This indicates that the compress has been effective in relieving lower back pain and has not caused any skin irritation or damage.
Choice B is wrong because the ability to concentrate while reading is not directly related to the effectiveness of a warm, moist compress for relieving lower back pain.
Choice C is wrong because vital signs being within the expected reference range does not necessarily indicate that the compress has been effective in relieving lower back pain.
Choice D is wrong because laughing at a television show does not necessarily indicate that the compress has been effective in relieving lower back pain.