Fundamentals of Nursing Practice Quiz 30

Answer: A – Withhold the moderation and notify the physician

Explanation: Initial sensitivity to penicillin is commonly manifested by a skin rash, even in individuals who have not been allergic to it previously. Because of the danger of anaphylactic shock, the nurse should withhold the drug and notify the physician, who may choose to substitute another drug, Administering an antihistamine is a dependent nursing intervention that requires a written physician’s order, Although applying cornstarch to the rash may relieve discomfort, it is not the nurse’s top priority in such a potentially life-threatening situation.

Answer: D – Rub the site vigorously after the injection to promote absorption

Explanation: The Z-track method is an I.M. injection technique in which the patient’s skin is pulled in such a way that the needle track is sealed off after the injection. This procedure seals medication deep into the muscle, thereby minimizing skin staining and irritation. Rubbing the injection site is contraindicated because it may cause the medication to extravasate into the skin.

Answer: D – Divide the area between the greater femoral trochanter and the lateral femoral condyle into thirds, and select the middle third on the anterior of the thigh

Explanation: The vastus lateralis, a long, thick muscle that extends the full length of the thigh, is viewed by many clinicians as the site of choice for I.M. injections because it has relatively few major nerves and blood vessels. The middle third of the muscle is recommended as the injection site. The patient can be in a supine or sitting position for an injection into this site.

Answer: A – Can accommodate only 1 ml or less of medication

Explanation: The mid-deltoid injection site can accommodate only 1 ml or less of medication because of its size and location (on the deltoid muscle of the arm, close to the brachial artery and radial nerve).

Answer: D – 25G, 5/8” long

Explanation: A 25G, 5/8” needle is the recommended size for insulin injection because insulin is administered by the subcutaneous route, An 18G, 1 ½” needle is usually used for I.M. injections in children, typically in the vastus lateralis, A 22G, 1 ½” needle is usually used for adult I.M. injections, which are typically administered in the vastus lateralis or ventrogluteal site.

Answer: D – 26G

Explanation: Because an intradermal injection does not penetrate deeply into the skin, a small-bore 26G-27G needle is recommended. This type of injection is used primarily to administer antigens to evaluate reactions for allergy or sensitivity studies, A 20G needle is usually used for I.M. injections of oil-based medications; a 22G-25G needle for I.M. injections; and a 25G needle, for subcutaneous insulin injections.

Answer: D – 600 mg

Explanation: gr 10 x 60 mg/gr 1 = 600 mg

Answer: C – 25 gtt/minute

Explanation: 100ml/60 min X 15 gtt/ 1 ml = 25 gtt/minute

Answer: A – Hemoglobinuria

Explanation: Hemoglobinuria, the abnormal presence of hemoglobin in the urine, indicates a hemolytic reaction (incompatibility of the donor’s and recipient’s blood). In this reaction, antibodies in the recipient’s plasma combine rapidly with donor RBC’s; the cells are hemolyzed in either circulatory or reticuloendothelial system. Hemolysis occurs more rapidly in ABO incompatibilities than in Rh incompatibilities, Chest pain and urticaria may be symptoms of impending anaphylaxis, Distended neck veins are an indication of hypervolemia.

Answer: C – Renal Failure

Explanation: In renal failure, the kidney loses their ability to effectively eliminate wastes and fluids. Because of this, limiting the patient’s intake of oral and I.V. fluids may be necessary, Fever, chronic obstructive pulmonary disease, and dehydration are conditions for which fluids should be encouraged.