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Questions 158

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Extract:


Question 1 of 5

A 1-year-old child is to receive an IM injection ordered by his pediatrician. He has fallen asleep in his mother's arms when the nurse approaches. Which approach is most appropriate at this time?

Correct Answer: B

Rationale: If awakened first, the child will know that nothing painful will be done without the child being alerted. The ventrogluteal site is a safe site for children because it is a large muscle free of major nerves and blood vessels. The dorsogluteal site is not recommended in children who have not been walking for at least 1 year because the muscle is not fully developed. The parent will be able to offer support and comfort during and after the injection.

Question 2 of 5

Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:

Correct Answer: D

Rationale: Apical pulse should be measured for 1-minute prior to digoxin administration. Digoxin decreases the heart rate. Digoxin should be withheld if apical rates are <60 bpm or >120 bpm.

Question 3 of 5

The client is diagnosed with glaucoma. Which medication is most likely to be prescribed?

Correct Answer: A

Rationale: Timolol, a beta-blocker, is commonly prescribed for glaucoma to reduce intraocular pressure by decreasing aqueous humor production. Atropine increases pressure, pilocarpine is less common, and acetazolamide is used acutely.

Question 4 of 5

The nurse is caring for a client post-myocardial infarction on the cardiac unit. The client is exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?

Correct Answer: B

Rationale: Chest pain is a hallmark of cardiogenic shock due to myocardial ischemia, distinguishing it from anaphylactic shock, which typically involves urticaria or bronchospasm. Low BP (
A) and anxiety (
C) are common in both, and normal temperature (
D) is nonspecific.

Question 5 of 5

The nurse is caring for a client following a myocardial infarction. Which of the following enzymes are specific to cardiac damage?

Correct Answer: C

Rationale: CK-MB and LDH are specific to cardiac damage, with CK-MB being highly specific for myocardial infarction due to its presence in heart muscle.

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