The healthcare professional retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM 6 hours PRN for severe pain. How many mL should the healthcare professional administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth)

Correct Answer: A

Rationale: In this scenario, the correct answer is A) 0.8 mL. To calculate the amount to administer, you need to use the formula: Desired dose / Available dose = Volume to administer. The client requires 3 mg of hydromorphone, and the concentration available is 4 mg/mL. By dividing 3 mg by 4 mg/mL, you get 0.75 mL. However, since rounding to the nearest tenth is required, you round 0.75 mL to 0.8 mL, making option A the correct answer. Option B (0.75 mL) is close but not rounded to the nearest tenth as required. Option C (0.7 mL) and Option D (0.9 mL) are further from the correct calculated value. Educationally, understanding how to calculate medication dosages accurately is crucial for nurses to prevent medication errors and ensure patient safety. Nurses must have a strong foundation in medication calculations to deliver optimal care. Practicing these calculations through scenarios like this one helps reinforce this essential skill.

Correct Answer: D

Rationale: In this scenario, option D is the most critical issue that requires immediate intervention by the nurse. Purulent drainage around the insertion site of the feeding tube indicates a potential infection that needs prompt assessment and treatment to prevent systemic complications. This finding suggests a risk of sepsis, which is a life-threatening condition requiring urgent attention. Option A, the enteral feeding rate of 40 mL/hr, is within a normal range and does not pose an immediate threat to the client's safety. Option B, a full urine meter, indicates the need to empty the drainage bag but does not present an urgent concern for the client's well-being. Option C, a dependent loop in the urinary drainage tubing, can impede urine flow but is not as critical as a potential infection indicated by purulent drainage. By prioritizing the assessment and management of the purulent drainage, the nurse can address the most pressing issue affecting the client's health and prevent further complications. Educationally, this question highlights the importance of prioritizing nursing interventions based on the urgency of the client's condition. It emphasizes the significance of recognizing signs of infection and taking immediate action to prevent serious consequences for the client. This rationale underscores the critical thinking skills required in nursing practice to prioritize care effectively and ensure patient safety and well-being.

Correct Answer: B

Rationale: In this situation, providing space and privacy for the family allows them to openly discuss their concerns regarding the client's discharge. It respects the family's need for support, communication, and involvement in the decision-making process, ultimately fostering a more effective and compassionate care environment.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Rely on cultural norms as the basis for providing healthcare for this client. This is the most appropriate action because it acknowledges the importance of cultural competence in nursing care. Understanding and respecting the cultural background of a patient is essential in providing effective and holistic healthcare. Option A is incorrect because just providing an interpreter does not address the broader cultural considerations that should be taken into account. While language translation is important, it is not sufficient to ensure culturally sensitive care. Option B is incorrect as commending the client for patience does not directly address the cultural aspects that may impact the patient's care and experience during the admission process. Option C is incorrect as assuming the need for a chaplain based solely on the patient's cultural background is not appropriate. It is important to respect the client's beliefs and preferences regarding spiritual care rather than making assumptions based on ethnicity. In an educational context, it is crucial for nursing students to understand the significance of cultural competence in nursing practice. Providing culturally sensitive care leads to better patient outcomes, increased trust between the healthcare provider and patient, and overall improved quality of care. Nurses should be equipped with the knowledge and skills to effectively assess and address the cultural needs of diverse patient populations to deliver patient-centered care.

Correct Answer: C

Rationale: In teaching the correct administration of subcutaneous (subQ) injections, the healthcare professional should emphasize option C: Pinch the skin before inserting the needle. This instruction is crucial as pinching the skin helps to lift the subcutaneous tissue away from the muscle, ensuring that the medication is delivered into the fatty layer beneath the skin. By pinching the skin, the risk of injecting the medication into the muscle is minimized, which can lead to discomfort and potential complications. Option A is incorrect because subQ injections are typically administered at a 45-degree angle for thinner individuals or a 90-degree angle for those with more adipose tissue. Inserting the needle at a 90-degree angle can lead to injecting the medication into the muscle instead of the subcutaneous layer. Option B is incorrect because aspirating for blood return is not necessary for subQ injections since the subcutaneous tissue has fewer blood vessels compared to the muscle tissue. Aspirating can increase the risk of tissue trauma and discomfort for the patient. Option D is incorrect because massaging the site after administering a subQ injection is not recommended. Massaging can cause discomfort, bruising, or the dispersion of the medication beyond the intended area. In an educational context, understanding the correct technique for subQ injections is essential for nursing students and healthcare professionals to ensure safe and effective medication administration. Emphasizing the importance of correct injection angles, skin preparation, and post-injection care is vital for providing quality patient care and minimizing complications.