The LPN is preparing to administer an injection of vitamin K to the newborn. The nurse should administer the injection in the:

Correct Answer: B

Rationale: The vastus lateralis muscle is the preferred site for vitamin K injection in newborns, offering a large, safe muscle mass away from nerves and vessels, standard for intramuscular prophylaxis against hemorrhagic disease. Rectus femoris is smaller, deltoid underdeveloped, and dorsogluteal risky near sciatic nerve. Nurses use this site for efficacy and safety, teaching parents its purpose in clotting support.

Correct Answer: C

Rationale: Diminished breath sounds signal a respiratory complication from immobility, suggesting poor ventilation or issues like atelectasis or pneumonia due to shallow breathing. Stronger muscles or expanded lungs indicate healthy function, not problems, while a normal breathing rate doesn't reveal underlying lung issues. Nurses auscultate for this to detect early respiratory decline, prompting interventions like repositioning or breathing exercises, ensuring timely action to safeguard oxygenation in immobile patients.

Correct Answer: C

Rationale: Observing the emesis checks for medication remnants, guiding next steps.

Correct Answer: C

Rationale: Legal documentation supports quality (A), is evidence (B), must be accurate (D) 'can be altered anytime' (C) isn't true, strict rules apply, per law. C's flexibility contradicts standards, like Mr. Gary's records, making it untrue.

Correct Answer: D

Rationale: Aspirating urine from the tubing port with a sterile syringe is the appropriate action for obtaining a sterile urine specimen from an indwelling catheter. This maintains the closed system's integrity, minimizing infection risk by avoiding exposure to external contaminants. The port is designed for sterile sampling, ensuring the specimen reflects bladder contents accurately for testing. Using sterile gloves aids asepsis but isn't the complete action; it supports the procedure, not defines it. Opening the drainage bag introduces bacteria, risking contamination and infection. Disconnecting the catheter breaks the sterile circuit, increasing urinary tract infection likelihood contrary to best practice. Aspiration via the port, paired with aseptic technique, upholds infection control standards, ensuring patient safety and reliable diagnostic results, making it the optimal nursing action.

Correct Answer: C

Rationale: Spinach should be removed from the diet of a client with cirrhosis and esophageal varices, as its rough texture and high vitamin K content could irritate fragile varices or alter clotting, risking rupture and hemorrhage a critical concern in advanced liver disease. Custard, mashed potatoes, and raisins are softer and safer, lacking this risk. Nurses adjust diets to minimize esophageal trauma, teaching clients to avoid coarse foods, protecting against bleeding episodes that could require urgent interventions like banding or transfusion.

Correct Answer: C

Rationale: Sudden breathing difficulty, weakness, and nausea during antibiotic administration suggest a severe allergic reaction, known as anaphylaxis. This life-threatening condition involves systemic histamine release, causing airway constriction, hypotension, and gastrointestinal distress. Pulmonary egophony relates to lung sound changes, not systemic symptoms. Amniotic fluid embolism presents with cardiovascular collapse and bleeding, not primarily nausea. Bronchospasm is airway narrowing but lacks the broader symptoms here. Immediate recognition of anaphylaxis prompts epinephrine administration and airway support, critical for maternal and fetal survival in labor.

Correct Answer: A

Rationale: Post-morphine pain assessment at 20-30 minutes evaluates peak effect, critical post-surgery. Later checks miss this window. Nurses time this for efficacy.

Correct Answer: A

Rationale: Oral temp is most accessible e.g., quick tongue placement needing minimal prep, unlike rectal (invasive), tympanic (equipment), or axillary (longer). Convenient for alert patients, nurses favor it e.g., clinics for routine ease, per practice standards.