The nurse is administering an intradermal injection for a tuberculosis skin test. Which technique should the nurse use?

Correct Answer: B

Rationale: In administering an intradermal injection for a tuberculosis skin test, the nurse should use a 27-gauge needle at a 15-degree angle, which is the correct answer (B). This technique is appropriate for intradermal injections because the skin in this area is thin, and a smaller needle size and a shallow angle are needed to ensure accurate placement of the medication just below the skin's surface. Option A (A 25-gauge needle at a 90-degree angle) is incorrect because a 90-degree angle and a larger needle size are more suitable for intramuscular injections, not intradermal ones. Option C (A 22-gauge needle at a 45-degree angle) is also incorrect as the needle gauge is too large for intradermal injections, which require a smaller gauge needle. Option D (A 20-gauge needle at a 90-degree angle) is not appropriate for intradermal injections as it is a larger needle size and a 90-degree angle, which is more suitable for intramuscular injections. Educationally, understanding the correct technique for administering intradermal injections is crucial for nurses to ensure accurate delivery of medications and to prevent complications. It is important for nurses to be knowledgeable about the appropriate needle size, angle, and injection site for different types of injections to provide safe and effective patient care.

Correct Answer: B

Rationale: In this scenario, the correct action for the nurse to take first is to inform the anesthesia care provider (Option B). The reason for this is that anesthesia providers need to be aware of the patient's recent intake of food or drink to prevent complications during surgery, such as aspiration. By notifying the anesthesia care provider, they can determine if it is safe to proceed with the cesarean section or if any precautions need to be taken. Canceling the surgery (Option A) would be an extreme measure at this point and may not be necessary if proper precautions can be taken. Asking the client if she has had other liquids (Option C) is important but not the first priority in this situation. Proceeding with routine preparations (Option D) without addressing the coffee intake could potentially lead to complications during surgery. From an educational perspective, this question highlights the importance of thorough preoperative assessments and communication between healthcare team members to ensure patient safety and optimal outcomes. Nurses need to understand the implications of patients consuming food or drink before surgery and the appropriate steps to take in such situations to prevent complications.

Correct Answer: B

Rationale: In the context of the HESI RN Exit Exam Capstone, understanding the importance of surgical hand scrub duration is crucial for maintaining aseptic technique and preventing surgical site infections. The correct answer, B) Extend scrub time to 5 minutes, is based on evidence-based practice guidelines that recommend a 5-minute scrub to effectively reduce microbial flora on the hands prior to surgery. Option A) Proceed with surgery preparation is incorrect because a 3-minute scrub is not considered sufficient to adequately reduce the microbial flora on the hands. Option C) Use an alcohol-based hand sanitizer is also incorrect because while alcohol-based sanitizers are effective in certain situations, they are not a substitute for a thorough surgical hand scrub before surgery. Option D) Scrub time depends on the type of surgery is incorrect because regardless of the type of surgery, a 5-minute hand scrub is generally recommended to ensure proper hand hygiene practices are followed consistently. Educationally, this question highlights the importance of adhering to evidence-based guidelines in healthcare settings to promote patient safety and prevent healthcare-associated infections. Understanding and following proper hand hygiene protocols is a fundamental aspect of nursing practice that directly impacts patient outcomes and quality of care.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) 75 ml/hour. To calculate the infusion rate, we need to consider the concentration of the medication in the solution. Isoproterenol is ordered at 300 mcg/hour and is diluted in D5W. To determine the mL/hour rate, we need to convert the mcg to mg (1 mcg = 0.001 mg) and then calculate the total volume of the solution. Considering the concentration of isoproterenol and the diluent, the correct calculation is as follows: 300 mcg/hour = 0.3 mg/hour 0.3 mg x 1000 mcg = 300 mcg in 1 ml So, 0.3 mg is in 1 ml of the solution. Therefore, the nurse should set the pump to 75 ml/hour to deliver the prescribed dose of isoproterenol. Now, let's analyze the other options: A) 100 ml/hour: This is incorrect because it does not consider the concentration of the medication and would result in an incorrect dosage. C) 60 ml/hour: This option is incorrect as it does not account for the correct rate of infusion needed for the prescribed dose. D) 125 ml/hour: This option is incorrect as it would result in an incorrect dosage due to not considering the concentration of the medication. Understanding medication calculations is crucial for nurses to ensure patient safety and provide accurate care. Nurses must be able to calculate infusion rates correctly to administer medications safely and effectively. Practice and proficiency in medication calculations are essential skills for nursing practice.

Correct Answer: D

Rationale: The correct follow-up question for the nurse to ask in this scenario is "D) Have you had recent cold intolerance or unusual fatigue?" This question is most appropriate because the client's symptoms (coarse hair, eyebrow changes, puffy eyes) are indicative of hypothyroidism, a condition where the thyroid gland is underactive. Cold intolerance and unusual fatigue are common symptoms of hypothyroidism, so asking about these can provide valuable information for further assessment and potential diagnosis. Option A) "Have you noticed any changes in your fingernails?" is less relevant in this context as changes in the nails are not specific to thyroid dysfunction. Option B) "Have you had any changes in weight or energy levels?" While weight gain and low energy can be seen in hypothyroidism, they are not as specific to the symptoms described by the client. Option C) "Do you have a family history of thyroid problems?" While family history can be important in assessing risk factors for thyroid disorders, the client's current symptoms are more indicative of her own thyroid status rather than her family history. In an educational context, it is crucial for nurses to understand the importance of thorough assessment and the relevance of specific questions based on presenting symptoms. This question highlights the need for critical thinking in connecting symptoms to potential underlying conditions, demonstrating the importance of holistic care and assessment in nursing practice.