ATI LPN
NCLEX Questions Medication Administration Questions
Question 1 of 5
The nurse is preparing to give an aqueous intramuscular (IM) injection to an average-sized adult. Which actions are appropriate? (Select one that does not apply.)
Correct Answer: C
Rationale: In general, aqueous medications can be given with a 22- to 27-gauge needle, and average needle lengths for adults range from 1 to 1 1/2 inches. Insert the needle at a 90-degree angle. Checking for blood return is also part of the technique for IM injections to prevent inadvertent administration into the bloodstream. The ventrogluteal site is the preferred site for IM injections in adults. The dorsogluteal site is to be avoided because of proximity to nerves and blood vessels. (Note: Options E and F are 'Insert the needle at a 90-degree angle' and 'Before injecting the medication, withdraw the plunger to check for blood return,' respectively, as corrected from the document's typo of 40 degrees.)
Question 2 of 5
A nurse is caring for a client who has a surgical incision with sutures. The nurse observes that the edges of the wound are well approximated and there is minimal drainage from the site. The nurse documents this type of wound healing as:
Correct Answer: A
Rationale: Primary intention is a type of wound healing that occurs when the edges of the wound are well approximated and there is minimal tissue loss or infection. It results in minimal scarring and fast healing.
Question 3 of 5
A client with a burn wound on the chest has a silver sulfadiazine (Silvadene) cream applied to the wound. Which adverse reaction should the nurse monitor for in this client?
Correct Answer: D
Rationale: Silver sulfadiazine (Silvadene) is a topical antimicrobial agent used to prevent or treat infection in burn wounds. The nurse should monitor for hypersensitivity or allergic reaction, such as rash, itching, swelling, or difficulty breathing; and leukopenia or decreased white blood cell count, which can increase the risk of infection. The nurse should obtain a baseline complete blood count (CBC) before applying the cream and repeat it every few days during treatment.
Question 4 of 5
A nurse is assessing a client with a pressure ulcer on the sacrum. Which finding indicates a potential complication of the wound?
Correct Answer: C
Rationale: Foul-smelling greenish discharge from the wound indicates a possible infection, which can delay wound healing and increase the risk of sepsis. The nurse should notify the provider and obtain a wound culture to identify the causative organism and guide antibiotic therapy.
Question 5 of 5
A client is admitted to the hospital with a diabetic foot ulcer. The nurse notes that the wound has a black, dry, and hard eschar covering most of its surface. Which action should the nurse take?
Correct Answer: D
Rationale: The nurse should consult with the provider about surgical debridement for a wound that has a black, dry, and hard eschar covering most of its surface. This type of eschar indicates necrotic tissue that impairs wound healing and increases the risk of infection. Surgical debridement is the most effective method of removing large amounts of necrotic tissue from a wound.