Question

23. The client is currently receiving a continuous IV infusion of heparin. Which procedure should the nurse avoid when possible? a. Giving intramuscular injections b. Measuring urine output C. Measuring noninvasive blood pressure d. Assessing respirations 24. The nurse is working with a 5-year-old boy who must receive repeated intravenous injections as part of his treatment. He hates the injections, however, and is frightened whenever he sees the syringe and needle. In an attempt to overcome this fear, the nurse holds the syringe up for him to see and tells him, "This looks kind of like a space rocket, don't you think? Here comes the space rocket-it needs to refuel." Which pain management technique is the nurse using here? a. Imagery b. Thought stopping C. Hypnosis d. Biofeedback 25. The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice? a. preparing solution for administration b. ordering type of solution, additive, amount of infusion, and duration c. performing venipuncture d. regulating the rate of administration 26. When the nurse is starting an intravenous infusion on a client who will be receiving multiple intravenous antibiotics, which guideline should the nurse follow? a. Use veins of the lower extremities. b. Use distal veins before proximal veins. c. Use small veins before larger veins. d. Use the brachial plexus vein. 27. A nurse is administering intramuscular injections to clients. What needle sizes has the nurse used correctly? Select all that apply. a. 5/8-inch needle for the vastus lateralis site b. 5/8-inch needle for an adult in the ventrogluteal site c. 1 1/2-inch needle for a child in the deltoid site d. 1 1/2-inch needle for an adult in the deltoid site e. 5/8-inch needle for a child in the deltoid site f. 5/8-inch needle for an adult in the ventrogluteal site 28. A nurse needs to administer a subcutaneous injection to a client. Which techniques should the nurse use to reduce discomfort? Select all that apply. a. Support the client's tissue when withdrawing the needle. b. Numb the skin with an ice pack before the injection. c. Use the Z-track method when administering the injection.

Answer 1

23. a is the answer. IM injections of Heparin to be avoided as the risk of hematoma.

24. b is the answer. Thought stopping is the technique followed by nurse to avoid panic and anxiety.

25. b is the answer. Ordering type of solution , duration, additive is done normally by physician.

26. b is the answer. Use distal vein and move proximally.

27. e, d is correct