A nurse is caring for a patient admitted with a lower respiratory infection.

After assisting the patient to bed and applying the prescribed oxygen, which finding would help the nurse evaluate the effectiveness of the nursing care?

Blood pressure is 130/78 mm Hg

Respiratory rate is 20 breaths/min

Apical pulse is 100 beats/min

Pain level is 6/10

Answer and Explanation

The Correct Answer is B

Choice B rationale

A respiratory rate of 20 breaths per minute is within the normal range for an adult, indicating that the patient’s respiratory status is stable. This would be an important indicator of the effectiveness of nursing care in a patient admitted with a lower respiratory infection.

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Correct Answer is A

Explanation

Choice A rationale
The abdomen is a common site for subcutaneous injections because it allows for consistent absorption. The area above the iliac crest is often used because it is easy to access and usually has enough subcutaneous tissue for the injection.
Choice B rationale
A 1-inch needle is typically too long for a subcutaneous injection. A shorter needle (usually 1/2 to 5/8 inch) is usually used to ensure the medication is delivered to the subcutaneous tissue.
Choice C rationale
A 22-gauge needle is typically too large for a subcutaneous injection. Smaller gauge needles (usually 25-27 gauge) are usually used for subcutaneous injections.
Choice D rationale
Massaging the injection site after administration of heparin is not recommended. It can cause the medication to be absorbed too quickly and can also lead to bruising.

A. Place a wedge pillow between the legs. B. Place a footboard on the bed. C. Place a sandbag to the lateral calf. D. Place a trochanter roll against the thigh.

Correct Answer is A

Explanation

After a total hip arthroplasty, it is important to prevent hip dislocation. One way to do this is to place a wedge pillow between the legs. This helps to keep the hip in a stable position and prevents the hip from moving too much, which could lead to dislocation.

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A nurse is caring for a patient admitted with a lower respiratory infection. After assisting the patient to bed and applying the prescribed oxygen, which finding would help the nurse evaluate the effectiveness of the nursing care?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer heparin subcutaneously to a client. Which action by the nurse is appropriate?

Correct Answer is A

Explanation

A nurse is helping a postoperative patient following a total hip arthroplasty into a supine position. Which of the following actions is appropriate to prevent hip dislocation?

Correct Answer is A

Explanation

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A nurse is caring for a patient admitted with a lower respiratory infection.

After assisting the patient to bed and applying the prescribed oxygen, which finding would help the nurse evaluate the effectiveness of the nursing care?