A nurse is preparing to administer a medication that is available in a glass ampule.
Which of the following actions should the nurse plan to take?
The nurse should use a filter needle to withdraw the medication.
The nurse should break the neck of the ampule toward their body.
The nurse should use the same needle to draw up and inject the client.
The nurse should dispose of the ampule in the trash can.
The Correct Answer is A
This is because glass ampules can leave small shards of glass in the solution, which can be harmful if injected into the client. A filter needle has a small mesh that traps any glass particles and prevents them from entering the syringe.
Choice B is wrong because the nurse should break the neck of the ampule away from their body to avoid injury from the glass.
Choice C is wrong because the nurse should use a different needle to inject the client after withdrawing the medication with a filter needle. This is to prevent contamination and reduce pain for the client.
Choice D is wrong because the nurse should dispose of the ampule in a sharps container, not in the trash can. This is to prevent injury and infection from the broken glass.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. BP 150/92 mm Hg:
- This blood pressure reading is elevated and not a therapeutic effect of magnesium sulfate. In the context of preeclampsia, the goal is usually to lower blood pressure to prevent complications.
B. Pulse rate 100/min:
- The pulse rate of 100/min is not a specific therapeutic effect of magnesium sulfate. However, magnesium sulfate may cause a decrease in heart rate, so monitoring for bradycardia would be important.
C. Flushed face:
- A flushed face is not a specific therapeutic effect of magnesium sulfate. Facial flushing may be associated with other factors, but it is not a primary consideration when monitoring the effectiveness of magnesium sulfate in the context of preeclampsia.
D. Negative clonus:
- Negative clonus is the correct therapeutic effect to monitor. Clonus refers to a series of involuntary, rhythmic, and repetitive muscle contractions and relaxations. In the context of magnesium sulfate administration for preeclampsia, negative clonus (the absence of abnormal reflexes) is a sign that the magnesium levels are within the therapeutic range, helping to prevent seizures.
Correct Answer is D
Explanation
The correct answer is choice D. Place a wedge under one of the client’s hips. This is because placing a wedge under one of the hips can help prevent compression of the inferior vena cava by the uterus, which can compromise placental blood flow and cause fetal hypoxia. Placing a wedge under the hip can also help reduce the risk of maternal hypotension, which can also affect fetal oxygenation.
Choice A is wrong because inserting a pillow under the client’s knees can increase the risk of thromboembolism, which is a potential complication of cesarean birth.
Choice B is wrong because positioning the client in reverse Trendelenburg can increase the risk of maternal aspiration, which is another potential complication of cesarean birth.
Choice C is wrong because assisting the client into the lithotomy position can also compress the inferior vena cava and reduce placental blood flow. The lithotomy position is also not necessary for cesarean birth, as the baby is delivered through an incision in the abdomen and uterus.
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