A nurse is preparing to administer a tetanus and diphtheria toxoids (Td) to a client. Which of the following images indicates the technique nurse should plan to use?

Answer and Explanation

The Correct Answer is A

A: Image A shows an injection being prepared at the deltoid muscle, which is the correct site and technique for administering the tetanus and diphtheria (Td) vaccine. The Td vaccine should be given intramuscularly, typically into the deltoid muscle of the upper arm in adults, using a 90-degree angle to ensure proper muscle penetration.

B: Image B shows an injection technique appropriate for intradermal or possibly subcutaneous injection, indicated by the shallow angle of insertion into the skin. This method is not correct for a Td vaccine, which requires intramuscular administration for proper absorption and effectiveness.

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Correct Answer is D

Explanation

A. Explain the rounding schedule to the client: While explaining the rounding schedule helps reassure the client that frequent checks will occur, it does not immediately address safety needs. Immediate actions to reduce fall risk are prioritized before providing routine information.

B. Tell the client about the visiting hours: Informing the client about visiting hours is part of general orientation but is not critical to preventing falls. Safety interventions must be implemented first to minimize risk of injury as soon as possible upon admission.

C. Review meal options with the client: Discussing meal options is part of admission and planning for nutrition, but it is not an urgent action to ensure the client's immediate safety, particularly when there is a known risk for falls.

D. Place the call light within reach of the client: Ensuring the call light is within reach allows the client to easily request assistance before attempting to move independently. This simple action is a high-priority intervention to prevent falls and promote immediate client safety.

A. Maintain 30 ml sterile water in the drainage collection chamber B. Place the drainage device level with the tube insertion site C. Keep system tubing connections taped together. D. Empty the drainage collection chamber every 4 hr.

Correct Answer is C

Explanation

A. Maintain 30 ml sterile water in the drainage collection chamber: The sterile water is maintained in the water-seal chamber, not the drainage collection chamber. The water-seal chamber typically holds about 2 cm of water to create a one-way valve preventing air from entering the pleural space, not 30 mL in the drainage area.

B. Place the drainage device level with the tube insertion site: The drainage device should always be kept below the level of the chest tube insertion site to allow gravity to assist drainage and to prevent backflow of fluid or air into the pleural cavity, which could cause complications.

C. Keep system tubing connections taped together: Taping the system tubing connections securely helps maintain a closed system, preventing accidental disconnections that could lead to air leaks or loss of the negative pressure needed for proper lung re-expansion. This is essential for the effectiveness of chest tube management.

D. Empty the drainage collection chamber every 4 hr: The drainage collection chamber is not emptied routinely. Instead, it is replaced when full or according to facility protocol. Frequent opening of the system increases the risk of introducing infection or losing the closed negative-pressure system.

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A nurse is preparing to administer a tetanus and diphtheria toxoids (Td) to a client. Which of the following images indicates the technique nurse should plan to use?

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Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who is at risk for falls. Which of the following actions is the nurse's priority?

Correct Answer is D

Explanation

A nurse is contributing to the plan of care for a client who has a pleural chest tube with a closed drainage system. Which of the following actions should the nurse recommend for the client's care?

Correct Answer is C

Explanation

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