Adult Health Nursing Test Banks

Correct Answer: D

Rationale: When performing an intramuscular (IM) injection, the nurse should insert the needle at a 90-degree angle into the muscle. This angle helps ensure proper and deep penetration into the muscle tissue for effective administration of the medication. It also helps prevent leakage or tissue damage at the injection site. Additionally, inserting the needle at a 90-degree angle facilitates accurate delivery of the medication into the muscle where it can be absorbed properly. Therefore, selecting the correct angle for inserting the needle is critical in ensuring the success and effectiveness of the IM injection.

Correct Answer: A

Rationale: The primary intervention that should be prioritized for managing a catheter-related bloodstream infection (CRBSI) associated with a central venous catheter is to remove the central venous catheter. CRBSI is a serious complication that can lead to severe infections and sepsis. The removal of the catheter is crucial to eliminate the source of the infection and prevent further dissemination of the pathogens into the bloodstream. Once the catheter is removed, the healthcare team can consider other interventions such as administering targeted antibiotics based on culture results, performing blood cultures to identify the causative organism, and implementing sterile dressing changes and catheter care protocols. However, immediate removal of the catheter takes precedence in managing CRBSI to prevent worsening of the infection and improve patient outcomes.

Correct Answer: A

Rationale: An occiput posterior fetal position, where the baby's head is facing the mother's abdomen rather than her back, can lead to prolonged and severe back pain during labor. This position can cause irregular contractions and difficulty in descending through the birth canal, resulting in abnormal labor progress. The back pain experienced in this case is often intense due to the pressure exerted on the mother's lower back and may also be associated with intense back labor. It is essential for the nurse to recognize this potential issue and assist in maneuvers or positions to help the baby rotate to a more optimal position for delivery.

Correct Answer: B

Rationale: In this scenario, the nurse is asking the patient to elaborate on their feelings and thoughts related to the upcoming surgery. By asking, "What do you fear MOST about your surgery tomorrow?" the nurse is seeking clarification to better understand the patient's concerns and enable effective communication. Seeking clarification involves asking open-ended questions that encourage the patient to express themselves more fully, allowing the healthcare provider to address their specific worries or needs more effectively.

Correct Answer: A

Rationale: Battery refers to the intentional and offensive physical contact with another person without their consent, resulting in harm or injury. In this scenario, the victim clearly expressed their unwillingness to be touched or helped by saying, "Don't touch me!" multiple times. By ignoring the victim's refusal and physically forcing them into the ambulance, the EMT is committing battery even though they may have had good intentions to provide assistance. It is important for medical professionals, including EMTs, to always respect a person's right to refuse medical treatment or assistance, even in emergency situations.