A nurse is preparing to administer tetanus and diphtheria toxoids (Td) to a client. What technique the nurse should plan to use?

Answer and Explanation

The Correct Answer is ["intramuscular injection technique"]

The Td vaccine is typically administered into the muscle, most commonly in the deltoid muscle of the upper arm for adults. The IM injection technique involves inserting the needle into the muscle and injecting the vaccine into the muscle tissue.

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Correct Answer is C

Explanation

Overhearing a discussion about a client's private information is a breach of confidentiality, and it is the nurse's responsibility to address the situation promptly.

While documenting the event in the client's progress notes might be necessary in some cases, it is not the initial action to take in this scenario. Similarly, submitting an incident report to the risk manager may be required for documentation purposes, but it is not the immediate action to address the breach of confidentiality.

Informing the client of the APs' actions may not be necessary unless there is evidence that the client's privacy has been compromised or if the client specifically requests to know. However, the priority is to address the issue of the conversation between the APs and ensure that confidentiality is maintained.

A. Massage the affected extremity every 4 hr. B. Initiate bed rest. C. Apply an ice pack to the affected extremity for 20 min every 2 hr. D. Administer aspirin for pain.

Correct Answer is B

Explanation

Deep-vein thrombosis (DVT) is a condition where a blood clot forms in a deep vein, usually in the legs. Bed rest is often recommended for clients with DVT to reduce the risk of the clot dislodging and causing a pulmonary embolism. By minimizing movement and keeping the leg elevated, the nurse can help prevent further complications.

The other options listed are incorrect:

Massage the affected extremity every 4 hours: Massaging the affected extremity can dislodge the clot, increasing the risk of a pulmonary embolism. It is contraindicated and should not be performed on clients with DVT.
Apply an ice pack to the affected extremity for 20 minutes every 2 hours: While applying cold compresses or ice packs may be useful in some situations to reduce swelling or pain, it is not recommended for clients with DVT. Heat application or cold application should be avoided because they can promote blood circulation and potentially dislodge the clot.
Administer aspirin for pain: Aspirin is not typically used for pain management in DVT. Anticoagulant therapy is the primary treatment for DVT, and specific anticoagulant medications are prescribed to prevent further clot formation and reduce the risk of complications.

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A nurse is preparing to administer tetanus and diphtheria toxoids (Td) to a client. What technique the nurse should plan to use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is 12 hr postpartum and has deep-vein thrombosis of the left leg. The client is receiving anticoagulant therapy. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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