The nurse is conducting an initial admission assessment for a woman who is a Jehovah's Witness and is scheduled to deliver a baby by Cesarean section within the next 24 hours. Which action should the nurse take?

Commend the client for her patience after a long wait in the admission process.

Determine the client's decision about homologous blood transfusion.

Arrange for a ritual meeting together with other Jehovah's Witnesses before surgery.

Obtain primary source of information from the head of the spiritual group.

Answer and Explanation

The Correct Answer is B

A. Commend the client for her patience after a long wait in the admission process is not appropriate at this time. While acknowledging the client's feelings is important, it is not the most relevant or immediate intervention for this situation.

B. Determine the client's decision about homologous blood transfusion is the most important action. Jehovah's Witnesses generally refuse blood transfusions based on their religious beliefs. The nurse should assess the client’s wishes regarding blood transfusions to ensure informed consent and respect for her beliefs.

C. Arrange for a ritual meeting together with other Jehovah's Witnesses before surgery is not the most immediate action. While spiritual support is important, the priority is addressing the client’s medical decisions, particularly regarding blood transfusions, which may impact her care.

D. Obtain primary source of information from the head of the spiritual group is unnecessary. The client herself is the primary source of information about her beliefs and preferences, and the nurse should focus on her individual decisions rather than seeking information from a religious leader.

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Correct Answer is C

Explanation

A. Select upper arm as the injection site is incorrect. While the upper arm can be an appropriate site for an intradermal injection, the most common site for ID injections is the inner forearm. The choice of site depends on the procedure and provider's preferences.

B. Massage the site gently after injection is incorrect. Massaging the site after an intradermal injection can disrupt the injection, causing the medication to be dispersed under the skin rather than remaining in the dermis.

C. Ensure bevel of the needle is pointing up is the correct action. For intradermal injections, the bevel of the needle should be facing upward to ensure that the medication is injected just beneath the skin, creating a visible wheal.

D. Hold the syringe perpendicular to the skin is incorrect. For intradermal injections, the needle should be inserted at a 5-15 degree angle to the skin, not perpendicular.

Correct Answer is ["2.5"]

Explanation

Convert mcg to mg: 1 mg = 1000 mcg, so 125 mcg = 125/1000 = 0.125 mg

· Set up a proportion: (Desired dose / Concentration) = Volume to administer

0.125 mg / 0.05 mg/mL = X mL

· Solve for X: X = 2.5 mL

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The nurse is conducting an initial admission assessment for a woman who is a Jehovah's Witness and is scheduled to deliver a baby by Cesarean section within the next 24 hours. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

Correct Answer is C

Explanation

The healthcare provider prescribes digoxin elixir 125 mcg PO daily. The drug is available in a 60 mL bottle labeled, "Digoxin elixir 0.05 mg/mL How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["2.5"]

Explanation

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