The patient comes to the hospital with a variety of symptoms.
Which symptom will the nurse assess first?
Joint stiffness after sitting for a long period of time.
Nausea with a small amount of vomitus earlier this morning.
A rash that developed after the second dose of antibiotics.
Shortness of breath with audible wheezing.
The Correct Answer is D
Choice A rationale
Joint stiffness after sitting for a long period of time, often referred to as "gelling," is a common symptom associated with inflammatory joint conditions like osteoarthritis or rheumatoid arthritis. While it can be a source of discomfort and reduced mobility, it typically does not indicate an immediate life-threatening situation. The body's synovial fluid thins with inactivity, leading to increased friction and stiffness upon movement.
Choice B rationale
Nausea with a small amount of vomitus suggests gastrointestinal upset. While it can cause discomfort and lead to dehydration if persistent, it is generally not an acute emergency unless accompanied by severe abdominal pain, signs of dehydration, or other systemic symptoms. The body's chemoreceptor trigger zone can be activated by various stimuli, leading to the sensation of nausea and subsequent emesis.
Choice C rationale
A rash that developed after a second dose of antibiotics could indicate an allergic reaction, which ranges from mild to severe. While allergic reactions require assessment and intervention, they are not immediately life-threatening unless accompanied by signs of anaphylaxis such as angioedema or respiratory distress. This hypersensitivity reaction involves the immune system's response to the drug as an antigen.
Choice D rationale
Shortness of breath with audible wheezing indicates respiratory distress, which is a critical and potentially life-threatening condition. Wheezing suggests airway narrowing, which impedes oxygen-carbon dioxide exchange. Immediate assessment and intervention are required to prevent respiratory arrest and ensure adequate oxygenation to vital organs. This physiological response reflects bronchoconstriction and inflammation, severely compromising ventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Partially withdrawing and redirecting the needle after aspirating blood significantly increases the risk of tissue trauma, pain, and the formation of a hematoma at the injection site. Furthermore, there is a risk of inadvertently injecting medication into a blood vessel or the interstitial tissue, which could lead to complications such as nerve damage or localized irritation.
Choice B rationale
Aspirating blood indicates the needle tip has entered a blood vessel. Administering medication intravenously when an intramuscular injection is intended can have serious systemic consequences, including rapid absorption and potential adverse drug reactions or toxicity. Therefore, the safest action is to withdraw the needle, discard the contaminated medication, and prepare a new dose to ensure proper drug delivery.
Choice C rationale
Administering the drug despite aspirating blood significantly increases the risk of injecting the medication directly into a blood vessel (intravascular injection) rather than the muscle. This can lead to rapid systemic absorption, potentially causing adverse effects or toxicity, and may also result in a larger, more painful hematoma and delayed drug action.
Choice D rationale
Continuing to administer the drug after aspirating blood, regardless of the injection speed, is dangerous because it confirms the needle's placement within a blood vessel. Intravascular administration of an IM medication can lead to immediate systemic effects, allergic reactions, or drug overdose, bypassing the intended slower absorption rate of muscle tissue, and increasing risk of complications.
Correct Answer is D
Explanation
Choice A rationale
The abdomen, specifically 2 inches from the umbilicus, is a common site for subcutaneous injections due to the presence of ample adipose tissue, which allows for slower absorption of medications like insulin or heparin. Intradermal injections require a site with a thin epidermis and minimal subcutaneous tissue to ensure the medication remains within the dermal layer, making the abdomen unsuitable.
Choice B rationale
The anterior thigh is a common site for intramuscular injections, particularly in infants, due to the large muscle mass (vastus lateralis). While it can be used for subcutaneous injections, its muscularity and varying skin thickness make it less ideal for the precise shallow angle required for an intradermal injection, where the goal is to deposit the medication into the dermis.
Choice C rationale
The posterior upper arm, specifically the triceps area, is frequently utilized for subcutaneous injections, such as insulin or certain vaccines, because it offers sufficient subcutaneous tissue. However, similar to the anterior thigh, its anatomical characteristics with thicker skin and subcutaneous fat layers make it less optimal for the very superficial intradermal injection technique.
Choice D rationale
The upper chest, particularly below the clavicle and above the breasts, is an appropriate site for intradermal injections. This area, along with the inner forearm and upper back, has a thin epidermis and less subcutaneous tissue, which facilitates the proper placement of the medication within the dermis, allowing for the formation of a visible wheal, a key indicator of a successful intradermal injection.
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