DOH Nursing Nursing Fundamentals & Patient Care 4 — Questions and Answers
Question 1: Which site is preferred for intramuscular injection in adults to avoid the sciatic nerve?
- Ventrogluteal site (Correct answer)
- Dorsogluteal site
- Deltoid site for all volumes
- Rectus femoris
Correct answer: Ventrogluteal site
The ventrogluteal site is the preferred IM injection site in adults because it is free of major nerves and blood vessels, has a thick muscle mass, and is easy to locate. The dorsogluteal site carries risk of sciatic nerve injury.
Question 2: A patient's blood pressure reads 168/98 mmHg. According to JNC guidelines, this is classified as:
- Hypertension Stage 2 (Correct answer)
- Hypertension Stage 1
- Elevated blood pressure
- Normal blood pressure
Correct answer: Hypertension Stage 2
Per ACC/AHA guidelines, Stage 2 hypertension is defined as systolic ≥140 mmHg or diastolic ≥90 mmHg. A reading of 168/98 mmHg exceeds both thresholds and requires prompt clinical evaluation and management.
Question 3: What does a pulse oximetry reading of 88% SpO2 indicate in a previously healthy adult?
- Significant hypoxemia requiring immediate oxygen therapy (Correct answer)
- Mild hypoxemia acceptable for COPD patients only
- Normal reading at high altitude only
- Borderline acceptable with no intervention needed
Correct answer: Significant hypoxemia requiring immediate oxygen therapy
Normal SpO2 in a healthy adult is 95–100%. An SpO2 of 88% represents significant hypoxemia. Supplemental oxygen should be applied immediately and the cause investigated. Target SpO2 is generally ≥94% for most patients.
Question 4: Which action best demonstrates the principle of patient autonomy in nursing care?
- Providing complete information so the patient can make an informed decision (Correct answer)
- Deciding on the best treatment for the patient based on clinical judgment
- Referring all decisions to the family without consulting the patient
- Proceeding with care the nurse believes is best even if the patient refuses
Correct answer: Providing complete information so the patient can make an informed decision
Autonomy means the patient's right to self-determination. Nurses uphold this by ensuring patients receive complete, understandable information to make informed decisions. Overriding a patient's decision violates autonomy.
Question 5: A nurse accidentally administers the wrong medication. What is the first priority action?
- Assess the patient for adverse reactions and notify the physician (Correct answer)
- Document the error in the chart before doing anything else
- Inform the charge nurse without assessing the patient
- Wait to see if any symptoms develop before reporting
Correct answer: Assess the patient for adverse reactions and notify the physician
Patient safety is the first priority. The nurse must immediately assess the patient for harm, notify the physician for orders if needed, and then follow facility incident reporting procedures. Documentation follows patient stabilization.
Question 6: What is the purpose of a nursing diagnosis (as defined by NANDA)?
- To describe a clinical judgment about a human response to health conditions (Correct answer)
- To identify a medical disease or pathological condition
- To create a billing code for insurance purposes
- To assign a patient to a specific nursing care unit
Correct answer: To describe a clinical judgment about a human response to health conditions
A NANDA nursing diagnosis is a clinical judgment about a patient's, family's, or community's response to actual or potential health problems. It differs from a medical diagnosis, which identifies disease. Nursing diagnoses guide nursing interventions.
DOH Nursing Nursing Fundamentals & Patient Care 4
Which site is preferred for intramuscular injection in adults to avoid the sciatic nerve?