Nursing Elites

1. A client newly diagnosed with type 1 diabetes mellitus is resistant to learning self-injection of insulin and asks the nurse to administer all the injections. The nurse explains the importance of learning self-care and appropriately adds which of the following statement?

• A. Insulin injections are not difficult to learn.
• B. Tell me what I can do to help you overcome your fear of giving yourself injections.
• C. It’s important to learn self-care for future independence.
• D. You need to learn this for your health.

Correct answer: B

Rationale: Choice B is the correct answer because it addresses the client's fear and offers support to help them overcome the resistance to self-care. By expressing willingness to assist and asking for ways to help the client, the nurse encourages open communication and collaboration in finding solutions to the client's concerns. Choices A, C, and D, while valid statements, do not directly address the client's fear or resistance, which is crucial in promoting self-care adherence in this situation.

2. A healthcare provider is preparing to insert an IV catheter into a client's arm before starting IV fluid therapy. Which of the following interventions should the provider implement to prevent infection?

• A. Thread the IV catheter so that the hub rests at the insertion site
• B. Shave excess hair from around the insertion site
• C. Cleanse the site with hydrogen peroxide before IV catheter insertion
• D. Palpate the site carefully just before inserting the IV catheter

Correct answer: A

Rationale: Inserting the IV catheter so that the hub rests at the insertion site reduces the risk of contamination along the length of the catheter. This technique helps prevent introducing microbes into the bloodstream during the catheter insertion process. Shaving excess hair is unnecessary and can increase the risk of skin irritation and infection. Cleansing the site with hydrogen peroxide is outdated as it can cause tissue damage and delay wound healing. Palpating the site just before insertion can introduce bacteria from the skin surface into the insertion site, increasing the risk of infection.

3. Postoperatively, signs of hemorrhagic shock are observed. The nurse notifies the surgeon, who instructs to continue monitoring vitals every 15 minutes and report back in one hour. What should the nurse do next?

• A. Notify the nurse manager
• B. Continue monitoring as instructed
• C. Administer IV fluids as per protocol
• D. Prepare for immediate transfer to the ICU

Correct answer: B

Rationale: The correct answer is to continue monitoring the patient as instructed. This is crucial to assess the patient's condition and response to initial interventions. Administering IV fluids or preparing for transfer to the ICU should only be done based on further assessment or explicit orders from the healthcare provider. Notifying the nurse manager, as suggested in choice A, without further assessment or intervention could delay immediate patient care and management.

4. The healthcare provider is assessing a 17-month-old with acetaminophen poisoning. Which lab reports should the provider review first?

• A. Prothrombin time (PT) and partial thromboplastin time (PTT)
• B. Red blood cell and white blood cell counts
• C. Blood urea nitrogen and creatinine levels
• D. Liver enzymes (AST and ALT)

Correct answer: D

Rationale: In acetaminophen poisoning, liver damage is a significant concern due to the potential for hepatotoxicity. Therefore, the healthcare provider should first review liver enzymes such as AST (aspartate aminotransferase) and ALT (alanine aminotransferase) to assess liver function. Prothrombin time and partial thromboplastin time are coagulation studies and are not the priority in acetaminophen poisoning. Red blood cell and white blood cell counts are important in assessing for anemia or infection but are not specific to acetaminophen poisoning. Blood urea nitrogen and creatinine levels primarily assess kidney function, which is not the primary concern in acetaminophen poisoning.

5. During an eye irrigation for a client exposed to smoke and ash, which nursing action should receive the highest priority?

• A. Wearing gloves during the procedure
• B. Using a sterile solution
• C. Irrigating from the inner to the outer canthus
• D. Positioning the client's head properly

Correct answer: A

Rationale: The highest priority during an eye irrigation for a client exposed to smoke and ash is wearing gloves during the procedure. This action is crucial as it helps prevent contamination and protects both the client and the nurse. Using a sterile solution is important but not as critical as ensuring the nurse's safety by wearing gloves. Irrigating from the inner to the outer canthus and positioning the client's head properly are essential steps in eye irrigation, but they are not the highest priority in this scenario compared to ensuring infection control by wearing gloves.

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