Nursing Elites

1. A client reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?

• A. Closes the door to the client's room
• B. Flushes the client's toilet after emptying the urinary catheter's drainage bag
• C. Measures the client's vital signs routinely
• D. Asks a group of personnel in the hall to speak quietly

Correct answer: B

Rationale: The correct answer is B because flushing the client's toilet after emptying the urinary catheter's drainage bag could disturb the client's rest. The nurse should intervene to ensure a restful environment for the client. Choices A, C, and D are not actions that would be disruptive to the client's sleep. Closing the door to the client's room, measuring vital signs routinely, and asking personnel in the hall to speak quietly are appropriate actions that do not directly disturb the client's rest.

2. When administering an IM injection into a client's deltoid muscle, which of the following actions should the nurse take?

• A. Use a 21-gauge needle for the injection
• B. Inject the medication at a 90-degree angle
• C. Inject the medication 12.7 cm (5 in) below the acromion process
• D. Inject the medication 2.54 cm (1 in) below the acromion process

Correct answer: B

Rationale: The correct answer is to inject the medication at a 90-degree angle when administering an IM injection into the deltoid muscle. This angle ensures proper delivery of the medication into the muscle tissue. Choice A is incorrect because the gauge of the needle for a deltoid IM injection is usually smaller, around 23-25 gauge. Choices C and D are incorrect as the injection site for the deltoid muscle is approximately 2.54 cm (1 in) below the acromion process, not 12.7 cm (5 in).

3. A client has an indwelling urinary catheter. Which of the following interventions should the nurse implement to prevent infection?

• A. Change the catheter every 72 hours.
• B. Ensure the tubing is unkinked.
• C. Empty the drainage bag every 4 hours.
• D. Hang the drainage bag below the bladder.

Correct answer: D

Rationale: The correct answer is to hang the drainage bag below the bladder. This positioning helps prevent backflow of urine, reducing the risk of infection. Changing the catheter every 72 hours is not necessary unless clinically indicated and may increase infection risk by introducing pathogens. Ensuring the tubing is unkinked promotes proper urine flow but does not directly prevent infection. Emptying the drainage bag regularly is important to prevent urinary stasis but does not directly address infection prevention.

4. When teaching a patient about self-administration of insulin, what is the most important instruction to provide?

• A. Rotate injection sites to prevent tissue damage.
• B. Inject insulin at a 90-degree angle for proper absorption.
• C. Store insulin in the refrigerator to maintain potency.
• D. Teach the patient to administer insulin at the same time each day.

Correct answer: A

Rationale: The most important instruction to provide when teaching a patient about self-administration of insulin is to rotate injection sites to prevent tissue damage. Rotating injection sites helps prevent lipodystrophy (tissue damage) and ensures proper insulin absorption. Option B is incorrect because the angle of insulin injection varies depending on the patient's body composition. Injecting at a 90-degree angle is not always necessary. Option C is not the most crucial instruction; while storing insulin in the refrigerator is important, it is not the priority when teaching self-administration. Option D is also important for maintaining consistency but is not as critical as rotating injection sites to prevent tissue damage.

5. A nurse is assessing a postoperative patient for signs of infection. Which finding is most concerning?

• A. Mild redness at the incision site.
• B. Increased drainage from the surgical site.
• C. Fever of 101°F.
• D. Normal white blood cell count.

Correct answer: C

Rationale: A fever of 101°F is the most concerning finding when assessing a postoperative patient for signs of infection. Fever can indicate an inflammatory response to an infection, and in a postoperative patient, it can signal a surgical site infection or a systemic infection. Prompt attention is necessary to prevent complications such as sepsis. Mild redness at the incision site and increased drainage can be expected in the early postoperative period due to the normal healing process. A normal white blood cell count does not rule out infection as it can be influenced by various factors, and some infections may not initially cause a rise in white blood cells.

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