Nursing Elites

1. 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).

2. A nursing instructor is observing a nursing student practicing standard precautions. Which observation by the instructor indicates a need for further teaching?

• A. The nursing student wears a gown to change the bed of an incontinent client.
• B. The nursing student washes hands before making contact with the client.
• C. The nursing student washes her hands before glove removal after emptying a Foley bag.
• D. The nursing student changes gloves between tasks and procedures.

Correct answer: C

Rationale: The correct answer is C. The nursing student washing her hands before glove removal after emptying a Foley bag indicates a need for further teaching. Hands should be washed after glove removal to maintain proper infection control. Choice A is correct as wearing a gown when changing the bed of an incontinent client is a standard precaution. Choice B is correct as washing hands before making contact with the client is a good practice. Choice D is correct as changing gloves between tasks and procedures is a standard precaution to prevent the spread of infection.

3. A nurse is assigned to care for four clients. Which client should the nurse assess first?

• A. A client with chest pain and shortness of breath
• B. A client with a fever of 100°F
• C. A client scheduled for surgery
• D. A client with stable vital signs

Correct answer: A

Rationale: The correct answer is A. Chest pain and shortness of breath are symptoms that could indicate a life-threatening condition such as a heart attack or pulmonary embolism. Therefore, this client should be assessed first to ensure prompt intervention and treatment. Choice B, a client with a fever of 100°F, may indicate an infection but is not immediately life-threatening compared to the symptoms of chest pain and shortness of breath. Choice C, a client scheduled for surgery, is not an immediate priority unless there are specific preoperative assessments or interventions required. Choice D, a client with stable vital signs, does not indicate an urgent need for assessment compared to the client with chest pain and shortness of breath.

4. A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following statements indicates an understanding of the teaching?

• A. I should avoid taking acetaminophen while taking this medication
• B. I will take this medication at the same time each day
• C. I will need to get my blood tested regularly while taking this medication
• D. I should increase my intake of leafy green vegetables

Correct answer: C

Rationale: The correct answer is C. Warfarin therapy requires regular blood testing to monitor INR levels and ensure therapeutic dosing. Option A is incorrect because acetaminophen can be taken with warfarin. Option B is not specific to warfarin administration. Option D is incorrect as it does not address the key monitoring requirement of blood testing while on warfarin.

5. Which of the following is a common manifestation of opioid withdrawal?

• A. Bradycardia and hypotension
• B. Tremors and increased blood pressure
• C. Severe muscle weakness and fatigue
• D. Severe hallucinations and delusions

Correct answer: B

Rationale: The correct answer is B: Tremors and increased blood pressure. During opioid withdrawal, individuals commonly experience symptoms such as tremors, increased blood pressure, and restlessness. Choice A, which suggests bradycardia and hypotension, is incorrect as opioid withdrawal often leads to tachycardia (rapid heart rate) and increased blood pressure. Choice C, severe muscle weakness and fatigue, is not a typical manifestation of opioid withdrawal. Choice D, severe hallucinations and delusions, is more characteristic of conditions like delirium tremens associated with alcohol withdrawal, rather than opioid withdrawal.

Similar Questions