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. How should a healthcare professional respond to a patient experiencing hypoglycemia?

• A. Rechecking the blood glucose level in 15 minutes
• B. Encouraging the patient to eat a high-protein snack
• C. Administering 15g of fast-acting carbohydrates
• D. Administering glucagon if the patient is unconscious

Correct answer: C

Rationale: The correct response to a patient experiencing hypoglycemia is to administer 15g of fast-acting carbohydrates. This helps quickly increase the blood glucose levels in the patient, addressing the low blood sugar. Rechecking the blood glucose level in 15 minutes (Choice A) may delay necessary intervention, encouraging a high-protein snack (Choice B) is not recommended as it does not rapidly increase blood sugar levels, and administering glucagon if the patient is unconscious (Choice D) is typically done in severe cases of hypoglycemia when the patient is unable to eat or drink.

3. What are the clinical signs of hyperglycemia in a patient with diabetes mellitus, and how should a nurse respond?

• A. Monitoring blood glucose levels and administering insulin
• B. Polyuria, polydipsia, and polyphagia
• C. Fatigue, blurred vision, and fruity breath
• D. Educating the patient on blood glucose monitoring

Correct answer: B

Rationale: The correct signs of hyperglycemia in a patient with diabetes mellitus are polyuria (excessive urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). These symptoms indicate high blood sugar levels. Therefore, the correct response for a nurse would be to recognize these signs, monitor blood glucose levels, and administer insulin to manage the hyperglycemia. Choice A is incorrect because it only addresses the response aspect without mentioning the signs. Choices C and D are incorrect as they do not reflect the classic clinical signs of hyperglycemia in diabetes mellitus.

4. What is the most important nursing intervention when caring for a patient with a wound?

• A. Apply an occlusive dressing over the wound.
• B. Clean the wound with normal saline.
• C. Administer antibiotics as prescribed.
• D. Reassess the wound every 4 hours for changes.

Correct answer: B

Rationale: The most important nursing intervention when caring for a patient with a wound is to clean the wound with normal saline. This is crucial for preventing infection and promoting healing. Applying an occlusive dressing (Choice A) can be important but should come after cleaning the wound. Administering antibiotics (Choice C) is not the first-line intervention for all wounds and should be based on the healthcare provider's prescription. Reassessing the wound (Choice D) is essential but not the most important initial intervention.

5. A female client with anxiety disorder is being taught about alprazolam by a nurse. Which of the following information should the nurse include in the teaching?

• A. This medication may increase your blood pressure
• B. Use a reliable form of contraception while taking this medication
• C. If a dose is missed, double the next dose of medication
• D. Do not eat aged cheeses while taking this medication

Correct answer: B

Rationale: The correct answer is B. Alprazolam can increase the risk of pregnancy complications, so using a reliable form of contraception is essential to prevent unintended pregnancies. Choice A is incorrect because alprazolam typically does not increase blood pressure. Choice C is incorrect as doubling the next dose after a missed dose can lead to overdose and adverse effects. Choice D is unrelated to alprazolam and is not a concern when taking this medication.

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