Nursing Elites

1. A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client. Which site is safest for the nurse to use?

• A. Ventrogluteal
• B. Dorsogluteal
• C. Vastus lateralis
• D. Rectus femoris

Correct answer: A

Rationale: The correct answer is 'Ventrogluteal.' The ventrogluteal site is recommended for intramuscular injections in adults because it is free of major blood vessels and nerves, reducing the risk of injury or complications. Choice B, 'Dorsogluteal,' is not recommended due to the proximity of the sciatic nerve and major blood vessels. Choices C and D, 'Vastus lateralis' and 'Rectus femoris,' are sites commonly used for intramuscular injections but are more suitable for pediatric or specific population groups, not typically for adults.

2. A community health nurse is teaching a group of clients about first aid for different types of wounds. Which of the following client statements indicates an understanding of the teaching?

• A. I should apply clean dressings over blood-saturated dressings and hold pressure.
• B. I will rinse the wound with hot water to cleanse it.
• C. I can remove the dressing once the bleeding stops.
• D. I should apply antibiotic ointment directly to the wound.

Correct answer: A

Rationale: The correct answer is A because applying clean dressings over blood-saturated dressings and holding pressure helps prevent disruption of wound tissue, aiding in the clotting process and controlling bleeding. Choice B is incorrect as rinsing a wound with hot water can cause further tissue damage. Choice C is incorrect as the dressing should not be removed once applied as it can disrupt the formation of a clot. Choice D is incorrect as antibiotic ointment should not be applied directly to the wound during initial first aid.

3. A client has a new prescription for levothyroxine. What should the nurse teach the client?

• A. It should be taken at night
• B. Monitor for symptoms of hypothyroidism
• C. Take it with calcium supplements
• D. Take it on an empty stomach

Correct answer: D

Rationale: The correct answer is to take levothyroxine on an empty stomach. This is because levothyroxine should be taken in the morning on an empty stomach to ensure proper absorption. Option A is incorrect because levothyroxine is usually advised to be taken in the morning. Option B is not the priority teaching point as monitoring for hypothyroidism symptoms is ongoing care. Option C is incorrect as levothyroxine should not be taken with calcium supplements as they can interfere with its absorption.

4. A nurse is caring for a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?

• A. Lip-smacking
• B. Agranulocytosis
• C. Clang association
• D. Alopecia

Correct answer: A

Rationale: Lip-smacking is a symptom of tardive dyskinesia, a long-term side effect of antipsychotic medications like haloperidol, characterized by involuntary movements of the face and jaw. Agranulocytosis (Choice B) is a rare but serious side effect of some medications, characterized by a dangerously low white blood cell count. Clang association (Choice C) is a thought disorder characterized by the association of words based on sound rather than meaning. Alopecia (Choice D) refers to hair loss, which is not a known long-term side effect of haloperidol.

5. A client is experiencing suicidal thoughts and states, 'Why not end my misery?' What is the best response by the nurse?

• A. Why do you think your life isn’t worth living anymore?
• B. Do you have a plan to end your life?
• C. I need to understand what you mean by misery.
• D. You can trust me to share your thoughts.

Correct answer: B

Rationale: The correct answer is B: 'Do you have a plan to end your life?' When a client expresses suicidal thoughts, it is crucial to assess the immediate risk. Inquiring about a specific plan can help determine the seriousness of the situation. Choice A is less direct and may not provide a clear indication of the immediate risk. Choice C focuses on the interpretation of 'misery' rather than assessing the risk of suicide. Choice D offers support but does not address the critical assessment of the client's immediate safety.

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