Nursing Elites

1. What action is required by law when preparing to administer a controlled substance?

• A. Verify the client’s identification using two identifiers.
• B. Document the medication administration in the client’s chart immediately.
• C. Return any unused portion of the medication to the pharmacy.
• D. Have a second nurse witness the disposal of any unused portion.

Correct answer: D

Rationale: Having a second nurse witness the disposal of any unused portion of a controlled substance is a legal requirement to ensure proper disposal, prevent diversion, and maintain accountability. This practice helps in reducing the risk of misuse or unauthorized access to controlled substances, enhancing patient safety, and complying with legal regulations and standards.

2. When administering an IM injection to a 5-month-old infant, which of the following injection sites should be used?

• A. Deltoid
• B. Ventrogluteal
• C. Vastus lateralis
• D. Dorsogluteal

Correct answer: C

Rationale: For infants and young children, the vastus lateralis muscle located over the anterior thigh is the preferred site for intramuscular injections. This site is chosen for its large muscle mass and reduced risk of injury to major nerves and blood vessels. Infants have less developed muscle structures, making the vastus lateralis a safer and more effective site for injections compared to other sites like the deltoid, ventrogluteal, or dorsogluteal. Using the correct injection site is essential to prevent complications and ensure the proper absorption of the medication.

3. A client is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?

• A. Elevate the head of the bed to 30°
• B. Flush the tube with 50 mL of water every 2 hours
• C. Replace the feeding bag and tubing every 72 hours
• D. Check the client's gastric residual every 8 hours

Correct answer: A

Rationale: Elevating the head of the bed to 30° is the correct action to take when a client is receiving continuous enteral feedings through a nasogastric tube. This position helps prevent aspiration of the enteral feedings into the lungs, reducing the risk of aspiration pneumonia. Additionally, elevating the head of the bed promotes proper digestion and absorption of the feedings by utilizing gravity to facilitate movement into the stomach and through the gastrointestinal tract. Flushing the tube with water every 2 hours (Choice B) is not necessary for continuous feedings and may disrupt the feeding schedule. Replacing the feeding bag and tubing every 72 hours (Choice C) is not the standard recommendation unless there are specific concerns or complications. Checking the client's gastric residual every 8 hours (Choice D) is important but not the immediate action needed to prevent aspiration during enteral feedings.

4. A client with renal calculi is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should increase my intake of calcium-rich foods.
• B. I should decrease my intake of calcium-rich foods.
• C. I should increase my intake of sodium-rich foods.
• D. I should decrease my intake of potassium-rich foods.

Correct answer: B

Rationale: The correct answer is B because decreasing the intake of calcium-rich foods can help manage and prevent the formation of renal calculi. Excessive calcium intake can contribute to the formation of these stones, so reducing calcium-rich foods is a key dietary modification for individuals with renal calculi. Choice A is incorrect as increasing calcium-rich foods can exacerbate the condition. Choice C is incorrect because increasing sodium-rich foods can lead to more stone formation due to increased calcium excretion. Choice D is incorrect as potassium-rich foods do not directly contribute to the formation of renal calculi.

5. A client with a new diagnosis of hypothyroidism is being taught about medication management. Which of the following statements should the nurse include in the teaching?

• A. You should take your medication with a high-fiber meal.
• B. You should take your medication on an empty stomach.
• C. You should take your medication with a calcium supplement.
• D. You should take your medication before bedtime.

Correct answer: B

Rationale: The correct answer is B: 'You should take your medication on an empty stomach.' When educating a client with hypothyroidism, it is essential to advise taking thyroid medication on an empty stomach to enhance absorption and effectiveness. Taking the medication with food, especially high-fiber or with supplements like calcium, can interfere with absorption and reduce its efficacy. Therefore, it is crucial for the client to follow the recommendation of taking the medication on an empty stomach. Choices A, C, and D are incorrect because taking the medication with a high-fiber meal (Choice A) or with a calcium supplement (Choice C) can hinder absorption, and taking it before bedtime (Choice D) does not optimize absorption compared to taking it on an empty stomach.

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