Nursing Elites

1. A healthcare professional is preparing to administer a subcutaneous injection of insulin. Which of the following actions should the professional take?

• A. Use a 1-inch needle.
• B. Insert the needle at a 90-degree angle.
• C. Use a tuberculin syringe.
• D. Aspirate before injecting.

Correct answer: B

Rationale: When administering a subcutaneous injection, inserting the needle at a 90-degree angle is appropriate. This angle helps ensure proper delivery of the medication into the subcutaneous tissue. Using a 1-inch needle is common for subcutaneous injections to reach the subcutaneous fat layer adequately. Tuberculin syringes are typically used for intradermal injections, not subcutaneous injections. Aspirating before injecting is not necessary for subcutaneous injections as it is primarily used for intramuscular injections to ensure the needle is not in a blood vessel.

2. In an emergency department, a provider is assessing a client with an acute head injury following a motor-vehicle crash. Which of the following findings should be prioritized?

• A. A Glasgow Coma Scale score of 13
• B. Clear fluid leaking from the nose
• C. Nausea and vomiting
• D. Anisocoria

Correct answer: B

Rationale: The priority finding is the clear fluid leaking from the nose, which could indicate a cerebrospinal fluid leak and potential brain injury. This requires immediate attention to assess for possible cerebrospinal fluid leak, which is a serious complication of head trauma and needs prompt intervention to prevent further complications. While a Glasgow Coma Scale score of 13 may indicate a mild alteration in consciousness, it is not as urgent as assessing for a cerebrospinal fluid leak. Nausea and vomiting are common symptoms after head injuries but do not take precedence over assessing for a potential cerebrospinal fluid leak. Anisocoria (unequal pupils) is also important to note but is not as urgent as identifying a possible cerebrospinal fluid leak in this scenario.

3. A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?

• A. Monitor gastric residuals every 4 hours.
• B. Position the client in a semi-Fowler's position.
• C. Check for tube placement by auscultating air after feeding.
• D. Warm the formula to body temperature before feeding.

Correct answer: A

Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration. Therefore, the correct answer is to monitor gastric residuals to prevent aspiration, as it directly assesses the stomach's ability to empty properly and the tolerance of the feedings.

4. A client with a new diagnosis of hypertension is receiving teaching from a healthcare provider. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will decrease my intake of potassium.
• B. I will increase my intake of vitamin K.
• C. I will decrease my intake of sodium.
• D. I will increase my intake of magnesium.

Correct answer: C

Rationale: The correct answer is C: 'I will decrease my intake of sodium.' Lowering sodium intake is essential in managing hypertension as it helps reduce blood pressure levels. Excess sodium can lead to fluid retention and increased blood volume, putting more strain on the heart and blood vessels. Therefore, this response indicates an understanding of the teaching provided. Choices A, B, and D are incorrect because decreasing potassium intake, increasing vitamin K intake, and increasing magnesium intake are not primary dietary modifications recommended for hypertension. While potassium and magnesium can be beneficial for overall health, reducing sodium intake is the key dietary change to manage hypertension effectively.

5. When teaching a client about the proper use of a cane, which of the following instructions should be included?

• A. Hold the cane on the weaker side.
• B. Move the cane forward first.
• C. Keep the cane 12 inches away from the body.
• D. Use the cane for support only when climbing stairs.

Correct answer: B

Rationale: When using a cane, it is crucial to move the cane forward first to provide support and enhance balance. Advancing the cane before the weaker or stronger leg helps widen the base of support, thereby improving stability during ambulation. Keeping the cane too far or too close to the body can affect its supportive function. Moreover, utilizing the cane solely for stair climbing limits its overall utility in maintaining balance and stability during regular walking.

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