Nursing Elites

1. A nurse is preparing to administer an immunization to a 6-month-old infant. Which of the following actions should the nurse take to reduce pain at the injection site?

• A. Administer the immunization in the deltoid muscle
• B. Apply a cold compress to the injection site
• C. Apply pressure to the injection site for 5 minutes
• D. Administer a local anesthetic at the injection site

Correct answer: D

Rationale: Administering a local anesthetic at the injection site can help reduce pain during immunizations in infants. Options A, B, and C are incorrect. Administering the immunization in the deltoid muscle may not provide pain relief. Applying a cold compress or pressure to the injection site is not as effective as using a local anesthetic to reduce pain.

2. A client who has a new prescription for warfarin is being taught about the medication's adverse effects by a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. ''I should expect mild bruising around my elbows.''
• B. ''I should report a red rash to my provider.''
• C. ''I should stop taking this medication if I develop a cough.''
• D. ''I should expect black, tarry stools.''

Correct answer: D

Rationale: The correct answer is D. Black, tarry stools can indicate gastrointestinal bleeding, a serious adverse effect of warfarin that requires immediate medical attention. Option A is incorrect because while bruising is a common side effect of warfarin, it is not limited to the elbows. Option B is incorrect as a red rash is not a typical adverse effect of warfarin. Option C is also incorrect because developing a cough is not a reason to discontinue warfarin unless advised by a healthcare provider.

3. A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Respiratory rate 16/min.
• B. Blood pressure 118/78 mm Hg.
• C. Urinary output of 30 mL/hr.
• D. Absent deep-tendon reflexes.

Correct answer: D

Rationale: The correct answer is D. Absent deep-tendon reflexes indicate magnesium toxicity and should be reported immediately. Magnesium sulfate is used to prevent seizures in clients with preeclampsia, but toxicity can lead to serious complications, including respiratory depression and loss of deep-tendon reflexes. Choices A, B, and C are within normal limits and expected findings in a client receiving magnesium sulfate for preeclampsia, so they do not require immediate reporting.

4. A nurse is teaching a client who has iron deficiency anemia about food choices to increase iron intake. Which of the following foods should the nurse recommend?

• A. Eggs
• B. Carrots
• C. White bread
• D. Spinach

Correct answer: D

Rationale: Spinach is an excellent choice to recommend as it is rich in non-heme iron, which can help improve iron levels in clients with iron deficiency anemia. Eggs (Choice A) are a good source of protein but do not contain as much iron as spinach. Carrots (Choice B) are rich in vitamin A but are not a significant source of iron. White bread (Choice C) is not a good source of iron compared to spinach.

5. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which of the following interventions should the nurse include?

• A. Massage the affected extremity every 4 hours.
• B. Encourage the client to remain on bed rest.
• C. Apply cold packs to the affected extremity.
• D. Encourage the client to ambulate frequently.

Correct answer: C

Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to apply cold packs to the affected extremity. Cold packs help reduce swelling and pain by causing vasoconstriction. Massaging the affected extremity could dislodge a clot, leading to serious complications. Encouraging bed rest may increase the risk of clot propagation, while frequent ambulation is contraindicated as it can dislodge clots.

Similar Questions