Nursing Elites

1. A nurse is preparing to administer an intramuscular (IM) injection to a client. What is the most appropriate site to use for an IM injection in an adult?

• A. Dorsal gluteal muscle
• B. Vastus lateralis muscle
• C. Rectus femoris muscle
• D. Deltoid muscle

Correct answer: B

Rationale: The correct answer is B: Vastus lateralis muscle. The vastus lateralis muscle is a recommended site for IM injections in adults due to its size and accessibility. The dorsal gluteal muscle is not recommended for IM injections in adults due to the proximity to major nerves and blood vessels, increasing the risk of injury. The rectus femoris muscle is not a common site for IM injections in adults. The deltoid muscle is typically used for IM injections in small-volume medications or vaccines, especially in adults.

2. A client with endometrial carcinoma is receiving brachytherapy and has radioactive Cesium loaded in a vaginal applicator. What action should the nurse implement?

• A. Wear a dosimeter film badge when in the client’s room
• B. Spend 30 minutes at the bedside when providing direct care
• C. Change the linens every day after assisting with a bed bath
• D. Use gloves to remove the applicator if it is dislodged in the bed

Correct answer: A

Rationale: The correct action for the nurse to implement when caring for a client with a radioactive Cesium-loaded vaginal applicator during brachytherapy is to wear a dosimeter film badge when in the client’s room. Wearing a dosimeter badge is essential to monitor radiation exposure and ensure the safety of healthcare providers. Choice B is incorrect as the duration is not specified and unnecessary. Choice C is incorrect as changing linens daily does not directly relate to radiation safety. Choice D is incorrect as using gloves to remove the applicator if dislodged is important but not the primary action to monitor radiation exposure.

3. The nurse is caring for a client with a tracheostomy. Which action should the nurse perform when suctioning the tracheostomy tube?

• A. Increase wall suction while removing the suction catheter
• B. Instill 10 ml of sterile saline into the tracheostomy tube before applying continuous suction
• C. Suction the client’s oropharynx after tracheal suctioning
• D. Insert the suction catheter into the trachea, and apply intermittent suction with removal of the catheter

Correct answer: D

Rationale: When suctioning a tracheostomy tube, it is essential to insert the suction catheter into the trachea and apply intermittent suction with removal of the catheter. This technique helps prevent damage to the trachea and reduces discomfort for the client. Choice A is incorrect because increasing wall suction with the removal of the suction catheter can cause trauma to the tracheal mucosa. Choice B is incorrect because instilling saline into the tracheostomy tube before suctioning is not recommended as it can lead to complications. Choice C is incorrect as oropharyngeal suctioning should be done before tracheal suctioning to prevent the risk of aspiration.

4. What should be the school nurse's first action after being notified that Child A has bitten Child B on the arm, resulting in broken skin but no bleeding?

• A. Apply antibiotic cream to Child B’s arm immediately
• B. Determine if Child A has a history of Hepatitis C or HIV
• C. Determine the date of Child B’s latest tetanus booster
• D. Wash Child B’s arm thoroughly with soap and water

Correct answer: D

Rationale: The correct first action for the school nurse to take in this situation is to wash Child B’s arm thoroughly with soap and water. Washing the wound immediately is crucial to reduce the risk of infection from the bite. Applying antibiotic cream may come after cleaning the wound. Determining Child A's medical history or checking Child B's tetanus status is important but not the immediate priority when dealing with a bite wound.

5. After a client with leukemia undergoes a bone marrow biopsy and is found to have thrombocytopenia, which nursing assessment is most important following the procedure?

• A. Observe the aspiration site
• B. Assess body temperature
• C. Monitor skin elasticity
• D. Measure urinary output

Correct answer: A

Rationale: The correct answer is to observe the aspiration site. Thrombocytopenia, characterized by a low platelet count, increases the risk of bleeding. Therefore, monitoring the biopsy site for bleeding or hematoma is crucial to ensure early detection and intervention. Assessing body temperature (choice B) is not directly related to the increased bleeding risk associated with thrombocytopenia. Monitoring skin elasticity (choice C) and measuring urinary output (choice D) are important assessments but are not the priority in this situation where bleeding risk needs immediate attention.

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