Nursing Elites

1. A nurse is preparing to administer an intramuscular injection to a client. Which action should the nurse take to reduce the client's risk of injury?

• A. Use a 1-inch needle
• B. Select a large muscle for the injection
• C. Aspirate for blood return before injecting
• D. Massage the injection site

Correct answer: C

Rationale: The correct answer is to aspirate for blood return before injecting. This action helps ensure that the needle is not in a blood vessel, reducing the risk of injury. Using a 1-inch needle (Choice A) is a standard length for intramuscular injections but does not directly reduce the risk of injury. Selecting a large muscle for the injection (Choice B) is important for proper medication absorption but does not directly reduce the risk of injury. Massaging the injection site (Choice D) can help with medication absorption but does not reduce the risk of injury.

2. A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client's condition?

• A. The client is experiencing increased intracranial pressure
• B. He has a good prognosis for recovery
• C. This client is conscious, but is not oriented to time and place
• D. He is in a coma, and has a very poor prognosis

Correct answer: D

Rationale: A Glasgow Coma Scale of 3 indicates severe neurological impairment, suggesting a deep coma or even impending death. This client's condition is critical, and he has a very poor prognosis. Choice A is incorrect because a GCS of 3 does not directly indicate increased intracranial pressure. Choice B is incorrect as a GCS of 3 signifies a grave neurological status. Choice C is incorrect as a GCS of 3 represents a state of unconsciousness rather than being conscious but disoriented.

3. A 14-year-old girl with asthma complains of feeling nervous and jittery after a respiratory therapy bronchodilator treatment. What explanation is best for the nurse to provide to this adolescent?

• A. Nervousness should disappear when hypoxia is relieved after several bronchodilator treatments
• B. Tremors result from the rapid dilation of the bronchioles and an increased heart rate
• C. A fast heart rate and jitteriness are side effects of the bronchodilator treatment containing albuterol
• D. Excessive coughing, which causes tachypnea and anxiety, result from the use of bronchodilators

Correct answer: C

Rationale: The correct answer is C because a fast heart rate and jitteriness are common side effects of bronchodilators like albuterol. Choice A is incorrect as nervousness is more likely a side effect of the medication than solely related to hypoxia. Choice B is incorrect as it provides a partial explanation focusing only on tremors and heart rate, not mentioning jitteriness. Choice D is incorrect because excessive coughing and tachypnea are not typically associated with bronchodilator use; instead, they may indicate inadequate relief or other issues.

4. When evaluating the preoperative teaching of a client scheduled for arthroscopic anterior cruciate ligament repair, which statement by the client indicates that the teaching was effective?

• A. I will use crutches to keep my weight off my knee
• B. I will stay home until a wheelchair is delivered
• C. I can use the trapeze bar and side rails on the bed to help me turn regularly
• D. I can put my full weight on my foot starting the day after surgery

Correct answer: A

Rationale: The correct answer is A. Using crutches indicates an understanding of weight-bearing restrictions post-surgery. Choice B is incorrect because waiting for a wheelchair is not related to postoperative mobility instructions. Choice C is incorrect as turning in bed using the trapeze bar and side rails does not address weight-bearing restrictions. Choice D is incorrect because putting full weight on the foot immediately after surgery contradicts the need to keep weight off the knee.

5. A client is leaving the hospital against medical advice (AMA) and voluntarily signs the AMA form. Which nursing action is essential prior to the client leaving?

• A. Remove the client's peripheral IV access
• B. Administer requested pain relief medication
• C. Obtain the client's neurological vital signs
• D. Provide the client with the hospital's phone number

Correct answer: A

Rationale: Removing the client's peripheral IV access is essential before the client leaves against medical advice to prevent complications such as infection, thrombosis, or bleeding. Administering pain relief medication (choice B) can be important but not essential at this point. Obtaining neurological vital signs (choice C) is not specifically required before the client leaves. Providing the client with the hospital's phone number (choice D) may be helpful but is not as essential as ensuring the safe removal of IV access.

Similar Questions