Nursing Elites

1. A healthcare professional is preparing to administer an intramuscular injection to a client. Which site is most appropriate for the healthcare professional to use?

• A. Deltoid muscle
• B. Ventrogluteal site
• C. Dorsogluteal site
• D. Rectus femoris site

Correct answer: B

Rationale: The ventrogluteal site is the most appropriate site for administering an intramuscular injection to an adult client. This site is preferred due to its large muscle mass and distance from major nerves and blood vessels, reducing the risk of injury or complications. The deltoid muscle, while commonly used for vaccinations, may not be suitable for certain medications due to its smaller muscle mass. The dorsogluteal site is no longer recommended due to the proximity of the sciatic nerve, which can lead to complications. The rectus femoris site is not commonly used for intramuscular injections in clinical practice.

2. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?

• A. Remove the safety pin from the extinguisher.
• B. Aim the extinguisher at the base of the fire.
• C. Squeeze the handle to release the extinguishing agent.
• D. Sweep the extinguisher from side to side.

Correct answer: A

Rationale: The correct first step in using a fire extinguisher is to remove the safety pin. This action enables the extinguisher to be activated and used effectively. Choice B, aiming the extinguisher at the base of the fire, comes after removing the safety pin. Choice C, squeezing the handle to release the extinguishing agent, and choice D, sweeping the extinguisher from side to side, are subsequent steps in using a fire extinguisher and should follow removing the safety pin.

3. A client with a history of seizures is prescribed phenytoin (Dilantin). What side effect should the healthcare provider report immediately?

• A. Increased appetite
• B. Dry mouth
• C. Nausea and vomiting
• D. Gingival hyperplasia

Correct answer: D

Rationale: Gingival hyperplasia is a significant side effect associated with phenytoin therapy. It is characterized by an overgrowth of gum tissue, which can lead to issues such as difficulty in speaking, eating, and maintaining proper oral hygiene. This condition can progress rapidly and may require immediate intervention by the healthcare provider to prevent further complications. Increased appetite, dry mouth, and nausea/vomiting are common side effects of various medications, but they are not as urgent or serious as gingival hyperplasia in a client taking phenytoin.

4. A client is admitted for evaluation and control of HTN. Several hours after the client's admission, the nurse discovers the client supine on the floor, unresponsive to verbal or painful stimuli. The nurse's first reaction at this time is to:

• A. Establish an airway
• B. Call for assistance
• C. Check the client's pulse and blood pressure
• D. Perform CPR

Correct answer: A

Rationale: In a situation where a client is found unresponsive on the floor, the nurse's first priority is to establish an airway. This is crucial to ensure that the client can breathe adequately and receive oxygen. Without a patent airway, the client's oxygenation and ventilation may be compromised, leading to serious consequences. Calling for assistance is important, but establishing an airway takes precedence as it directly impacts the client's ability to breathe. Checking the client's pulse and blood pressure can be done after ensuring a clear airway. Performing CPR is not the immediate action needed unless the client's breathing and pulse are absent after the airway has been secured.

5. A client has just returned from surgery with an indwelling urinary catheter in place. What is the most important action for the nurse to take to prevent infection?

• A. Change the catheter every 72 hours.
• B. Ensure the catheter tubing is free of kinks.
• C. Clean the perineal area with antiseptic solution daily.
• D. Irrigate the catheter with normal saline every shift.

Correct answer: B

Rationale: The most crucial action to prevent infection in a client with an indwelling urinary catheter is to ensure the catheter tubing is free of kinks. Kinks in the tubing can lead to urine retention or obstruction, increasing the risk of infection. Changing the catheter every 72 hours is not necessary if there are no signs of infection or other issues. Cleaning the perineal area with antiseptic solution daily is important for hygiene but not the most critical action to prevent infection related to the catheter. Irrigating the catheter with normal saline every shift is not a routine practice and may increase the risk of introducing pathogens into the urinary system.

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