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 healthcare professional is caring for a group of clients on a medical-surgical unit. Which of the following clients is at increased risk for body-image disturbances?

• A. A client who had a laparoscopic appendectomy
• B. A client who had a mastectomy
• C. A client who had a left above-the-knee amputation
• D. A client who had a cardiac catheterization

Correct answer: C

Rationale: Clients who have undergone significant visible body changes, like amputation, are at increased risk for body-image disturbances. Amputation can have a profound impact on self-image and body perception due to the visible structural alteration. While conditions like laparoscopic appendectomy, mastectomy, and cardiac catheterization may also affect body image, they are less likely to cause significant disturbances compared to visible changes like amputation.

3. A nurse is caring for an older adult client who is confused and continually grabs at the nurse. Which of the following is a nursing action?

• A. Firmly tell the client not to grab
• B. Redirect the client’s attention
• C. Use physical restraints
• D. Avoid contact with the client

Correct answer: B

Rationale: Redirecting the client's attention is the appropriate nursing action in this scenario. When dealing with a confused client exhibiting grabbing behavior, redirection can help shift their focus to a more appropriate activity or object. Firmly telling the client not to grab may escalate the situation and create a confrontational environment, which is not recommended when caring for confused clients. The use of physical restraints should be a last resort and only implemented after all other strategies have been exhausted, as they can contribute to increased agitation and distress in older adults. Avoiding contact with the client is not a proactive approach to managing the behavior and may lead to feelings of neglect or abandonment in the client.

4. A client with a terminal illness asks the nurse about what would happen if she arrived at the emergency department and had difficulty breathing, despite declining resuscitation in her living will. Which of the following responses should the nurse provide?

• A. We will determine who the durable power of attorney for health care form has designated.
• B. We will apply oxygen through a tube in your nose.
• C. We will ask if you have changed your mind.
• D. We will insert a breathing tube while we evaluate your condition.

Correct answer: B

Rationale: The correct response is to provide oxygen through a tube in the client's nose. Oxygen therapy can offer comfort and support breathing without being considered resuscitative. Therefore, this intervention aligns with the client's wish to decline resuscitation. Option A is not directly related to addressing the client's immediate breathing difficulty. Option C does not acknowledge the client's living will decision. Option D involves a more invasive procedure that may go against the client's wishes to decline resuscitation.

5. The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the LPN/LVN administer?

• A. 1 ml.
• B. 1.5 ml.
• C. 1.75 ml.
• D. 2 ml.

Correct answer: B

Rationale: To calculate the correct dose of 15 mg, the LPN/LVN should administer 1.5 ml of Lasix (20 mg/2 ml). This calculation ensures precise dosing. Choice A (1 ml) is too low and would provide only 10 mg, while choice C (1.75 ml) and choice D (2 ml) would exceed the prescribed dose, resulting in potential adverse effects. It is important for the LPN/LVN to administer the exact prescribed dose to ensure therapeutic efficacy and avoid unnecessary complications.

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