Nursing Elites

1. A client is reviewing a medical record for advance directives. Which client statement indicates an understanding of the teaching?

• A. I don't need a living will because my family will make decisions.
• B. My living will takes effect only if I lose consciousness.
• C. My family will decide when to follow my living will.
• D. I can change my living will at any time.

Correct answer: D

Rationale: The correct answer is D because clients can change their living will at any time as long as they are mentally competent. Choice A is incorrect because relying solely on family to make decisions may not align with the client's wishes. Choice B is incorrect because a living will can address various situations, not just loss of consciousness. Choice C is incorrect because the client should be the primary decision-maker regarding their living will, not the family.

2. A healthcare professional is planning to administer an intramuscular injection to a client. What muscle should the healthcare professional choose to avoid injury?

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

Correct answer: B

Rationale: The ventrogluteal muscle is the preferred site for intramuscular injections to avoid injury. Choosing the ventrogluteal site reduces the risk of injury to major nerves and blood vessels, unlike the deltoid, rectus femoris, or dorsogluteal sites. The deltoid muscle is commonly used for vaccines but has a higher risk of injury due to its proximity to the radial nerve. The rectus femoris muscle is not recommended for intramuscular injections due to its location and the risk of injury. The dorsogluteal site is also not recommended as it poses a risk of injury to the sciatic nerve and superior gluteal artery.

3. A client who is postoperative following abdominal surgery is at risk for constipation due to which behavior?

• A. Increased fiber intake
• B. Decreased fluid intake
• C. Frequent urge suppression
• D. Increased physical activity

Correct answer: B

Rationale: Postoperative clients are at risk for constipation due to various factors, including decreased fluid intake. Insufficient fluid consumption can lead to hardening of stools, making them difficult to pass. Increased fiber intake (choice A) is actually beneficial for preventing constipation as it adds bulk to the stool. Frequent urge suppression (choice C) can contribute to constipation by disrupting normal bowel habits. Increased physical activity (choice D) generally helps promote bowel movements and reduce the risk of constipation.

4. A client with diabetes mellitus has a foot ulcer. What is an appropriate intervention to promote wound healing?

• A. Apply a heating pad to the wound
• B. Apply a moisture-retentive dressing
• C. Provide daily wound irrigation
• D. Apply an ice pack to the wound

Correct answer: B

Rationale: The correct answer is to apply a moisture-retentive dressing. This type of dressing promotes a moist wound environment, which is crucial for wound healing. Applying a heating pad can lead to tissue damage, while daily wound irrigation can disrupt the wound healing process. Applying an ice pack is not recommended for promoting wound healing in this scenario.

5. When teaching about safety risks for adolescents, what should the nurse emphasize?

• A. Adolescents have a decreased risk of injury
• B. Peer pressure can lead to risky behaviors
• C. Increased responsibility reduces risks
• D. Adolescents are less likely to engage in substance abuse

Correct answer: B

Rationale: The correct answer is B: 'Peer pressure can lead to risky behaviors.' Adolescents are at an increased risk for injury due to peer pressure and the tendency to engage in high-risk behaviors. Emphasizing the impact of peer pressure on decision-making can help adolescents make safer choices. Choices A, C, and D are incorrect because adolescents actually have an increased risk of injury, increased responsibility does not always reduce risks, and many adolescents are at risk of engaging in substance abuse.

Similar Questions