Nursing Elites

1. A nurse is teaching a client about self-administration of enoxaparin. Which of the following instructions should the nurse include?

• A. Administer the injection into the muscle of your thigh.
• B. Pinch the skin before inserting the needle.
• C. Rub the injection site after administering the medication.
• D. Administer the injection into the fat tissue of your abdomen.

Correct answer: D

Rationale: The correct instruction for self-administration of enoxaparin is to inject it into the fat tissue of the abdomen for proper absorption. Choice A is incorrect as enoxaparin should not be injected into the muscle. Choice B is unnecessary for enoxaparin administration. Choice C is incorrect as rubbing the injection site after administering the medication is not recommended.

2. A client has a new prescription for spironolactone. Which of the following instructions should the nurse include?

• A. Take this medication with a potassium supplement.
• B. Avoid foods that contain potassium.
• C. Limit your fluid intake while taking this medication.
• D. Take this medication on an empty stomach.

Correct answer: B

Rationale: The correct answer is B because spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium. Instructing the client to avoid foods high in potassium helps prevent hyperkalemia, a potential side effect of spironolactone. Choice A is incorrect because taking spironolactone with a potassium supplement can increase the risk of hyperkalemia. Choice C is not directly related to spironolactone use. Choice D is also incorrect as spironolactone does not need to be taken on an empty stomach.

3. A nurse is caring for a client who is 1 day postoperative following an open reduction and internal fixation of the right tibia. Which of the following findings should the nurse report to the provider?

• A. Serous drainage on the dressing
• B. Capillary refill of 2 seconds
• C. Heart rate of 88/min
• D. Pallor of the affected extremity

Correct answer: D

Rationale: Pallor of the affected extremity could indicate impaired circulation, such as compromised blood flow to the area, which is crucial to monitor postoperatively. This finding suggests potential vascular compromise or decreased blood supply to the extremity, which is a serious concern and should be reported promptly to the provider for further evaluation and intervention. Serous drainage on the dressing is a normal finding in the immediate postoperative period and does not necessarily indicate a complication requiring immediate provider notification. Capillary refill of 2 seconds is within the normal range (less than 3 seconds) and indicates adequate peripheral perfusion. A heart rate of 88/min is also within the normal range for an adult and is not typically a cause for immediate concern postoperatively.

4. A client with heart failure is being assessed by a nurse. Which of the following findings indicates the client is experiencing fluid overload?

• A. Dry, hacking cough
• B. Bounding peripheral pulses
• C. Decreased urinary output
• D. Weight loss of 1 kg in 24 hours

Correct answer: C

Rationale: In clients with heart failure, decreased urinary output is a classic sign of fluid overload. The kidneys try to compensate for the increased volume by reducing urine output, leading to fluid retention. A dry, hacking cough (choice A) is more indicative of heart failure complications like pulmonary edema. Bounding peripheral pulses (choice B) are a sign of increased volume, but not specifically fluid overload. Weight loss of 1 kg in 24 hours (choice D) is not indicative of fluid overload but rather rapid fluid loss.

5. What is the appropriate action for a patient experiencing a severe allergic reaction?

• A. Administer epinephrine
• B. Administer antihistamines
• C. Administer corticosteroids
• D. Administer oxygen

Correct answer: A

Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for severe allergic reactions as it helps reverse the symptoms rapidly by constricting blood vessels, increasing heart rate, and opening airways. Antihistamines (Choice B) may help with mild allergic reactions but are not effective for severe cases. Corticosteroids (Choice C) are used to reduce inflammation and are typically not the first-line treatment for acute severe allergic reactions. Administering oxygen (Choice D) may be necessary to support breathing in severe cases, but epinephrine is the primary treatment to reverse the allergic reaction symptoms.

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