Nursing Elites

1. A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse about insulin administration. Which of the following instructions should the nurse include?

• A. Store unopened vials of insulin in the refrigerator, not the freezer.
• B. Rotate injection sites within the same region to prevent tissue damage.
• C. Administer insulin at a 90-degree angle for subcutaneous injections.
• D. Avoid massaging the injection site after administering insulin.

Correct answer: B

Rationale: The correct answer is to rotate injection sites within the same region to prevent tissue damage. By rotating sites, the client can prevent lipodystrophy, which is a condition characterized by the loss or change in body fat at the site of repeated injections. This practice also helps to ensure proper insulin absorption. Storing unopened vials of insulin in the refrigerator (Choice A) is correct, not in the freezer, as freezing can damage the insulin. Administering insulin at a 90-degree angle (Choice C) is more appropriate for subcutaneous injections, while a 45-degree angle is used for intramuscular injections. Massaging the injection site after administering insulin (Choice D) is not recommended as it can affect insulin absorption rates.

2. A client who is postoperative following a colon resection reports pain. Which of the following actions should the nurse take?

• A. Assist the client in changing positions in bed
• B. Administer a PRN dose of morphine
• C. Encourage the client to use relaxation techniques
• D. Offer the client a back massage

Correct answer: B

Rationale: Administering a PRN dose of morphine is the most appropriate action to manage postoperative pain in a client following a colon resection. Morphine is a potent analgesic commonly used to relieve moderate to severe pain, especially in postoperative settings. While assisting the client to change positions in bed, encouraging relaxation techniques, and offering a back massage can provide comfort and support, they may not be sufficient in managing the pain following a major surgical procedure like a colon resection. Therefore, the priority intervention for acute postoperative pain control in this scenario is to administer medication like morphine.

3. A nurse is preparing a sterile field for a client with a surgical wound. Which of the following actions should the nurse take to maintain the sterile field?

• A. Open sterile packages using the flap closest to your body first.
• B. Don sterile gloves before opening the sterile package.
• C. Avoid reaching over the sterile field.
• D. Place sterile items at least 2.5 cm (1 in) from the edge of the sterile field.

Correct answer: C

Rationale: The correct action to maintain a sterile field is to avoid reaching over it. This prevents contamination of the sterile environment by reducing the risk of unintentionally dropping microorganisms from non-sterile areas onto the sterile field. Opening sterile packages using the flap closest to your body first (choice A) is a good practice but not directly related to maintaining the sterile field. Donning sterile gloves before opening the sterile package (choice B) is crucial for maintaining sterility but not specific to maintaining the sterile field. Placing sterile items at least 2.5 cm (1 in) from the edge of the sterile field (choice D) is important to prevent accidental contamination, but it is not the primary action to maintain the sterile field.

4. A client with schizophrenia is beginning therapy with clozapine. Which statement indicates a need for further teaching?

• A. I will need to have my blood work checked regularly while taking clozapine.
• B. I understand that clozapine may cause me to gain weight.
• C. I should report any signs of a fever while taking clozapine.
• D. I should discontinue clozapine once my symptoms improve.

Correct answer: D

Rationale: The correct answer is D because clients should continue taking clozapine even if their symptoms improve. Abruptly discontinuing the medication can lead to relapse. Choices A, B, and C are all correct statements regarding clozapine therapy. Regular blood work monitoring is necessary due to potential side effects, weight gain is a common side effect of clozapine, and reporting signs of fever is important as it can indicate a serious side effect of clozapine.

5. What is the most appropriate action when a patient experiences chest pain?

• A. Administer aspirin
• B. Administer nitroglycerin
• C. Reposition the patient
• D. Prepare for surgery

Correct answer: A

Rationale: Administering aspirin is the correct initial action when a patient experiences chest pain. Aspirin helps reduce the risk of clot formation and is a standard first-line treatment for chest pain related to possible cardiac issues. Administering nitroglycerin may be appropriate based on the underlying cause of chest pain, but aspirin is typically administered first. Repositioning the patient is not the primary intervention for chest pain, and preparing for surgery is not the immediate action required unless indicated by a healthcare provider after assessment.

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