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 nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan?

• A. Place food on the left side of the client's mouth when they are ready to eat
• B. Provide assistance with the client's ADLs
• C. Maintain the client in an upright position
• D. Place the client's left arm on a pillow while they are sitting

Correct answer: D

Rationale: Placing the client's left arm on a pillow while they are sitting helps prevent shoulder displacement and provides support for the limb post-stroke. This positioning is important to maintain proper alignment and prevent complications. Choices A, B, and C are incorrect because placing food on the left side of the mouth, providing total assistance with ADLs, and maintaining the client on bed rest do not directly address the specific needs related to unilateral paralysis and dysphagia post right hemispheric stroke.

3. A nurse is caring for a child who has cystic fibrosis and is receiving postural drainage. Which of the following actions should the nurse take?

• A. Perform the procedure after meals.
• B. Administer bronchodilators before the procedure.
• C. Hold hand flat to perform percussion.
• D. Perform the procedure twice a day.

Correct answer: C

Rationale: The correct action the nurse should take when caring for a child with cystic fibrosis receiving postural drainage is to hold the hand flat to perform percussion. This technique allows for effective chest physiotherapy. Choice A is incorrect because postural drainage should be performed before meals to prevent vomiting during the procedure. Choice B is incorrect because bronchodilators are typically administered before postural drainage to help open up the airways. Choice D is incorrect as the frequency of postural drainage may vary depending on the individual's condition, so performing it twice a day may not be appropriate for all patients.

4. A nurse is caring for a client who has a prescription for enoxaparin. Which of the following actions should the nurse take?

• A. Inject the medication into the deltoid muscle
• B. Inject the medication deep into subcutaneous tissue
• C. Massage the injection site for 2 minutes after administration
• D. Insert the needle at a 10-degree angle

Correct answer: B

Rationale: The correct action the nurse should take when administering enoxaparin is to inject the medication deep into subcutaneous tissue. This method helps ensure proper absorption of the medication and prevents tissue irritation. Injecting into the deltoid muscle (Choice A) is not recommended for enoxaparin administration. Massaging the injection site (Choice C) can lead to tissue damage and bruising. Inserting the needle at a 10-degree angle (Choice D) is not the correct technique for administering enoxaparin.

5. Which assessment finding is most concerning in a patient receiving morphine?

• A. Hypotension
• B. Bradycardia
• C. Respiratory depression
• D. Hypertension

Correct answer: C

Rationale: The correct answer is C, respiratory depression. When a patient is receiving morphine, respiratory depression is the most concerning side effect because it can lead to serious complications, including respiratory arrest and even death. Monitoring the patient's respiratory status is crucial to ensure early detection of any signs of respiratory depression. Choices A, B, and D are incorrect because although hypotension, bradycardia, and hypertension can occur as side effects of morphine, they are not as immediately life-threatening as respiratory depression in this context.

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