Nursing Elites

1. A group of clients are being educated about influenza. Which of the following client statements indicates an understanding of the teaching?

• A. ''I should wash my hands after blowing my nose to prevent spreading the virus.''
• B. ''I need to avoid drinking fluids if I develop symptoms.''
• C. ''I need a flu shot every 2 years because of the different flu strains.''
• D. ''I should cover my mouth with my hand when I sneeze.''

Correct answer: A

Rationale: The correct answer is, 'I should wash my hands after blowing my nose to prevent spreading the virus.' This statement shows understanding of the importance of hand hygiene in preventing the spread of influenza. Washing hands after activities like blowing the nose can help reduce the risk of transmitting the virus to others. Choices B, C, and D are incorrect as they do not reflect accurate understanding of influenza prevention measures.

2. What is the appropriate needle size for insulin injection?

• A. 18G, 1 ½” long
• B. 22G, 1” long
• C. 22G, 1 ½” long
• D. 25G, 5/8” long

Correct answer: D

Rationale: The appropriate needle size for insulin injection is 25G, 5/8” long. This size allows for accurate and comfortable insulin administration in subcutaneous tissue.

3. A client complains of difficulty swallowing when the nurse tries to administer capsule medication. Which of the following measures should the nurse take?

• A. Dissolve the capsule in a glass of water
• B. Break the capsule and give the contents with applesauce
• C. Check the availability of a liquid preparation
• D. Crush the capsule and place it under the tongue

Correct answer: C

Rationale: When a client has difficulty swallowing capsule medication, the nurse should check the availability of a liquid preparation. This is a safer approach and ensures that the medication's integrity is maintained, providing an alternative form that is easier for the client to take. Dissolving the capsule in water (choice A) may alter the medication's effectiveness, breaking the capsule and mixing the contents with applesauce (choice B) is not recommended as it may cause an unpleasant taste, and crushing the capsule and placing it under the tongue (choice D) can be unsafe and affect the medication's absorption.

4. All of the following interventions are correct when using the Z-track method of drug injection except:

• A. Prepare the injection site with alcohol
• B. Use a needle that is at least 1” long
• C. Aspirate for blood before injection
• D. Rub the site vigorously after the injection to promote absorption

Correct answer: D

Rationale: When using the Z-track method of drug injection, it is important to prepare the injection site with alcohol to ensure cleanliness, use a needle that is at least 1” long to reach the muscle tissue, and aspirate for blood before injection to verify correct needle placement. However, rubbing the site vigorously after the injection is not recommended as it can cause medication to leak into subcutaneous tissue, compromising the medication's intended absorption and efficacy.

5. A healthcare professional is assessing a client who has a pulmonary embolism. Which of the following information should the healthcare professional not expect to find?

• A. Bradypnea
• B. Pleural friction rub
• C. Petechiae
• D. Tachycardia

Correct answer: A

Rationale: In a client with a pulmonary embolism, bradypnea, which is abnormally slow breathing, is not an expected finding. Pulmonary embolism typically presents with tachypnea (rapid breathing) due to the body's compensatory mechanism to increase oxygen levels. Pleural friction rub, petechiae, and tachycardia are commonly associated with a pulmonary embolism due to the impaired oxygenation and increased workload on the heart. Therefore, the healthcare professional should not expect to find bradypnea during the assessment of a client with a pulmonary embolism.

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