Nursing Elites

1. A nursing care plan for a client with sleep problems has been implemented. All of the following should be expected outcomes except:

• A. the client reports no episodes of awakening during the night.
• B. the client falls asleep within 1 hour of going to bed.
• C. the client reports satisfaction with their amount of sleep.
• D. the client rates sleep as an 8 or more on the visual analog scale.

Correct answer: B

Rationale: An expected outcome for a nursing care plan targeting sleep problems is that the client reports no episodes of awakening during the night, the client reports satisfaction with their amount of sleep, and the client rates sleep as an 8 or more on the visual analog scale. Falling asleep within 1 hour of going to bed is not necessarily an expected outcome. While it is generally desirable for individuals to fall asleep within a reasonable time frame, this specific timeframe may vary among individuals, and it is not a strict criterion for successful sleep outcomes. Therefore, the correct answer is that the client falls asleep within 1 hour of going to bed, as this is not a definitive measure of the effectiveness of the nursing care plan for sleep problems.

2. A nurse is watching as a new nurse employee administers an intramuscular (IM) injection in a client's deltoid muscle. The nurse determines that the new employee is performing the procedure correctly if the new employee uses which technique?

• A. Administers the injection 2 inches below the acromion process
• B. Positions the client with the deltoid muscle exposed
• C. Administers the injection in the thigh
• D. Places the client in the Sims position

Correct answer: A

Rationale: When administering an intramuscular injection in the deltoid muscle, the correct technique involves administering the injection 2 inches below the acromion process, which is the bony structure on top of the shoulder blade. This location ensures safe and effective administration. Administering the injection in the thigh (vastus lateralis or rectus femoris muscle) is not appropriate for a deltoid injection as the deltoid muscle is located in the upper arm. The Sims position is not the correct position for a deltoid muscle injection. While positioning the client with the deltoid muscle exposed allows for proper access and visualization, the critical aspect for a correct deltoid injection is the accurate injection site, 2 inches below the acromion process.

3. A neighbor telephones the nurse to tell her that her child has erythema infectiosum and asks for information. The nurse knows that another name for the disorder is:

• A. Kawasaki disease
• B. rheumatic disease
• C. lupus erythematosus
• D. fifth disease

Correct answer: D

Rationale: The correct answer is 'fifth disease.' Erythema infectiosum, also known as fifth disease, is a parvovirus flu-like illness that is self-limiting but contagious for two to three weeks. Choice A, Kawasaki disease, is a different condition that involves inflammation of the blood vessels, predominantly affecting children. Choices B and C, rheumatic disease and lupus erythematosus, are also different conditions unrelated to erythema infectiosum.

4. Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes serosanguinous drainage on the dressing. The most appropriate intervention is to:

• A. notify the physician of the drainage.
• B. change the dressing.
• C. reinforce the dressing.
• D. apply an abdominal binder

Correct answer: C

Rationale: Serosanguinous drainage is expected after a classic cholecystectomy resection. The appropriate intervention is to reinforce the dressing to maintain pressure and promote clot formation. Changing the dressing prematurely increases the risk of infection as it disturbs the wound. Applying an abdominal binder is not indicated as it can interfere with visualizing the dressing and assessing for any signs of bleeding or infection. Notifying the physician is not necessary at this point unless there are signs of excessive bleeding or other concerning symptoms.

5. During a hospital program about in vitro fertilization, a television crew arrives to film for a series on hospital services. What action should the nurse conducting the program take?

• A. Ask the television crew to interview the individuals attending the program individually.
• B. Allow the television crew to videotape the program as long as they do not publicize that the program is about in vitro fertilization.
• C. Explain to the television crew that videotaping is not allowed.
• D. Allow the television crew to videotape the program.

Correct answer: C

Rationale: Privacy is a client's right to be free from unwanted intrusion into their private affairs. Videotaping constitutes an invasion of a client's privacy, and written permission is required from the client for actions such as photographing or videotaping. Therefore, the nurse must explain to the television crew that videotaping is not allowed to protect the attendees' privacy. Option A is incorrect as it still involves recording the individuals, breaching their privacy. Option B is incorrect because allowing videotaping without consent violates privacy rights. Option D is incorrect as it disregards the need for consent and privacy protection.

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