Nursing Elites

1. 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.

2. What is the most common injury among elderly persons?

• A. Atherosclerotic changes in the blood vessels
• B. Increased incidence of gallbladder disease
• C. Urinary Tract Infection
• D. Hip fracture

Correct answer: D

Rationale: Hip fracture is the most common injury among elderly persons. As people age, their bones become more fragile, making them more susceptible to hip fractures, often resulting from falls. These fractures can significantly impact an elderly person's quality of life and mobility, making them a significant concern in geriatric care.

3. A client with active tuberculosis is prescribed isoniazid, rifampin, pyrazinamide, and ethambutol. Which statement by the client indicates an understanding of the teaching?

• A. I can substitute one medication for another if I run out because they all fight infection.
• B. I will wash my hands each time I cough.
• C. I am glad I don't have to have any more sputum specimens.
• D. I don't need to worry about where I go once I start taking my medications.

Correct answer: B

Rationale: The correct statement indicating understanding of tuberculosis medication regimen is 'I will wash my hands each time I cough.' This statement shows knowledge of infection control practices to prevent the spread of tuberculosis. Washing hands after coughing helps in reducing the transmission of the disease to others. The other options are incorrect. Option A is incorrect as each medication in the regimen has a specific role, and substituting one for another can compromise the effectiveness of treatment. Option C is incorrect as obtaining sputum specimens is essential for monitoring treatment response. Option D is incorrect as the client should still adhere to infection control measures and avoid exposing others to tuberculosis.

4. A patient with no known allergies is to receive penicillin every 6 hours. When administering the medication, the nurse observes a fine rash on the patient’s skin. The most appropriate nursing action would be to:

• A. Withhold the medication and notify the physician
• B. Administer the medication and notify the physician
• C. Administer the medication with an antihistamine
• D. Apply corn starch soaks to the rash

Correct answer: A

Rationale: In this scenario, the appearance of a rash after administering penicillin, even in a patient with no known allergies, is concerning for a potential allergic reaction. The appropriate action for the nurse to take is to withhold the medication and notify the physician. This precaution is necessary to prevent further administration of a medication that may be causing an adverse reaction, as allergic reactions can range from mild to severe and require immediate intervention.

5. A client is scheduled for a thoracentesis. Which of the following supplies should NOT be in the client's room?

• A. Oxygen equipment
• B. Incentive spirometer
• C. Pulse oximeter
• D. Sterile dressing

Correct answer: B

Rationale: During a thoracentesis procedure, the focus is on draining fluid or air from the pleural space. An incentive spirometer, which helps improve lung function, is not a necessary supply for this specific procedure. Oxygen equipment, pulse oximeter for monitoring oxygen saturation levels, and sterile dressing for wound care may be needed during or after the procedure.

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