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. Which of the following scenarios represents nursing malpractice?

• A. The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and suffers cerebral damage due to anoxia.
• B. The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping.
• C. The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus.
• D. The nurse administers the wrong medication to a patient, resulting in vomiting. This error is documented and reported to the physician and the nursing supervisor.

Correct answer: A

Rationale: The correct answer is A. Administering a drug to a patient with a known allergy, leading to severe harm such as an allergic reaction causing cerebral damage due to anoxia, constitutes nursing malpractice. In this scenario, the nurse failed to adhere to the standard of care by administering a medication that the patient was allergic to, resulting in serious harm, which is a clear example of malpractice in nursing.

3. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge?

• A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg
• B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago
• C. A client who received 2 units of packed RBCs 6 hr ago for a postpartum hemorrhage
• D. A client who delivered precipitously 36 hr ago and has a second-degree perineal laceration

Correct answer: D

Rationale: The most appropriate client to recommend for discharge following a local disaster in the postpartum unit is the one who delivered precipitously 36 hours ago and has a second-degree perineal laceration. This client's condition is stable enough for discharge, and the timing and extent of the perineal laceration are within expectations for a safe discharge. Clients with conditions such as preeclampsia, recent emergency cesarean birth, or recent administration of packed RBCs for postpartum hemorrhage require further monitoring and care before being considered for discharge.

4. When caring for a client who speaks a language different from their own, what action should the nurse take?

• A. Request an interpreter of a different sex from the client.
• B. Request a family member or friend to interpret information for the client.
• C. Direct attention toward the interpreter when speaking to the client.
• D. Review the facility policy about the use of an interpreter.

Correct answer: D

Rationale: When caring for a client who speaks a different language, it is essential for the nurse to review the facility policy about the use of an interpreter. Using a professional interpreter ensures accurate communication and protects the client's confidentiality. Requesting an interpreter of a specific sex or relying on family members or friends can lead to miscommunication or breaches of confidentiality. Directing attention towards the interpreter helps facilitate communication but does not address the need for a professional interpreter as per facility policy.

5. A healthcare professional is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the healthcare professional NOT include in the plan of care?

• A. Have suction equipment available for use
• B. Feed the client thickened liquids
• C. Place food on the unaffected side of the client's mouth
• D. Assign an assistive personnel to feed the client slowly

Correct answer: D

Rationale: When caring for a client with dysphagia, it is crucial to ensure safe feeding practices. Assigning an assistive personnel to feed the client slowly may not be appropriate as it can increase the risk of aspiration. Thickened liquids, having suction equipment available, and placing food on the unaffected side of the mouth are all appropriate measures to support a client with dysphagia in safe eating and drinking.

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