Nursing Elites

1. Before administering an intramuscular injection, the nurse's finger is stuck with the needle. Which action should the nurse take?

• A. Go to the emergency room to have blood drawn
• B. Prepare the medication using a new syringe
• C. Apply clean gloves before giving the medication
• D. Review the medical history in the client's chart

Correct answer: B

Rationale: In this scenario, if the nurse's finger is stuck with the needle before administering the injection, the correct action is to prepare the medication using a new syringe. This step is crucial to prevent contamination and ensure the safety of the patient. Going to the emergency room to have blood drawn is unnecessary and does not address the immediate issue of contamination. Applying clean gloves is important for infection control but does not address the potential contamination from the needlestick. Reviewing the medical history in the client's chart is important for overall patient care but is not the priority in this situation where immediate action is required to prevent harm.

2. A client is admitted with acute low back pain. What action should the nurse implement to promote comfort?

• A. Ambulate with a walker for upper body support
• B. Perform abdominal curls to stretch the back muscles
• C. Position in semi-Fowler's with the knees flexed
• D. Encourage straight leg raises while lying supine

Correct answer: C

Rationale: Positioning the client in semi-Fowler's with the knees flexed is the most appropriate action to promote comfort in a client with acute low back pain. This position helps alleviate low back pain by reducing the pressure on the spine and supporting its natural curvature. Ambulating with a walker could strain the back, performing abdominal curls may exacerbate the pain, and straight leg raises while lying supine could cause further discomfort. Therefore, only positioning the client in semi-Fowler's with the knees flexed is the correct choice for promoting comfort in this scenario.

3. When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat?

• A. Vanilla frozen yogurt
• B. Vegetable juice
• C. Clear beef broth
• D. Canned fruit cocktail

Correct answer: A

Rationale: The correct answer should be provided as choice E: Vanilla frozen yogurt. For a postoperative full liquid diet, the nurse should encourage the client to eat foods that are fully liquid and easy to digest. Vanilla frozen yogurt is a suitable choice as it provides calories and nutrients while being in a liquid form. Creamy peanut butter, vegetable juice, and canned fruit cocktail are not appropriate for a full liquid diet as they are not fully liquid and may not be easy to digest. Creamy peanut butter is solid, vegetable juice is not fully liquid, and canned fruit cocktail contains solid pieces.

4. A client is admitted with pyelonephritis, and cultures reveal an Escherichia coli infection. The client is allergic to penicillins, and the healthcare provider prescribed vancomycin IV. The nurse should plan to carefully monitor the client for which finding during IV administration?

• A. Tissue sloughing upon extravasation
• B. Elevated blood pressure and heart rate
• C. Tinnitus and vertigo
• D. Erythema of the face, neck, and chest

Correct answer: C

Rationale: The correct answer is C: Tinnitus and vertigo. Vancomycin can cause ototoxicity and nephrotoxicity, leading to symptoms like tinnitus and vertigo. Monitoring for these adverse effects is crucial to prevent further complications. Choices A, B, and D are incorrect because tissue sloughing, elevated blood pressure and heart rate, and erythema of the face, neck, and chest are not typically associated with vancomycin administration. Therefore, the nurse should focus on monitoring for signs of ototoxicity and nephrotoxicity such as tinnitus and vertigo.

5. After a sudden loss of consciousness, a female client is taken to the ED, and initial assessment indicates that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that she was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client’s discharge plan?

• A. Describe the importance of maintaining stable blood glucose levels.
• B. Encourage a balanced and nutritious diet.
• C. Reinforce the need to continue outpatient treatment.
• D. Educate on the risks of untreated anorexia nervosa.

Correct answer: C

Rationale: Continuing outpatient treatment is crucial for managing anorexia nervosa and preventing future complications. Reinforcing the need to continue outpatient treatment ensures ongoing support, monitoring, and therapy for the client's anorexia nervosa. Describing the importance of maintaining stable blood glucose levels (Choice A) is relevant but does not address the underlying eating disorder directly. Encouraging a balanced and nutritious diet (Choice B) is important; however, specific dietary recommendations should be tailored to the individual's condition by healthcare providers. Educating on the risks of untreated anorexia nervosa (Choice D) is informative but does not provide a direct actionable step for the client's immediate discharge plan, unlike the importance of continuing outpatient treatment.

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