Nursing Elites

1. A nurse is preparing to administer enoxaparin subcutaneously. Which of the following actions should the nurse take?

• A. Administer the medication with the needle at a 45-degree angle.
• B. Administer the medication with the needle at a 90-degree angle.
• C. Administer the medication with the needle at a 30-degree angle.
• D. Administer the medication with the needle at a 15-degree angle.

Correct answer: B

Rationale: Enoxaparin should be administered with the needle at a 90-degree angle to ensure proper subcutaneous delivery. Choice B is correct as it aligns with the recommended angle for subcutaneous injections. Administering enoxaparin at a 45-degree angle (Choice A), 30-degree angle (Choice C), or 15-degree angle (Choice D) would not be appropriate and may lead to improper administration or absorption of the medication.

2. A client with a tracheostomy collar has a decrease in heart rate and oxygen saturation during tracheal suctioning. Which of the following actions should the nurse take?

• A. Elevate the head of the bed.
• B. Remove the inner cannula.
• C. Irrigate the stoma.
• D. Discontinue suctioning.

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to discontinue suctioning. Suctioning should be stopped immediately to prevent further decrease in heart rate and oxygen saturation. Elevating the head of the bed may help with oxygenation, but the priority is to stop the suctioning procedure. Removing the inner cannula or irrigating the stoma are not appropriate actions and could worsen the client's condition.

3. How should the nurse transcribe the dosage of this medication on the client's medical record?

• A. 0.3 mg
• B. 0.3 mg
• C. 0.30 mg
• D. 3/10 mg

Correct answer: B

Rationale: The correct way to transcribe the dosage of three tenths of a milligram of levothyroxine IV STAT is 0.3 mg. When expressing decimals less than 1, there should be a leading zero before the decimal point. Choice A is incorrect (.3 mg) because it lacks the leading zero. Choice C (0.30 mg) is incorrect as it includes a trailing zero after the decimal point, which is unnecessary. Choice D (3/10 mg) is incorrect as it presents the dosage as a fraction, which is not the standard format for transcribing medication dosages. Therefore, B (0.3 mg) is the most appropriate and accurate way to document this prescription on the client's medical record.

4. A client reports increased pain following physical therapy. Which of the following questions should be asked to assess the quality of the pain?

• A. Is your pain sharp or dull?
• B. Is your pain constant or intermittent?
• C. On a scale from 1 to 10, how severe is your pain?
• D. Where exactly is your pain located?

Correct answer: A

Rationale: Correct Answer: A. Asking whether the pain is sharp or dull helps in determining the quality of the pain. Sharp pain is often associated with acute conditions, while dull pain may indicate chronic issues. Choices B, C, and D focus on different aspects of pain assessment. Option B pertains to the pattern of pain, either constant or intermittent. Option C addresses the severity of pain on a numerical scale. Option D inquires about the location of pain. While all these questions are essential in pain assessment, when specifically evaluating the quality of pain, distinguishing between sharp and dull sensations is crucial.

5. A client is scheduled for an appendectomy and has given informed consent. Which statement by the client should the nurse address first preoperatively?

• A. “I am afraid to walk if it hurts too much.”
• B. “I don’t understand why I need this surgery.”
• C. “I don’t want my family helping me after the surgery.”
• D. “I am afraid the scar will make me look disfigured.”

Correct answer: B

Rationale: The nurse should address the client's lack of understanding regarding the need for surgery first. Ensuring that the client comprehends the rationale for the procedure is essential for informed consent. Choices A, C, and D, while important, do not directly impact the client's understanding of the necessity of the surgery and can be addressed after clarifying the reason for the procedure.

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