Nursing Elites

1. The healthcare provider is preparing to administer an IM injection to an adult client. Which site is the preferred location for this injection?

• A. Deltoid muscle
• B. Vastus lateralis muscle
• C. Ventrogluteal muscle
• D. Dorsogluteal muscle

Correct answer: C

Rationale: The ventrogluteal site is the preferred site for IM injections in adults due to its muscle mass and low risk of nerve injury. The deltoid muscle, although commonly used for vaccines in adults due to easy accessibility, has a smaller muscle mass making it less ideal for IM injections. The vastus lateralis muscle is typically used in infants and young children, not in adults. The dorsogluteal site has a higher risk of injury to the sciatic nerve and is no longer recommended for IM injections in any age group.

2. A client is prescribed warfarin for the prevention of thromboembolism. What dietary instruction should the nurse provide?

• A. Increase intake of green leafy vegetables
• B. Maintain a consistent intake of vitamin K-rich foods
• C. Avoid all foods containing vitamin K
• D. Consume a high-protein diet

Correct answer: B

Rationale: The correct answer is B. Maintaining a consistent intake of vitamin K-rich foods is important for patients taking warfarin as it helps keep the effects of the medication stable. Choice A is incorrect because while green leafy vegetables are high in vitamin K, they should not be avoided completely but rather consumed consistently. Choice C is also incorrect as avoiding all foods containing vitamin K can lead to fluctuations in warfarin's effectiveness. Choice D is incorrect as a high-protein diet is not specifically recommended for patients taking warfarin.

3. When counting a client's radial pulse, the nurse notes the pulse is weak and irregular. To record the most accurate heart rate, what should the nurse do?

• A. Recheck the radial pulse in thirty minutes
• B. Palpate the radial pulse for thirty seconds and double the rate
• C. Count the apical pulse rate for sixty seconds
• D. Compare the radial pulse rate bilaterally and record the higher rate

Correct answer: C

Rationale: The correct answer is to count the apical pulse rate for sixty seconds. The apical pulse is more accurate, especially when peripheral pulses are weak or irregular. Counting the apical pulse for a full minute provides a more precise heart rate measurement. Option A is incorrect because waiting for thirty minutes is unnecessary and could delay potential interventions. Option B is incorrect because doubling the radial pulse rate may not provide an accurate representation of the heart rate. Option D is incorrect because comparing radial pulses bilaterally does not give the most accurate heart rate measurement; the apical pulse is preferred in this situation.

4. A client with type 1 diabetes is experiencing symptoms of hypoglycemia. What is the nurse's priority intervention?

• A. Administer glucagon intramuscularly
• B. Provide a complex carbohydrate snack
• C. Administer 50% dextrose intravenously
• D. Give 15 grams of a fast-acting carbohydrate

Correct answer: D

Rationale: The priority intervention for a client with type 1 diabetes experiencing symptoms of hypoglycemia is to give 15 grams of a fast-acting carbohydrate. In a hypoglycemic state, the priority is to quickly raise the blood glucose level. Administering glucagon intramuscularly (Choice A) is reserved for severe hypoglycemia when the client is unable to take oral carbohydrates. Providing a complex carbohydrate snack (Choice B) is beneficial after the initial treatment of hypoglycemia to prevent recurrence. Administering 50% dextrose intravenously (Choice C) is a more invasive intervention typically done in a hospital setting for severe cases.

5. The nurse plans to administer the rubella vaccine to a postpartum client whose titer is < 1:8 and who is breastfeeding. What information should the nurse provide this client?

• A. The client should bottle feed and pump her breast for 3 days following immunization
• B. The vaccine is given to produce maternal antibodies before lactation occurs
• C. The infant will receive immunization through the mother's breast milk
• D. The client should not get pregnant for 3 months after immunization

Correct answer: D

Rationale: Educating about the waiting period helps prevent possible rubella infection in a subsequent early pregnancy.

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