Nursing Elites

1. The healthcare professional is preparing to administer an intramuscular injection to an adult client. Which site is most appropriate for the LPN/LVN to use?

• A. Deltoid muscle
• B. Ventrogluteal site
• C. Dorsogluteal site
• D. Rectus femoris site

Correct answer: B

Rationale: The ventrogluteal site is the most appropriate and safest site for administering an intramuscular injection to an adult client. It is preferred due to its thick muscle mass and fewer major blood vessels and nerves in the area, reducing the risk of injury or complications. The deltoid muscle is commonly used for vaccines and small-volume injections but may not be suitable for larger volumes. The dorsogluteal site has fallen out of favor due to the risk of injury to the sciatic nerve and other underlying structures. The rectus femoris site is not typically used for intramuscular injections in adults.

2. A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?

• A. Why don’t we now have the client turn back to the left side.
• B. That was done correctly. Did you have any problems with the insertion?
• C. Let’s check to see if the suppository is in far enough.
• D. Did you feel any stool in the intestinal tract?

Correct answer: B

Rationale: The appropriate comment by the nurse is to affirm the correct technique while offering support and checking for any issues during the insertion.

3. A healthcare professional is assessing postoperative circulation of the lower extremities for a client who had knee surgery. The healthcare professional should test which of the following?

• A. Range of motion
• B. Skin color
• C. Edema
• D. Skin temperature

Correct answer: B

Rationale: Corrected Rationale: Assessing skin color is crucial to evaluate perfusion and circulation postoperatively. Skin color changes can indicate compromised circulation, such as pallor or cyanosis. Edema may suggest fluid retention but is not a direct indicator of circulation status. Range of motion is more related to joint function and mobility, not specifically circulation.

4. A client with diabetes mellitus and a new prescription for insulin is being discharged. Which of the following actions should the nurse plan to complete first?

• A. Provide the client with printed information on insulin self-administration.
• B. Obtain printed information on insulin self-administration.
• C. Make a copy of the medication reconciliation form for the client.
• D. Determine whether the client can afford the insulin administration supplies.

Correct answer: B

Rationale: Obtaining printed information on insulin self-administration should be the nurse's first priority. This action ensures that the client has the necessary knowledge to safely self-administer insulin at home. Providing the client with printed information (Choice A) is essential to empower the client with the required knowledge before considering additional resources. Making a copy of the medication reconciliation form for the client (Choice C) is important for documentation purposes but not as urgent as ensuring the client's understanding of insulin administration. Determining the client's ability to afford insulin administration supplies (Choice D) is crucial but should follow after ensuring the client is equipped with the necessary information for safe self-administration.

5. A client with amphetamine toxicity and sensory overload is being cared for by a nurse. Which intervention should the nurse implement?

• A. Immediately conduct a thorough assessment.
• B. Encourage visitors to distract the client.
• C. Provide a private room and limit stimulation.
• D. Speak softly to the client.

Correct answer: C

Rationale: The most appropriate intervention for a client with amphetamine toxicity and sensory overload is to provide a private room and limit stimulation. This approach helps reduce external stimuli, which can exacerbate sensory overload, and creates a calming environment for the client. Encouraging visitors to distract the client may worsen sensory overload by adding more stimulation. Speaking softly, rather than at a higher volume, is more suitable to help maintain a calm environment. Therefore, the correct choice is to provide a private room and limit stimulation (option C) in this scenario.

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