Nursing Elites

1. The nurse is teaching a client about the administration of a subcutaneous injection. Which site is most appropriate for this type of injection?

• A. Deltoid muscle
• B. Dorsogluteal muscle
• C. Ventrogluteal muscle
• D. Abdomen

Correct answer: D

Rationale: The abdomen is a common site for subcutaneous injections due to its accessibility and ample subcutaneous tissue. Subcutaneous injections are typically given in areas with a layer of fat between the skin and muscle, such as the abdomen, to allow for slow and consistent absorption of the medication. The deltoid muscle is more appropriate for intramuscular injections, not subcutaneous. The dorsogluteal muscle and ventrogluteal muscle are also more suited for intramuscular injections, not subcutaneous.

2. Following an open reduction of the tibia, the nurse notes fresh bleeding on the client's cast. What intervention should the nurse implement?

• A. Assess the client's hemoglobin levels to determine if the client is in shock
• B. Call the surgeon and prepare to take the client back to the operating room
• C. Outline the area with ink and check it every 15 minutes to monitor for changes in bleeding
• D. No action is required as postoperative bleeding can be expected

Correct answer: C

Rationale: In this scenario, the correct intervention is to outline the area with ink and check it every 15 minutes to monitor for changes in bleeding. This approach helps in assessing the extent and progression of the bleeding. Option A is incorrect because assessing hemoglobin levels would not provide immediate information on the ongoing bleeding. Option B is premature without first monitoring the bleeding site. Option D is incorrect because although some postoperative bleeding can be expected, fresh bleeding on the cast warrants immediate monitoring and evaluation.

3. The nurse is caring for a 75-year-old male client who is beginning to form a decubitus ulcer at the coccyx. Which intervention will be most helpful in preventing further development of the decubitus ulcer?

• A. Encourage the client to eat foods high in protein
• B. Assess the client for daily range of motion exercises
• C. Teach the family how to perform sterile wound care
• D. Ensure the IV fluids are administered as prescribed

Correct answer: A

Rationale: Encouraging the client to eat foods high in protein is crucial in preventing further development of decubitus ulcers as high protein foods support tissue repair and skin integrity. Adequate protein intake is essential for wound healing. Assessing the client for daily range of motion exercises is important for preventing complications related to immobility, but it may not directly address the prevention of decubitus ulcers. Teaching the family how to perform sterile wound care is significant for wound management but may not be the most effective intervention to prevent further development of decubitus ulcers. Ensuring IV fluids are administered as prescribed is essential for maintaining hydration status but is not the most relevant intervention for preventing decubitus ulcers.

4. The nurse plans to evaluate the effectiveness of several drugs administered by different routes. Arrange the routes of administration from fastest to slowest rate of absorption. 1. Intravenous 2. Sublingual 3. Intramuscular 4. Subcutaneous

• A. 1,2,3,4
• B. 4,3,2,1
• C. 2,4,3,1
• D. 3,4,1,2

Correct answer: A

Rationale: The correct order of routes of administration from fastest to slowest rate of absorption is 1. Intravenous, 2. Sublingual, 3. Intramuscular, 4. Subcutaneous. Intravenous administration provides the fastest absorption as the drug is directly injected into the bloodstream. Sublingual administration allows for rapid absorption through the mucous membranes under the tongue. Intramuscular administration has a slower absorption rate as the drug is injected into the muscle tissue. Subcutaneous administration is the slowest as the drug is injected into the fatty tissue under the skin, leading to a slower absorption compared to the other routes.

5. A client with chronic kidney disease is being evaluated for dialysis. Which laboratory value would be most concerning to the nurse?

• A. Hemoglobin 9.5 g/dL
• B. Potassium 6.2 mEq/L
• C. Creatinine 3.5 mg/dL
• D. BUN 50 mg/dL

Correct answer: B

Rationale: The correct answer is B: Potassium 6.2 mEq/L. In chronic kidney disease, the kidneys struggle to regulate potassium levels, leading to hyperkalemia. A potassium level of 6.2 mEq/L is dangerously high and can cause life-threatening cardiac arrhythmias. Hemoglobin of 9.5 g/dL may indicate anemia, which is common in chronic kidney disease but is not immediately life-threatening. Creatinine and BUN levels are markers of kidney function; although elevated levels indicate kidney impairment, they are not acutely life-threatening like severe hyperkalemia.

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