Nursing Elites

1. The client is being taught how to self-administer a subcutaneous injection. To ensure sterility of the procedure, which subject is most important for the instructor to include in the teaching plan?

• A. Hand washing before preparing the injection.
• B. Technique for drawing medication from a vial.
• C. Selection and rotation of injection sites.
• D. Proper disposal of injection equipment.

Correct answer: B

Rationale: To maintain the sterility of the procedure, it is crucial to teach the client the correct technique for drawing medication from a vial. This ensures that the medication remains sterile during preparation and administration. While hand washing, injection site selection, and equipment disposal are important aspects of injection safety, the key focus should be on maintaining the sterility of the medication itself to prevent infections and ensure the effectiveness of the treatment.

2. A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment because she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

• A. Advise the UAP to wear a standard face mask to take vital signs and then get fitted for a filter mask before providing personal care.
• B. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client.
• C. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client.
• D. Before changing assignments, determine which staff members have fitted particulate filter masks.

Correct answer: C

Rationale: The correct answer is C. For droplet precautions, such as in the case of pertussis, a standard face mask is sufficient for protection. Particulate filter masks are required for airborne precautions, not for droplet precautions. Therefore, the UAP can proceed with taking the vital signs using a standard mask without the need for a particulate filter mask. Choice A is incorrect because the UAP does not need to get fitted for a particulate filter mask before providing care in this situation. Choice B is incorrect as fitting for a particulate filter mask is not necessary for droplet precautions. Choice D is also incorrect because determining which staff members have fitted particulate filter masks is not relevant to the UAP's situation with the client on droplet precautions. It is important for healthcare workers to understand the appropriate use of personal protective equipment based on the type of precautions in place to provide safe and effective care to clients.

3. A client is admitted with a diagnosis of right-sided heart failure. What assessment finding should the nurse anticipate?

• A. Jugular vein distention.
• B. Crackles in the lungs.
• C. Peripheral edema.
• D. Hepatomegaly.

Correct answer: C

Rationale: In right-sided heart failure, the heart's inability to effectively pump blood to the lungs leads to fluid backup in the systemic circulation, resulting in peripheral edema (swelling in lower extremities). While jugular vein distention (A) and hepatomegaly (D) can also occur in right-sided heart failure, peripheral edema is a hallmark sign due to fluid retention. Crackles in the lungs (B) are more commonly associated with left-sided heart failure, where fluid accumulates in the lungs.

4. Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway outside her room. What is the best action?

• A. Ask the family to wait in the cafeteria while the next of kin makes the necessary arrangements
• B. Provide space and privacy for the family to share their concerns about the client’s discharge
• C. Ask the social worker to encourage the family to clear the hallway
• D. Explain to the family the client’s need for privacy so that she can make independent decisions

Correct answer: B

Rationale: In this situation, providing space and privacy for the family allows them to openly discuss their concerns regarding the client’s discharge. It respects the family's need for support, communication, and involvement in the decision-making process, ultimately fostering a more effective and compassionate care environment.

5. Which assessment data indicates the need for the nurse to include the problem 'Risk for falls' in a client’s plan of care?

• A. Recent serum hemoglobin level of 16 g/dL
• B. Opioid analgesic received one hour ago
• C. Stooped posture with an unsteady gait
• D. Expressed feelings of depression

Correct answer: B

Rationale: The correct answer is B. The administration of opioid analgesics can impair balance and increase the risk of falls, justifying the inclusion of 'Risk for falls' in the client’s care plan. Choice A, a recent serum hemoglobin level of 16 g/dL, is not directly related to the risk of falls. Choice C, stooped posture with an unsteady gait, may indicate a risk for falls, but the direct influence of opioid analgesics on balance is more immediate. Choice D, expressed feelings of depression, while important, is not a direct indicator of the immediate risk for falls associated with opioid analgesic use.

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