Nursing Elites

1. To avoid nerve injury, what location should the nurse select to administer a 3 mL IM injection?

• A. Ventrogluteal
• B. Outer upper quadrant of the buttock
• C. Two inches below the acromion process
• D. Vastus lateralis

Correct answer: A

Rationale: The ventrogluteal site is the preferred location for administering large volume IM injections to avoid nerve injury. This site is situated away from major nerves and blood vessels, reducing the risk of complications associated with injecting into other areas. The ventrogluteal site allows for deep muscle penetration and is recommended for injections over 2 mL in volume to ensure proper dispersion and absorption of the medication. Choices B, C, and D are incorrect because the outer upper quadrant of the buttock is not the recommended site for large volume injections, two inches below the acromion process is a location for a deltoid injection, and the vastus lateralis is typically used for smaller volume injections.

2. A client has a nursing diagnosis of 'spiritual distress.' What intervention is best for the nurse to implement when caring for this client?

• A. Use distraction techniques during times of spiritual stress and crisis.
• B. Reassure the client that their faith will be regained with time and support.
• C. Consult with the staff chaplain and request that the chaplain visit with the client.
• D. Use reflective listening techniques when the client expresses spiritual doubts.

Correct answer: D

Rationale: When a client is going through spiritual distress, employing reflective listening techniques is crucial. This method allows the client to voice their concerns and emotions, providing them with a supportive environment to explore their feelings. Options A and B do not directly address the client's spiritual distress and may undermine the client's feelings. While option C involves a chaplain, using reflective listening directly involves the nurse in addressing and supporting the client's spiritual concerns.

3. The healthcare provider is conducting an initial admission assessment for a woman who is Mexican-American and who is scheduled to deliver a baby by C-section in the next 24 hours. What should the healthcare provider include in the assessment?

• A. Provide an interpreter to convey the meaning of words and messages in translation
• B. Commend the client for her patience during a long wait in the admission process
• C. Arrange for the hospital chaplain to visit the client during her hospital stay
• D. Rely on cultural norms as the basis for providing healthcare for this client

Correct answer: D

Rationale: When caring for patients from diverse cultural backgrounds, it is essential to respect and consider their cultural norms and practices while providing healthcare. Understanding and incorporating cultural beliefs and values can enhance the quality of care and improve patient outcomes.

4. The nursing staff in the cardiovascular intensive care unit is creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy?

• A. Remove identifying information of the clients who participated
• B. Recall that authored content may be legally discoverable
• C. Share material from credible, peer-reviewed sources only
• D. Respect all copyright laws when adding website content

Correct answer: A

Rationale: To protect client privacy on social media, it is essential to remove any identifying information of clients who participated in the project. This ensures that sensitive information is not disclosed without consent and maintains confidentiality. Choice B is incorrect because while authored content may be legally discoverable, it does not directly relate to protecting client privacy on social media. Choice C is incorrect as it pertains to the credibility of sources, not client privacy. Choice D is also incorrect as it focuses on copyright laws rather than client privacy protection.

5. Which instruction should be included in the discharge teaching plan for an adult client with hypernatremia?

• A. Monitor daily urine output volume
• B. Drink plenty of water whenever thirsty
• C. Use salt tablets for sodium content
• D. Review food labels for sodium content

Correct answer: D

Rationale: In hypernatremia, there is an excess of sodium in the blood. Reviewing food labels for sodium content is crucial as it helps the client identify and avoid high-sodium foods, which can contribute to elevated sodium levels. Monitoring urine output volume may be important for other conditions but is not directly related to managing hypernatremia. Drinking water whenever thirsty is generally good advice for staying hydrated but does not specifically address the issue of high sodium levels. Using salt tablets would worsen hypernatremia by further increasing sodium intake.

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