Nursing Elites

1. What is the best intervention for a patient with constipation?

• A. Administer a stool softener
• B. Encourage fluid intake
• C. Provide a high-fiber diet
• D. Administer a laxative

Correct answer: B

Rationale: Encouraging fluid intake is the best intervention for a patient with constipation. Fluids help soften stools, making them easier to pass. While stool softeners and laxatives can also help with constipation, they are more of a short-term solution and may not address the root cause. A high-fiber diet is beneficial for preventing constipation in the long run, but in the immediate situation of constipation, fluid intake is key.

2. A client with type 1 diabetes mellitus is being taught self-administration of insulin by a nurse. Which of the following instructions should the nurse include?

• A. Inject air into the vial before withdrawing the insulin.
• B. Draw up the short-acting insulin first, then the long-acting insulin.
• C. Store unopened insulin vials in the freezer.
• D. Rotate injection sites within the same anatomical region.

Correct answer: D

Rationale: The correct instruction the nurse should include is to rotate injection sites within the same anatomical region. This practice helps reduce the risk of lipodystrophy, a condition characterized by fatty tissue changes due to repeated insulin injections in the same spot. By rotating sites, the client ensures better insulin absorption and prevents localized skin changes. Injecting air into the vial before withdrawing insulin (Choice A) is unnecessary and not recommended. Drawing up short-acting insulin before long-acting insulin (Choice B) is not a standard practice and can lead to errors in dosing. Storing unopened insulin vials in the freezer (Choice C) is incorrect as insulin should be stored in the refrigerator, not the freezer, to maintain its effectiveness.

3. A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching?

• A. I will need to have my INR checked regularly while taking this medication.
• B. I should avoid eating leafy green vegetables while taking this medication.
• C. I will stop taking this medication if I experience nausea.
• D. I will avoid taking aspirin while taking this medication.

Correct answer: A

Rationale: The correct answer is A because clients taking warfarin should have their INR (International Normalized Ratio) checked regularly to monitor the medication's effectiveness and adjust the dose if needed. This monitoring helps to ensure the medication is working correctly and the client is within the therapeutic range. Choice B is incorrect because clients on warfarin should not avoid leafy green vegetables but should maintain a consistent intake. Leafy green vegetables contain vitamin K, which can affect warfarin, so it's important to maintain a consistent intake to keep INR stable. Choice C is incorrect as clients should not stop taking warfarin abruptly without consulting their healthcare provider as it can lead to serious health risks like blood clots. Choice D is incorrect because while taking warfarin, it is important to avoid unnecessary aspirin use due to an increased risk of bleeding. However, this statement does not indicate an understanding of the teaching about the need for regular INR monitoring.

4. What is the initial intervention for a patient with chest pain?

• A. Administer aspirin
• B. Administer nitroglycerin
• C. Provide pain relief
• D. Prepare for surgery

Correct answer: A

Rationale: The correct initial intervention for a patient with chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation by inhibiting platelet aggregation, which can be beneficial in case the chest pain is due to a cardiac event. Administering nitroglycerin may follow aspirin administration to help relieve chest pain by dilating blood vessels. Providing pain relief is a general approach and may not address the underlying cause of chest pain. Preparing for surgery would not be the initial intervention for chest pain unless there are specific indications for immediate surgical intervention.

5. What is the correct method of administering insulin to a patient with diabetes?

• A. Administer subcutaneously
• B. Administer intramuscularly
• C. Administer intravenously
• D. Administer orally

Correct answer: A

Rationale: The correct method of administering insulin to a patient with diabetes is to administer it subcutaneously. Insulin is typically injected into the fatty tissue just below the skin, allowing for a slow and consistent absorption into the bloodstream. Administering insulin intramuscularly (Choice B) is not recommended as it can lead to unpredictable absorption rates and potential complications. Administering insulin intravenously (Choice C) is only done in specific medical settings and not for routine diabetes management. Administering insulin orally (Choice D) is ineffective as the stomach acid would break down the insulin before it can be absorbed.

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