Nursing Elites

1. When giving an intramuscular injection to an infant, which of the following sites is preferred?

• A. Ventrogluteal region
• B. Deltoid
• C. Vastus lateralis
• D. Dorsogluteal region

Correct answer: C

Rationale: The correct answer is the Vastus lateralis when giving an intramuscular injection to an infant. The Vastus lateralis muscle, located in the thigh, is the preferred site for infants as it has a larger muscle mass and is well-developed, making it suitable for injections. The Ventrogluteal region and Dorsogluteal region are not recommended for infants due to their smaller muscle mass and potential risk of damaging nearby structures. The Deltoid muscle is typically used for older children and adults, not infants.

2. A nurse is instructing a patient about the warning signs of Digitalis side effects. Which of the following side effects should the nurse tell the patient are sometimes associated with excessive levels of Digitalis?

• A. Seizures
• B. Muscle weakness
• C. Depression
• D. Anxiety

Correct answer: B

Rationale: The correct answer is 'Muscle weakness.' Palpitations and muscle weakness are commonly associated with excessive levels of Digitalis. Seizures, depression, and anxiety are not typically linked to Digitalis toxicity. Seizures could be more related to other medications or conditions, while depression and anxiety are not commonly reported side effects of Digitalis.

3. When encountering the significant other of a patient with end-stage AIDS crying during her smoke break, what is the most appropriate action for the nurse to take?

• A. Allow her to grieve by herself.
• B. Tell her to go ahead and cry, after all, your husband’s pretty bad off.
• C. Tell her you realize how upset she is, but you don’t want to talk about it now.
• D. Approach her, offering tissues, and encourage her to verbalize her feelings

Correct answer: D

Rationale: Approaching the significant other, offering tissues, and encouraging her to verbalize her feelings is the most appropriate action for the nurse to take. Being left alone during the grief process isolates individuals, and they need an outlet for their feelings. By showing empathy and providing support, the nurse can help the significant other cope with her emotions. Choices A, B, and C are inappropriate because they do not offer support or encourage the expression of feelings, which are crucial in such situations.

4. The schizophrenic client tells you that they are "Jesus"? and "there to save the world"?. They are reading from the Bible and warning others of hell and damnation. The whole unit is getting upset and several are beginning to cry. What should the nurse do at this time?

• A. Set limits and send the client to their room.
• B. Explain to the client that not all people are Christians.
• C. Remove the Bible from the client and explain that they are not "Jesus"?.
• D. Ask the client to share with the group how he knows that he is "Jesus"?.

Correct answer: A

Rationale: In this situation, the most appropriate action for the nurse to take is to set limits with the client and redirect them to their room. The client's behavior is disruptive and causing distress among others in the unit. Sending the client to their room allows them to cool down and prevents further agitation among other patients. Removing the client from the current environment can help de-escalate the situation. Asking the client to share how they know they are "Jesus"? (Choice D) may further agitate the situation and is not the immediate priority. Explaining to the client that not all people are Christians (Choice B) may not effectively address the disruptive behavior. Removing the Bible from the client (Choice C) without addressing the underlying issue may escalate the situation further.

5. Following a thyroidectomy, a client is complaining of shortness of breath (SOB) and neck pressure. Which nursing action is the best response?

• A. Stay with the client, remove the dressing, and elevate the head of bed.
• B. Call a code, open the trach set, and position the client supine.
• C. Have the client say "EEE"? to check for laryngeal integrity.
• D. Immediately go to the nurse's station and call the physician

Correct answer: A

Rationale: Correct! The client is displaying signs of respiratory distress after a thyroidectomy. By staying with the client, removing the dressing around the neck, and elevating the head of the bed, the nurse can assess the airway and breathing status more effectively. This immediate action can help alleviate any potential airway obstruction. Choice B is incorrect because calling a code and opening the trach set without initial assessment and basic interventions may delay necessary actions. Choice C is incorrect as having the client say "EEE"? is not as immediate or effective in addressing the respiratory distress. Choice D is incorrect as leaving the client alone and calling the physician without providing immediate assistance can be detrimental in a situation of potential airway compromise.

Similar Questions