Nursing Elites

1. Which serum laboratory value should the nurse monitor carefully for a client who has had an NG tube for suctioning for the past week?

• A. White blood cell count
• B. Albumin
• C. Calcium
• D. Sodium

Correct answer: D

Rationale: The nurse should carefully monitor serum sodium levels for a client with an NG tube on suction for an extended period due to potential fluid loss and the risk of developing hyponatremia, an electrolyte imbalance. Hyponatremia can occur as a result of continual suctioning leading to fluid loss, making it crucial to monitor sodium levels to prevent complications associated with low sodium levels. Monitoring white blood cell count, albumin, or calcium is not directly related to the impact of NG tube suction on fluid and electrolyte balance, so these values are not the priority in this scenario.

2. When assessing for orthostatic hypotension during blood pressure measurement, what action should the nurse implement first?

• A. Position the client supine for a few minutes
• B. Assist the client to stand at the bedside
• C. Apply the blood pressure cuff securely
• D. Record the client’s pulse rate and rhythm

Correct answer: A

Rationale: When assessing for orthostatic hypotension, the initial step is to position the client supine for a few minutes. This allows the body to adjust to the supine position before assessing blood pressure changes that may indicate orthostatic hypotension. By observing the blood pressure after the client has rested supine, the nurse can accurately assess for any drop in blood pressure upon standing, which is indicative of orthostatic hypotension. Choices B, C, and D are incorrect as they do not address the initial step in assessing for orthostatic hypotension, which is ensuring the client is positioned correctly to detect blood pressure changes upon standing.

3. The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?

• A. Perform range-of-motion exercises to prevent contractures.
• B. Decrease the client's fluid intake to prevent diarrhea.
• C. Massage the client's legs to reduce the occurrence of embolisms.
• D. Turn the client from side to back every shift.

Correct answer: A

Rationale: Performing range-of-motion exercises is essential in preventing contractures, which are common complications of immobility. These exercises help maintain joint flexibility and muscle strength, reducing the risk of contractures that can lead to functional limitations or pain for the client. Choices B, C, and D are incorrect. Decreasing fluid intake does not prevent immobility complications, but it can lead to dehydration. Massaging the client's legs does not directly address the prevention of immobility complications like contractures. Turning the client from side to back every shift is important for preventing pressure ulcers but does not directly address complications of immobility like contractures.

4. 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.

5. After a needle stick occurs while removing the cap from a sterile needle, what action should the individual take?

• A. Complete an incident report.
• B. Select another sterile needle.
• C. Disinfect the needle with an alcohol swab.
• D. Notify the supervisor immediately.

Correct answer: B

Rationale: In the scenario described, the correct action after a needle stick injury is to discard the contaminated needle safely and choose a new sterile needle to continue the procedure. This step helps prevent potential transmission of infections and ensures the safety of both the individual and the patient. Disinfecting the needle with an alcohol swab is not adequate to address the risk of infection transmission. While completing an incident report and notifying the supervisor are important, the immediate action should be to replace the contaminated needle with a new sterile one to prevent any potential harm.

Similar Questions