Nursing Elites

1. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first?

• A. Plan low carbohydrate and high protein meals
• B. Engage in strenuous activity for an hour daily
• C. Keep a record of food and drinks consumed daily
• D. Participate in a group exercise class 3 times a week

Correct answer: C

Rationale: Keeping a food diary is a good first step to understand eating habits before making any dietary or activity changes.

2. During a 30-second interval, the nurse counts six respirations, and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. What respiratory rate should the nurse document?

• A. 14
• B. 16
• C. 17
• D. 28

Correct answer: B

Rationale: The nurse should document a respiratory rate of 16. The second count of eight respirations in a 30-second interval is the most accurate as it was not interrupted by the client coughing. Therefore, this rate reflects the client's typical respiratory pattern and should be documented. Choices A, C, and D are incorrect as they do not consider the interruption caused by the client coughing during the first count, which could have affected the accuracy of the result. The second count of eight respirations provides a more reliable indication of the client's respiratory rate.

3. When planning care for a client with an indwelling urinary catheter, which nursing diagnosis has the highest priority?

• A. Self-care deficit
• B. Functional incontinence
• C. Fluid volume deficit
• D. High risk for infection

Correct answer: D

Rationale: The highest priority nursing diagnosis when planning care for a client with an indwelling urinary catheter is 'High risk for infection.' Indwelling urinary catheters pose a significant risk of infection due to their direct contact with the urinary system. Preventing and managing infections is crucial in the care of these clients. Monitoring for signs of infection, following proper catheter care protocols, and maintaining aseptic technique during catheter maintenance are essential steps to prevent complications associated with catheter-related infections. Choices A, B, and C are not the highest priority because in this case, the immediate concern is the risk of infection associated with the presence of the urinary catheter. While self-care deficit, functional incontinence, and fluid volume deficit are important considerations in overall patient care, they are not as critical as preventing potentially serious infections related to the indwelling urinary catheter.

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. What action should the nurse implement to prepare a client for the potential side effects of a newly prescribed medication?

• A. Assess the client for health alterations that may be impacted by the effects of the medication
• B. Teach the client how to administer the medication to promote the best absorption
• C. Administer a half dose and observe the client for side effects before administering a full dosage
• D. Encourage the client to drink plenty of fluids to promote effective drug distribution

Correct answer: A

Rationale: Before initiating a new medication, the nurse should conduct a thorough assessment of the client to identify any pre-existing health conditions or risk factors that could be affected by the medication. This assessment helps in establishing a baseline for monitoring potential side effects and determining the medication's appropriateness for the client. Choice B is incorrect as teaching the client how to administer the medication does not directly address preparing for potential side effects. Choice C is incorrect because administering a half dose without a proper assessment could be unsafe. Choice D is incorrect as encouraging fluid intake is not directly related to preparing for potential side effects of a medication.

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