Nursing Elites

1. A client with diabetes mellitus is learning to self-administer insulin. Which action by the client indicates the need for further teaching?

• A. The client rotates injection sites on the abdomen.
• B. The client draws up the insulin dose after warming the vial to room temperature.
• C. The client pinches the skin before injecting the insulin.
• D. The client injects the insulin at a 90-degree angle.

Correct answer: B

Rationale: Drawing up insulin after warming the vial to room temperature indicates a need for further teaching, as insulin should be at room temperature for administration. Choice A is correct as rotating injection sites helps prevent lipodystrophy. Choice C is correct as pinching the skin helps ensure proper subcutaneous injection. Choice D is correct as injecting insulin at a 90-degree angle is the recommended technique for subcutaneous injections.

2. A 3-year-old child diagnosed with celiac disease attends a daycare center. Which of the following would be an appropriate snack?

• A. Cheese crackers
• B. Peanut butter sandwich
• C. Potato chips
• D. Vanilla cookies

Correct answer: C

Rationale: The correct answer is potato chips. As a child with celiac disease needs to avoid gluten, potato chips are a suitable snack choice as they are typically gluten-free. Cheese crackers (Choice A) and vanilla cookies (Choice D) contain gluten, which should be avoided by individuals with celiac disease. While peanut butter sandwiches (Choice B) could be gluten-free depending on the bread used, it is not the best choice as cross-contamination is a concern in shared environments like daycare centers.

3. A nurse is precepting a newly licensed nurse who is preparing to help a client perform tracheostomy care. The nurse should intervene if the equipment the preceptee gathered included:

• A. Cotton balls
• B. Sterile gloves
• C. A suction catheter
• D. Tracheostomy tubes

Correct answer: A

Rationale: The correct answer is A: Cotton balls. Cotton balls are not suitable for tracheostomy care due to the risk of lint and contamination. When performing tracheostomy care, sterile supplies such as sterile gloves, a suction catheter, and tracheostomy tubes are essential. Sterile gloves are needed to maintain asepsis, a suction catheter is necessary for airway clearance, and tracheostomy tubes are crucial for maintaining a patent airway. Cotton balls should be avoided to prevent introducing lint or fibers into the tracheostomy site, which can lead to infection or airway obstruction.

4. A client with a diagnosis of hypertension is being assessed. Which symptom would be most concerning?

• A. Headache
• B. Blurred vision
• C. Dizziness
• D. Chest pain

Correct answer: D

Rationale: Chest pain in a client with hypertension is the most concerning symptom as it may indicate a myocardial infarction or other serious cardiac event related to hypertension. Immediate intervention is required to address potential life-threatening conditions. Headache, blurred vision, and dizziness are common symptoms associated with hypertension but are not typically indicative of an acute cardiac event requiring urgent attention.

5. A client has been sitting in a chair for 1 hour. Which of the following complications poses the greatest risk to the client?

• A. Decreased subcutaneous fat
• B. Muscle atrophy
• C. Pressure injury
• D. Fecal impaction

Correct answer: C

Rationale: The correct answer is C: Pressure injury. Prolonged sitting can lead to pressure injuries due to continuous pressure on certain body areas, reducing blood flow and causing tissue damage. While decreased subcutaneous fat, muscle atrophy, and fecal impaction are potential concerns, pressure injuries pose the greatest immediate risk as they can lead to serious complications such as tissue necrosis and infection if not addressed promptly. Decreased subcutaneous fat and muscle atrophy may develop over time with prolonged immobility but are not as acutely dangerous as a pressure injury. Fecal impaction, while uncomfortable and potentially serious, does not pose an immediate life-threatening risk compared to the development of a pressure injury.

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