Nursing Elites

1. A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?

• A. Restrict protein intake to less than 40 g/day
• B. Initiate seizure precautions for the client
• C. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr
• D. Encourage the client to ambulate twice per day

Correct answer: B

Rationale: The correct action for the nurse to take is to initiate seizure precautions for the client. Severe preeclampsia increases the risk of seizures (eclampsia), making it crucial to prioritize the safety of the client. Restricting protein intake (Choice A) is not the priority in this situation as seizure prevention takes precedence. While maintaining hydration is essential, starting an infusion of 0.9% sodium chloride (Choice C) is not the initial action needed for seizure prevention. Encouraging the client to ambulate (Choice D) may not be safe or appropriate considering the severity of preeclampsia and the risk of seizures.

2. A nurse is developing discharge care plans for a client who has osteoporosis. To prevent injury, the nurse should instruct the client to:

• A. Perform weight-bearing exercises
• B. Avoid crossing the legs beyond the midline
• C. Avoid sitting in one position for prolonged periods
• D. Splint the affected area

Correct answer: A

Rationale: The correct answer is A: Perform weight-bearing exercises. Weight-bearing exercises strengthen bones and help prevent fractures, which is crucial for clients with osteoporosis. Choices B, C, and D are incorrect. Avoiding crossing the legs beyond the midline and avoiding sitting in one position for prolonged periods are general recommendations for preventing musculoskeletal issues but are not specific to osteoporosis. Splinting the affected area is not a standard practice for managing osteoporosis and preventing fractures.

3. A nurse is preparing to administer an intramuscular injection to an adult client. At what angle should the nurse administer the medication using the ventrogluteal site?

• A. 90-degree angle
• B. 60-degree angle
• C. 75-degree angle
• D. 45-degree angle

Correct answer: A

Rationale: The correct answer is A: 90-degree angle. The ventrogluteal site is preferred for intramuscular injections because it is away from major nerves and blood vessels. Administering the injection at a 90-degree angle ensures that the medication reaches deep into the muscle tissue, allowing for proper absorption of the drug. Choice B, 60-degree angle, is incorrect as it is not the recommended angle for the ventrogluteal site. Choice C, 75-degree angle, and Choice D, 45-degree angle, are also incorrect as they are not the appropriate angles for administering an intramuscular injection using the ventrogluteal site.

4. A client diagnosed with pneumonia is receiving oxygen therapy at 4 L/min via nasal cannula. Which of the following interventions is most important?

• A. Encourage fluid intake.
• B. Monitor oxygen saturation levels.
• C. Change the oxygen tubing daily.
• D. Assist with frequent position changes.

Correct answer: B

Rationale: Monitoring oxygen saturation levels is the most important intervention in this scenario. It ensures that the client is receiving adequate oxygenation, which is crucial for a client with pneumonia. By monitoring saturation levels, the nurse can promptly identify any oxygenation issues and adjust the oxygen delivery if necessary. Encouraging fluid intake, changing oxygen tubing daily, and assisting with frequent position changes are also important aspects of care for a client with pneumonia, but they are not as critical as monitoring oxygen saturation levels in ensuring immediate respiratory support.

5. While in the cafeteria, a nurse overhears two APs discussing a hospitalized patient. What action should the nurse take?

• A. Report the incident to the supervisor.
• B. Join the conversation to intervene.
• C. Quietly tell the APs that this is not appropriate.
• D. Ignore the conversation.

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to choose option C: 'Quietly tell the APs that this is not appropriate.' The nurse should immediately and discreetly address the situation, reminding the APs that discussing patient information in public areas violates confidentiality. Reporting the incident to the supervisor (option A) may be necessary if the behavior continues. Joining the conversation to intervene (option B) may escalate the situation and compromise patient confidentiality. Ignoring the conversation (option D) does not address the violation or prevent it from recurring.

Similar Questions