Nursing Elites

1. A client has been on bed rest for 3 days. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?

• A. The client uses a walker to move from the bed to the chair.
• B. The client has a strong cough.
• C. The client can bear weight on both legs.
• D. The client has a normal respiratory rate.

Correct answer: C

Rationale: The ability to bear weight on both legs indicates muscle strength and stability necessary for ambulation. This skill is crucial for the client to support their body weight and move independently when standing or walking. Choices A, B, and D are incorrect because using a walker, having a strong cough, or having a normal respiratory rate do not directly indicate the readiness to ambulate. The key factor in determining readiness for ambulation is the client's ability to bear weight on both legs, demonstrating the necessary strength for standing and walking.

2. A healthcare professional is preparing to administer an IM injection to a client. Which of the following techniques should the healthcare professional use to reduce discomfort?

• A. Use a 25-gauge needle.
• B. Administer the injection slowly.
• C. Massage the site after the injection.
• D. Apply ice to the injection site before administration.

Correct answer: B

Rationale: Administering the injection slowly is the recommended technique to reduce discomfort associated with IM injections. This approach allows the medication to disperse more gradually into the muscle, minimizing the sensation of pressure or pain during administration. Administering the injection slowly can also help prevent tissue damage and reduce the likelihood of injection site reactions.

3. A healthcare professional is supervising a newly licensed colleague who is preparing to administer an intramuscular injection. Which of the following actions by the newly licensed colleague requires intervention?

• A. Selecting a 25-gauge needle
• B. Administering the injection at a 45° angle
• C. Using the ventrogluteal site for the injection
• D. Aspirating for blood return before injecting the medication

Correct answer: B

Rationale: The correct answer is B. Administering an intramuscular injection at a 90° angle is essential for proper medication delivery into the muscle tissue. Injecting at a 45° angle is incorrect for intramuscular injections and is typically used for subcutaneous injections where the needle is inserted into the fatty tissue layer beneath the skin. Choice A is correct as selecting a 25-gauge needle is appropriate for an intramuscular injection. Choice C is also correct as the ventrogluteal site is a suitable site for intramuscular injections. Choice D is correct as aspirating for blood return is a necessary step to ensure the needle is not in a blood vessel before injecting the medication.

4. A client with a new diagnosis of hypertension is receiving teaching from a healthcare provider. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will decrease my intake of potassium.
• B. I will increase my intake of vitamin K.
• C. I will decrease my intake of sodium.
• D. I will increase my intake of magnesium.

Correct answer: C

Rationale: The correct answer is C: 'I will decrease my intake of sodium.' Lowering sodium intake is essential in managing hypertension as it helps reduce blood pressure levels. Excess sodium can lead to fluid retention and increased blood volume, putting more strain on the heart and blood vessels. Therefore, this response indicates an understanding of the teaching provided. Choices A, B, and D are incorrect because decreasing potassium intake, increasing vitamin K intake, and increasing magnesium intake are not primary dietary modifications recommended for hypertension. While potassium and magnesium can be beneficial for overall health, reducing sodium intake is the key dietary change to manage hypertension effectively.

5. A client has a new diagnosis of hyperkalemia and is receiving teaching from a healthcare provider on dietary management. Which of the following statements should the healthcare provider include in the teaching?

• A. You should increase your intake of potassium-rich foods.
• B. You should decrease your intake of potassium-rich foods.
• C. You should avoid foods that contain lactose.
• D. You should increase your intake of dairy products.

Correct answer: B

Rationale: The correct answer is B: 'You should decrease your intake of potassium-rich foods.' Hyperkalemia is a condition characterized by excess potassium in the blood. To manage hyperkalemia effectively, it is crucial to reduce the intake of potassium-rich foods. This helps in lowering the overall potassium levels in the body and prevents complications associated with hyperkalemia. Choices A, C, and D are incorrect. Increasing the intake of potassium-rich foods (Choice A) would exacerbate hyperkalemia. Avoiding foods that contain lactose (Choice C) is not directly related to managing hyperkalemia. Increasing the intake of dairy products (Choice D) is not recommended as they can be a significant source of dietary potassium.

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