Nursing Elites

1. A healthcare provider is assessing a client who has fluid volume excess. Which of the following findings should the healthcare provider expect?

• A. Hypotension
• B. Bradycardia
• C. Crackles in the lungs
• D. Dry mucous membranes

Correct answer: C

Rationale: Crackles in the lungs are indicative of fluid accumulation in the alveoli, which is a characteristic finding in clients with fluid volume excess. The crackling sound occurs due to the presence of excess fluid in the lungs, impairing normal ventilation and gas exchange. Monitoring for crackles is essential for early detection and management of fluid overload in clients. Choices A, B, and D are incorrect because in fluid volume excess, hypervolemia leads to increased blood pressure (not hypotension), compensatory tachycardia (not bradycardia), and moist mucous membranes (not dry).

2. A healthcare provider is preparing to administer an intramuscular injection to an adult client. Which of the following injection sites should the healthcare provider select?

• A. Deltoid muscle
• B. Dorsogluteal muscle
• C. Vastus lateralis muscle
• D. Rectus femoris muscle

Correct answer: A

Rationale: The deltoid muscle is a common site for intramuscular injections in adults due to its accessibility and muscle mass. It is located in the upper arm and provides a sufficient area for injection. The deltoid muscle is preferred for administering vaccines and other medications that require IM administration. Choice B, the dorsogluteal muscle, is not recommended for intramuscular injections due to the proximity of major nerves and blood vessels in that area, which can lead to nerve damage or injury. Choice C, the vastus lateralis muscle, is more commonly used for infants and young children, while choice D, the rectus femoris muscle, is not typically used for intramuscular injections in adults.

3. A client with a new diagnosis of pancreatitis is being taught about dietary management. Which of the following statements should the nurse include in the teaching?

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

Correct answer: B

Rationale: The correct statement the nurse should include in teaching a client with pancreatitis is to decrease the intake of high-fat foods. This dietary modification is crucial in managing symptoms and preventing exacerbations of pancreatitis. High-fat foods can put a strain on the pancreas, potentially leading to further complications. Choice A is incorrect because increasing intake of high-fat foods can worsen pancreatitis. Choice C is unrelated to pancreatitis management, as lactose intolerance is not directly linked to pancreatitis. Choice D is also incorrect, as increasing dairy product intake may not be suitable for all individuals with pancreatitis due to the fat content in many dairy products.

4. A client with chronic kidney disease is being educated by a nurse about dietary management. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should limit my intake of protein to prevent overworking my kidneys.
• B. I should increase my intake of potassium-rich foods.
• C. I should increase my intake of phosphorus-rich foods.
• D. I should increase my intake of calcium-rich foods.

Correct answer: A

Rationale: The correct answer is A. In chronic kidney disease, limiting protein intake is crucial to prevent overworking the kidneys. Excessive protein consumption can lead to the accumulation of metabolic waste products that the kidneys struggle to process, worsening kidney function. Therefore, by recognizing the need to restrict protein intake, the client demonstrates an understanding of the dietary management required for their condition. Choices B, C, and D are incorrect. Increasing intake of potassium-rich foods (Choice B) is not recommended in chronic kidney disease as it can lead to hyperkalemia. Similarly, increasing intake of phosphorus-rich foods (Choice C) is not advised because impaired kidneys struggle to excrete phosphorus, leading to elevated levels in the blood. Lastly, increasing intake of calcium-rich foods (Choice D) may not be necessary unless there is a specific deficiency or requirement, as calcium balance is often disrupted in chronic kidney disease.

5. 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.

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