Nursing Elites

1. A client has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.

• A. Inject 5 units of air into the bottle of regular insulin
• B. Withdraw the correct dose of NPH insulin from the bottle
• C. Inject 10 units of air into the bottle of NPH insulin
• D. Withdraw the correct dose of regular insulin from the bottle

Correct answer: B

Rationale: The correct order of steps for this procedure is to first inject air into the NPH insulin bottle to prevent vacuum formation. After injecting air into the NPH insulin, the next step is to withdraw the correct dose of regular insulin from its bottle. This sequence ensures that the regular insulin is drawn after the NPH insulin, preventing contamination and ensuring accurate dosing. Therefore, choice B is correct. Choices A, C, and D are incorrect because air should be injected into the NPH insulin first, not the regular insulin, and the doses should be withdrawn in the appropriate order to maintain the integrity and potency of each insulin type.

2. A client tells the nurse, “I have to check with my partner and see if they think I am ready to go home.” The nurse responds, “How do you feel about going home today?” Which clarifying technique is the nurse using to enhance communication with the client?

• A. Pacing
• B. Reflecting
• C. Paraphrasing
• D. Restating

Correct answer: B

Rationale: Reflecting is the correct answer as it involves echoing back the client’s feelings and concerns, helping them explore their thoughts. In this scenario, the nurse mirrors the client's statement to encourage the client to delve deeper into their emotions. Pacing involves matching the rate and flow of communication, paraphrasing is restating in different words, and restating is repeating what the client said without adding new information. Therefore, choices A, C, and D are not the appropriate clarifying technique demonstrated in the situation described.

3. The LPN/LVN is assisting with the care of a client who has had a stroke. Which intervention is most important to include in the client's plan of care to prevent joint contractures?

• A. Encourage the client to perform active range-of-motion exercises.
• B. Use pillows to keep the client's extremities in a functional position.
• C. Place the client in a prone position for 30 minutes each day.
• D. Perform passive range-of-motion exercises on the affected side.

Correct answer: B

Rationale: Using pillows to keep the client's extremities in a functional position is crucial in preventing joint contractures. This intervention helps maintain proper alignment of the joints and reduces the risk of contractures by preventing prolonged positioning that can lead to muscle shortening. Encouraging the client to perform active range-of-motion exercises (Choice A) is beneficial for maintaining mobility but may not be the most important intervention to prevent joint contractures. Placing the client in a prone position for 30 minutes each day (Choice C) can be helpful for preventing pressure ulcers but is not directly related to preventing joint contractures. Performing passive range-of-motion exercises on the affected side (Choice D) can aid in maintaining joint flexibility but may not be as crucial as using pillows to prevent joint contractures.

4. A nurse in a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which concept should the nurse and client discuss in the termination phase of the relationship?

• A. Loss
• B. Autonomy
• C. Confidentiality
• D. Accountability

Correct answer: A

Rationale: In the termination phase of a nurse-client relationship, discussing 'loss' is crucial to help the client understand and process the end of the therapeutic relationship and any emotional impact. This discussion can aid in closure and transitioning out of the professional relationship. 'Autonomy' refers to the client's right to make decisions about their care, which is important throughout the relationship but not specifically in the termination phase. 'Confidentiality' is essential for maintaining trust but is not the primary focus during termination. 'Accountability' involves being answerable for one's actions, which is important in nursing practice but not a central topic in the termination phase of the relationship.

5. A client is grieving the loss of her partner and expresses thoughts of not wanting to live. Which of the following actions should the nurse take?

• A. Request additional support for the client from her family.
• B. Ask the client if she plans to harm herself.
• C. Inform the client that feeling this way is a normal response to grief.
• D. Suggest that the client seek counseling for support.

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to ask the client if she plans to harm herself. This is crucial to assess the client's risk of self-harm or suicide. Providing immediate safety and appropriate interventions is the priority when a client expresses such thoughts. Requesting additional support from the family (Choice A) may be helpful but does not address the immediate safety concern. Informing the client that feeling this way is normal (Choice C) may invalidate her feelings and does not address the safety risk. Suggesting counseling (Choice D) may be beneficial in the long term but is not the immediate priority when assessing for self-harm or suicide risk.

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