Nursing Elites

1. A nurse is caring for a client who has a prescription for enoxaparin. Which of the following actions should the nurse take?

• A. Inject the medication into the deltoid muscle
• B. Inject the medication deep into subcutaneous tissue
• C. Massage the injection site for 2 minutes after administration
• D. Insert the needle at a 10-degree angle

Correct answer: B

Rationale: The correct action the nurse should take when administering enoxaparin is to inject the medication deep into subcutaneous tissue. This method helps ensure proper absorption of the medication and prevents tissue irritation. Injecting into the deltoid muscle (Choice A) is not recommended for enoxaparin administration. Massaging the injection site (Choice C) can lead to tissue damage and bruising. Inserting the needle at a 10-degree angle (Choice D) is not the correct technique for administering enoxaparin.

2. A client with a new diagnosis of type 2 diabetes mellitus is being taught about foot care by a nurse. Which of the following instructions should the nurse include?

• A. Soak your feet in warm water daily.
• B. Wear shoes that are one size larger than your normal size.
• C. Wear cotton socks to keep your feet dry.
• D. Trim your toenails straight across.

Correct answer: D

Rationale: The correct answer is D: "Trim your toenails straight across." This instruction is essential to prevent ingrown toenails in clients with diabetes. Soaking feet in warm water daily (choice A) may increase the risk of skin breakdown and infection. Wearing shoes one size larger than normal (choice B) can lead to friction and cause blisters. While wearing cotton socks (choice C) is generally recommended, the emphasis should be on moisture-wicking materials rather than just cotton.

3. A nurse is planning care for a client who has dementia and is frequently agitated. Which of the following interventions should the nurse include in the plan of care?

• A. Offer the client several choices when scheduling activities.
• B. Confront the client when inappropriate behavior occurs.
• C. Use a calm, reassuring approach when speaking to the client.
• D. Encourage the client to engage in stimulating activities.

Correct answer: C

Rationale: The correct intervention for a client with dementia who is frequently agitated is to use a calm and reassuring approach when speaking to them. This approach helps reduce agitation and create a more therapeutic environment. Offering several choices may overwhelm the client and increase agitation, making choice A incorrect. Confronting the client can escalate the situation and worsen agitation, making choice B inappropriate. While encouraging stimulating activities is beneficial, it may not be the most effective intervention for immediate agitation management, making choice D less priority compared to using a calm and reassuring approach.

4. A nurse is providing dietary teaching to a client who has a new prescription for warfarin. Which of the following client statements indicates an understanding of the teaching?

• A. I will avoid eating leafy green vegetables while taking this medication.
• B. I will increase my intake of calcium-rich foods.
• C. I will avoid foods high in vitamin K while taking this medication.
• D. I will take this medication at bedtime to avoid dizziness.

Correct answer: C

Rationale: Clients taking warfarin should avoid foods high in vitamin K, as it can interfere with the effectiveness of the medication.

5. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take to prevent infection?

• A. Change the TPN tubing every 48 hours.
• B. Change the TPN tubing every 24 hours.
• C. Monitor the client's urine output every 8 hours.
• D. Monitor the client's weight every 72 hours.

Correct answer: B

Rationale: The correct answer is to change the TPN tubing every 24 hours. This action helps reduce the risk of infection because the high glucose content of TPN promotes bacterial growth. Choice A is incorrect as changing the tubing every 48 hours would not provide adequate infection prevention. Option C, monitoring urine output, is important for assessing renal function but is not directly related to preventing TPN-related infections. Option D, monitoring weight, is essential for assessing nutritional status but does not directly address infection prevention in TPN administration.

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