Nursing Elites

1. A client has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?

• A. Apply a fecal collection system
• B. Apply a barrier cream
• C. Cleanse and dry the area
• D. Check the client's perineum

Correct answer: D

Rationale: When a client with major fecal incontinence reports irritation in the perianal area, the nurse's initial action should be to assess the client's perineum to gather more information. By checking the perineum, the nurse can identify the extent and nature of the irritation, allowing for appropriate interventions to be initiated. This assessment is crucial in developing a comprehensive care plan and addressing the client's immediate needs effectively. Applying the nursing process priority-setting framework helps in planning care and prioritizing nursing actions, making assessment the initial step in this scenario. Applying a fecal collection system (choice A) would be premature without assessing the perineal area first. Similarly, applying a barrier cream (choice B) or cleansing and drying the area (choice C) should follow the assessment to ensure appropriate interventions are chosen based on the assessment findings.

2. A healthcare provider is planning to administer medications to a client who is receiving enteral feedings through an NG tube. Which of the following actions should the healthcare provider plan to take?

• A. Dissolve each medication in 5 mL of sterile water.
• B. Administer medications through a secondary infusion.
• C. Mix medications with the enteral feeding.
• D. Flush the NG tube with 30 mL of water before and after administering medications.

Correct answer: D

Rationale: Flushing the NG tube with water before and after administering medications is essential to prevent clogging of the tube and ensure proper delivery of medication. This practice helps maintain tube patency and decreases the risk of obstruction, which could compromise the client's treatment and nutrition. By flushing the tube, the healthcare provider ensures that the medication is completely delivered and that there are no residual drug particles left in the tube, which could lead to blockages or inconsistent dosing. Therefore, flushing the NG tube is a crucial step in the safe administration of medications to clients receiving enteral feedings. Choices A, B, and C are incorrect. Dissolving medications in sterile water (Choice A) may not be suitable for all drugs, as some medications may require specific diluents. Administering medications through a secondary infusion (Choice B) is not the standard practice for enteral medication administration. Mixing medications with the enteral feeding (Choice C) can cause interactions between medications and the feeding formula, affecting their absorption and effectiveness.

3. When providing teaching to a client with a new prescription for digoxin, which of the following instructions should the nurse include?

• A. Take your pulse before taking the medication.
• B. Take the medication with an antacid.
• C. Double the dose if you miss one.
• D. Take the medication with a high-fiber meal.

Correct answer: A

Rationale: The correct instruction for a client with a new prescription for digoxin is to take their pulse before taking the medication. Digoxin can lead to bradycardia as a side effect, and monitoring the pulse helps in assessing the heart rate prior to medication administration. This precaution allows for the identification of any significant changes in heart rate that may require medical attention.

4. When educating a client on the proper use of a metered-dose inhaler (MDI), which of the following instructions should be included?

• A. Shake the inhaler before use.
• B. Inhale quickly and deeply.
• C. Use the inhaler as needed.
• D. Do not use a spacer with the inhaler.

Correct answer: A

Rationale: Shaking the inhaler before use is crucial to ensure proper mixing of the medication. This action helps distribute the medication evenly, allowing for consistent dosing with each use. It is a vital step in using a metered-dose inhaler correctly to optimize its effectiveness in managing respiratory conditions.

5. When administering an IM injection to a 5-month-old infant, which of the following injection sites should be used?

• A. Deltoid
• B. Ventrogluteal
• C. Vastus lateralis
• D. Dorsogluteal

Correct answer: C

Rationale: For infants and young children, the vastus lateralis muscle located over the anterior thigh is the preferred site for intramuscular injections. This site is chosen for its large muscle mass and reduced risk of injury to major nerves and blood vessels. Infants have less developed muscle structures, making the vastus lateralis a safer and more effective site for injections compared to other sites like the deltoid, ventrogluteal, or dorsogluteal. Using the correct injection site is essential to prevent complications and ensure the proper absorption of the medication.

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