Nursing Elites

1. When administering an IM injection into a client's deltoid muscle, which of the following actions should the nurse take?

• A. Use a 21-gauge needle for the injection
• B. Inject the medication at a 90-degree angle
• C. Inject the medication 12.7 cm (5 in) below the acromion process
• D. Inject the medication 2.54 cm (1 in) below the acromion process

Correct answer: B

Rationale: The correct answer is to inject the medication at a 90-degree angle when administering an IM injection into the deltoid muscle. This angle ensures proper delivery of the medication into the muscle tissue. Choice A is incorrect because the gauge of the needle for a deltoid IM injection is usually smaller, around 23-25 gauge. Choices C and D are incorrect as the injection site for the deltoid muscle is approximately 2.54 cm (1 in) below the acromion process, not 12.7 cm (5 in).

2. A patient reports nausea and vomiting after chemotherapy. What is the nurse's priority action?

• A. Administer an antiemetic as prescribed.
• B. Encourage the patient to eat small, frequent meals.
• C. Provide the patient with anti-nausea wristbands.
• D. Encourage the patient to rest after eating.

Correct answer: A

Rationale: The correct answer is to administer an antiemetic as prescribed. Chemotherapy-induced nausea and vomiting can be distressing for patients. Administering an antiemetic helps alleviate these symptoms effectively. Choice B, encouraging the patient to eat small, frequent meals, may be helpful for other gastrointestinal issues but is not the priority when the patient is experiencing nausea and vomiting. Choice C, providing anti-nausea wristbands, may offer some relief but is not as direct and immediate as administering an antiemetic. Choice D, encouraging the patient to rest after eating, is not the priority in this situation where the focus should be on managing the nausea and vomiting.

3. A client with cirrhosis and ascites requires a care plan. Which intervention should the nurse include?

• A. Increase the client's sodium intake
• B. Increase the client's saturated fat intake
• C. Decrease the client's carbohydrate intake
• D. Decrease the client's fluid intake

Correct answer: D

Rationale: In cirrhosis with ascites, decreasing fluid intake is crucial to manage the condition. This helps prevent further fluid accumulation in the abdomen. Increasing sodium intake (Choice A) can worsen fluid retention and edema. Increasing saturated fat intake (Choice B) is not recommended as it can contribute to liver damage. Decreasing carbohydrate intake (Choice C) is not directly related to managing ascites in cirrhosis.

4. A healthcare provider is assessing a patient with dehydration. Which finding indicates the patient's condition is worsening?

• A. Dry mucous membranes.
• B. Tachycardia and low blood pressure.
• C. Bradycardia and shallow respirations.
• D. Clear lung sounds.

Correct answer: B

Rationale: Tachycardia and low blood pressure are indicative of worsening dehydration in a patient. Tachycardia is the body's compensatory mechanism to maintain cardiac output in response to decreased intravascular volume, while low blood pressure reflects inadequate perfusion due to decreased fluid levels. Bradycardia and shallow respirations are not typical findings in worsening dehydration, and clear lung sounds do not directly correlate with the severity of dehydration.

5. In the context of personality disorders, what is a common characteristic of a client with Borderline Personality Disorder?

• A. A need for admiration and a grandiose view of self-importance
• B. Unlawful actions and lack of empathy
• C. Fear of abandonment and impulsiveness
• D. A disregard for others with manipulative behaviors

Correct answer: C

Rationale: The correct answer is C: Fear of abandonment and impulsiveness. Individuals with Borderline Personality Disorder often exhibit intense fears of abandonment, engage in impulsive behaviors such as self-harm or substance abuse, and struggle with unstable relationships. Choices A, B, and D do not align with the characteristic features commonly associated with Borderline Personality Disorder. A need for admiration and grandiosity (Choice A) is more characteristic of Narcissistic Personality Disorder. Unlawful actions and lack of empathy (Choice B) are more typical of Antisocial Personality Disorder. A disregard for others with manipulative behaviors (Choice D) is often seen in individuals with traits of Histrionic or Antisocial Personality Disorders.

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