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 nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take first?

• A. Provide assistance to the bathroom
• B. Insert a straight catheter
• C. Increase fluids
• D. Perform a bladder scan

Correct answer: D

Rationale: Performing a bladder scan is the first step to assess bladder retention before any further interventions.

3. What are the key nursing interventions for a patient experiencing acute respiratory distress syndrome (ARDS)?

• A. Positioning the patient in a prone position
• B. Monitoring vital signs and lung sounds
• C. Preparing for mechanical ventilation
• D. Administering supplemental oxygen

Correct answer: A

Rationale: The correct answer is A: Positioning the patient in a prone position. Prone positioning is a key nursing intervention for patients with acute respiratory distress syndrome (ARDS) as it helps improve oxygenation by allowing better lung ventilation. Choice B, monitoring vital signs and lung sounds, is important but not a key intervention specific to ARDS. Choice C, preparing for mechanical ventilation, may be necessary in severe cases of ARDS but is not a primary nursing intervention. Choice D, administering supplemental oxygen, is a common supportive measure but is not specific to ARDS interventions.

4. A patient reports feeling dizzy when standing up. What is the most appropriate nursing intervention?

• A. Encourage the patient to take deep breaths.
• B. Assist the patient to sit down slowly.
• C. Instruct the patient to use a walker for support.
• D. Teach the patient how to change positions safely.

Correct answer: B

Rationale: The correct answer is to assist the patient to sit down slowly. This intervention is appropriate for a patient experiencing dizziness when standing up, as it helps prevent falls due to orthostatic hypotension. Encouraging deep breaths (Choice A) may not address the underlying cause of dizziness, which is related to postural changes. Instructing the patient to use a walker for support (Choice C) or teaching the patient how to change positions safely (Choice D) are not the most immediate and direct interventions to address the immediate risk of falling when feeling dizzy upon standing.

5. What are the key considerations when administering medication via a nasogastric (NG) tube?

• A. Checking tube placement before administration
• B. Administering medication in liquid form whenever possible
• C. Crushing tablets and mixing them with water if needed
• D. Flushing the NG tube with water before and after medication

Correct answer: A

Rationale: The correct answer is A: Checking tube placement before administration. This is a crucial step to ensure that the medication reaches the stomach safely and does not end up in the lungs, which can lead to serious complications. Choice B is incorrect as not all medications can be administered in liquid form. Choice C is incorrect because crushing tablets can alter their effectiveness or cause harm. Choice D is incorrect as flushing the NG tube with water is not a standard practice before administering medication, unless specified by healthcare provider instructions.

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