Nursing Elites

1. A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client. Which site is safest for the nurse to use?

• A. Ventrogluteal
• B. Dorsogluteal
• C. Vastus lateralis
• D. Rectus femoris

Correct answer: A

Rationale: The correct answer is 'Ventrogluteal.' The ventrogluteal site is recommended for intramuscular injections in adults because it is free of major blood vessels and nerves, reducing the risk of injury or complications. Choice B, 'Dorsogluteal,' is not recommended due to the proximity of the sciatic nerve and major blood vessels. Choices C and D, 'Vastus lateralis' and 'Rectus femoris,' are sites commonly used for intramuscular injections but are more suitable for pediatric or specific population groups, not typically for adults.

2. A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. What should the nurse expect?

• A. Fetal hypoxia
• B. Abruptio placentae
• C. Post-maturity
• D. Head compression

Correct answer: D

Rationale: When early decelerations are noted on the fetal monitor tracing, it indicates fetal head compression, which is typically a benign finding associated with the progress of labor. Early decelerations mirror the uterine contractions and are often not a cause for concern as they are a normal response to fetal head compression during contractions. Choices A, B, and C are incorrect as they do not align with the expected outcome of early decelerations. Fetal hypoxia, abruptio placentae, and post-maturity would present with different patterns on the fetal monitor tracing and would require different interventions.

3. A nurse is caring for a client who has DVT. Which of the following instructions should the nurse include in the plan of care?

• A. Limit the client’s fluid intake to 1500 mL per day
• B. Massage the affected extremity to relieve pain
• C. Apply cold packs to the affected extremity
• D. Elevate the client’s affected extremity when in bed

Correct answer: D

Rationale: The correct instruction the nurse should include in the plan of care for a client with DVT is to elevate the affected extremity when in bed. Elevating the affected extremity helps improve venous return, reduces edema, alleviates discomfort, and promotes healing in clients with DVT. Limiting fluid intake can be detrimental as adequate hydration is important for circulation. Massaging the affected extremity can dislodge clots and worsen the condition. Applying cold packs can cause vasoconstriction, which is not recommended for DVT as it can impede blood flow further.

4. In orienting new staff nurses to a pediatric intensive care unit, what is an important consideration in providing information to parents of a critically ill child?

• A. Making sure they receive complete information during each encounter
• B. Assessing parents' preferences regarding the amount of information
• C. Allowing parents to observe key aspects of their child's care
• D. Providing patient education brochures explaining ICU protocols

Correct answer: B

Rationale: Assessing parents' preferences about the amount of information is crucial because it allows for individualized care that respects their needs and emotional capacity during a stressful time. Choice A is not ideal as overwhelming parents with complete information during each encounter may not align with their preferences. Choice C, while valuable, may not always be feasible or appropriate due to privacy concerns or medical procedures. Choice D, providing brochures, may not address the specific needs or preferences of each set of parents, making it less effective than assessing individual preferences.

5. A client who is having suicidal thoughts tells the nurse, “It just doesn’t seem worth it anymore. Why not end my misery?” Which of the following responses by the nurse is appropriate?

• A. Why do you think your life is not worth it anymore?
• B. Do you have a plan to end your life?
• C. I need to know what you mean by misery
• D. You can trust me and tell me what you’re thinking

Correct answer: B

Rationale: The appropriate response by the nurse is to ask about the client's plan to end their life. This question helps to assess the severity of the client's suicidal ideation and the immediacy of the risk, allowing the nurse to determine the appropriate level of intervention. Choices A, C, and D do not directly address the immediate risk assessment needed in this situation.

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