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 healthcare professional is preparing to administer a dose of sertraline. Which of the following should the healthcare professional assess first?

• A. Blood pressure
• B. Heart rate
• C. Respiratory rate
• D. Mood changes

Correct answer: A

Rationale: When administering sertraline, assessing blood pressure is crucial as this medication can potentially affect blood pressure levels. Monitoring blood pressure before giving sertraline helps ensure patient safety and allows for appropriate interventions if any significant changes are noted. Heart rate, respiratory rate, and mood changes are important assessments but are not typically the first priority when administering sertraline. While heart rate and respiratory rate can also be affected by sertraline, blood pressure assessment is a higher priority due to the medication's known effects on blood pressure regulation.

3. A client who has a new prescription for simvastatin is receiving teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will take this medication in the morning.
• B. I should avoid drinking grapefruit juice while taking this medication.
• C. I should expect my cholesterol levels to increase initially.
• D. I will need to have my kidney function checked every 3 months.

Correct answer: B

Rationale: The correct answer is B. Grapefruit juice can increase the risk of toxicity with simvastatin, so clients should avoid consuming it while on the medication. Choice A is incorrect because the timing of medication administration should be based on healthcare provider instructions. Choice C is incorrect because simvastatin is prescribed to lower cholesterol levels. Choice D is incorrect as monitoring kidney function is not specifically related to simvastatin therapy.

4. A nurse is reviewing the laboratory results of a newborn who is 24 hours old. Which of the following findings should the nurse report to the provider?

• A. Hemoglobin 12 g/dL
• B. Glucose 50 mg/dL
• C. Bilirubin 4 mg/dL
• D. Platelets 200,000/mm³

Correct answer: C

Rationale: The correct answer is C: Bilirubin 4 mg/dL. A bilirubin level of 4 mg/dL is elevated for a newborn and requires monitoring and potential intervention to prevent complications such as jaundice and kernicterus. Elevated bilirubin levels in newborns can lead to serious neurological consequences. Choices A, B, and D are within normal ranges for a newborn and do not require immediate reporting to the provider. Therefore, the nurse should prioritize reporting the elevated bilirubin level to the provider for further evaluation and management.

5. A nurse is assessing a client diagnosed with schizophrenia. The nurse asks the client to interpret the following statement: “When the cat’s away, the mice will play.” The client responds, “The mice come out when the cat is not around.” The nurse should document this finding as:

• A. Echolalia
• B. Associative looseness
• C. Neologisms
• D. Concrete thinking

Correct answer: D

Rationale: The client’s literal interpretation of the statement is an example of concrete thinking, a cognitive symptom often seen in schizophrenia where abstract thinking is impaired. Choice A, Echolalia, is the repetition of words spoken by others, which is not demonstrated in this scenario. Choice B, Associative looseness, refers to a disturbance in the logical progression of thoughts, leading to a disorganized thought process. Choice C, Neologisms, involves creating new words or phrases with unique meanings, which is not evident in the client's response.

Similar Questions