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. When educating a patient about gabapentin use, what should the nurse include?

• A. It can cause sedation
• B. It can be taken with alcohol
• C. It is a pain reliever
• D. It has no side effects

Correct answer: A

Rationale: The correct answer is A: 'It can cause sedation.' Gabapentin is known to cause sedation, and patients should be advised about this side effect, especially regarding activities that require alertness. Choice B is incorrect because gabapentin should not be taken with alcohol as it can increase the risk of central nervous system depression. Choice C is incorrect because while gabapentin is used to treat nerve pain, it is not classified as a traditional pain reliever. Choice D is incorrect because gabapentin, like any medication, can have side effects, such as dizziness, drowsiness, and fatigue.

3. A home health nurse is providing teaching to a patient who has a new diagnosis of a gastric ulcer and a new prescription for sucralfate oral suspension. What statement by the patient indicates an understanding of the teaching?

• A. I will take this medicine with meals.
• B. I will take this medicine right before bed.
• C. I will take this medicine 1 hour before meals and at bedtime.
• D. I will take this medicine only when I have symptoms.

Correct answer: C

Rationale: The correct answer is C because sucralfate should be taken on an empty stomach, 1 hour before meals, and at bedtime to coat the ulcer and protect it from stomach acid. Choice A is incorrect because taking it with meals may reduce its effectiveness. Choice B is incorrect as it should not be taken right before bed. Choice D is incorrect as sucralfate should be taken regularly as prescribed, not just when symptoms occur.

4. A nurse is admitting a client who has suspected appendicitis. Which of the following findings should the nurse report to the provider immediately?

• A. Distended, board-like abdomen
• B. WBC count of 15,000/mm³
• C. Rebound tenderness over McBurney’s point
• D. Temperature of 37.3°C (99.1°F)

Correct answer: A

Rationale: A distended, board-like abdomen is a concerning sign indicating the possibility of a ruptured appendix and peritonitis, which are medical emergencies. Reporting this finding immediately is crucial for prompt intervention. Choice B, an elevated WBC count, could indicate infection but is not as urgent as the risk of a ruptured appendix. Choice C, rebound tenderness over McBurney’s point, is a classic sign of appendicitis but does not indicate an immediate threat like a possible rupture. Choice D, a slightly elevated temperature, is a nonspecific finding and not as critical as the risk of peritonitis associated with a distended, board-like abdomen.

5. A nurse is assessing a client who has Clostridium difficile (C. diff) infection. Which infection control measure should the nurse implement?

• A. Wear a face shield when entering the room
• B. Place the client in a private room
• C. Place the client in a negative pressure room
• D. Use alcohol-based hand rub following client care

Correct answer: B

Rationale: The correct answer is to place the client in a private room. Clostridium difficile (C. diff) infection requires contact precautions, which include isolating the client in a private room to prevent the spread of infection to others. Wearing a face shield may be necessary in certain situations for protection but is not the primary measure for C. diff. Placing the client in a negative pressure room is not specifically indicated for C. diff unless the client has additional respiratory issues. Using alcohol-based hand rub following client care is not sufficient for C. diff control; thorough handwashing with soap and water is recommended due to the spore-forming nature of C. diff.

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