Nursing Elites

1. A nurse is preparing to administer an immunization to a 6-month-old infant. Which of the following actions should the nurse take to reduce pain at the injection site?

• A. Administer the immunization in the deltoid muscle
• B. Apply a cold compress to the injection site
• C. Apply pressure to the injection site for 5 minutes
• D. Administer a local anesthetic at the injection site

Correct answer: D

Rationale: Administering a local anesthetic at the injection site can help reduce pain during immunizations in infants. Options A, B, and C are incorrect. Administering the immunization in the deltoid muscle may not provide pain relief. Applying a cold compress or pressure to the injection site is not as effective as using a local anesthetic to reduce pain.

2. A nurse is planning care for a client who has a history of falls. Which of the following actions should the nurse include in the plan of care?

• A. Keep all four side rails up.
• B. Ensure the client's bed is in the lowest position.
• C. Use nonskid footwear while ambulating.
• D. Place a bedside commode close to the client's bed.

Correct answer: C

Rationale: The correct answer is C: 'Use nonskid footwear while ambulating.' This action is crucial in preventing falls in clients with a history of falls as it provides better traction and stability while walking. Choice A, 'Keep all four side rails up,' is not recommended as it can lead to client restraint and is not a fall prevention strategy. Choice B, 'Ensure the client's bed is in the lowest position,' is important for preventing injuries from falls out of bed but does not directly address fall prevention during ambulation. Choice D, 'Place a bedside commode close to the client's bed,' is a good practice for toileting safety but does not specifically address preventing falls while walking.

3. A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include?

• A. Establish a toileting schedule for the client.
• B. Use clothing with buttons and zippers.
• C. Discourage physical activity during the day.
• D. Engage the client in activities that increase sensory stimulation.

Correct answer: A

Rationale: The correct answer is A: Establish a toileting schedule for the client. A toileting schedule helps manage incontinence and prevent accidents, promoting client dignity. Choice B is incorrect because clothing with buttons and zippers may be difficult for a client with dementia to manage independently. Choice C is incorrect as physical activity during the day is beneficial for clients with dementia. Choice D is incorrect as activities that increase sensory stimulation may be overwhelming for a client with dementia.

4. A nurse is providing teaching to a client who has a new prescription for prednisone. Which of the following instructions should the nurse include?

• A. Take this medication on an empty stomach.
• B. Take this medication in the evening.
• C. You should avoid taking this medication with dairy products.
• D. You should monitor for signs of infection while taking this medication.

Correct answer: D

Rationale: The correct answer is D: "You should monitor for signs of infection while taking this medication." When a client is prescribed prednisone, it is essential to monitor for signs of infection due to the immunosuppressive effects of corticosteroids. Choices A, B, and C are incorrect because prednisone does not need to be taken on an empty stomach, at a specific time of day, or avoided with dairy products.

5. A nurse is caring for a client who is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?

• A. Keep the head of the bed elevated to 15 degrees.
• B. Change the feeding bag every 48 hours.
• C. Administer the feeding through a large-bore syringe.
• D. Flush the tube with 0.9% sodium chloride every 4 hours.

Correct answer: D

Rationale: The correct action the nurse should take is to flush the tube with 0.9% sodium chloride every 4 hours. This helps maintain patency and prevents clogs during enteral feedings. Keeping the head of the bed elevated to 15 degrees (Choice A) is important for preventing aspiration but is not directly related to tube care. Changing the feeding bag every 48 hours (Choice B) is not a standard practice as the bag should be changed every 24 hours to prevent bacterial growth. Administering the feeding through a large-bore syringe (Choice C) is incorrect as enteral feedings should be given through an appropriate feeding pump for accuracy and safety.

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