Nursing Elites

1. A healthcare provider is preparing to administer an intramuscular injection to an adult client. Which of the following injection sites should the healthcare provider select?

• A. Deltoid muscle
• B. Dorsogluteal muscle
• C. Vastus lateralis muscle
• D. Rectus femoris muscle

Correct answer: A

Rationale: The deltoid muscle is a common site for intramuscular injections in adults due to its accessibility and muscle mass. It is located in the upper arm and provides a sufficient area for injection. The deltoid muscle is preferred for administering vaccines and other medications that require IM administration. Choice B, the dorsogluteal muscle, is not recommended for intramuscular injections due to the proximity of major nerves and blood vessels in that area, which can lead to nerve damage or injury. Choice C, the vastus lateralis muscle, is more commonly used for infants and young children, while choice D, the rectus femoris muscle, is not typically used for intramuscular injections in adults.

2. A client is postoperative following abdominal surgery. Which of the following actions should be taken to prevent respiratory complications?

• A. Instruct the client to exhale into an incentive spirometer
• B. Reposition the client every 8 hours
• C. Assist the client with early ambulation
• D. Maintain the client on bed rest for the first 48 hours

Correct answer: C

Rationale: Assisting the client with early ambulation is crucial in preventing respiratory complications after abdominal surgery. Early ambulation helps to prevent conditions like atelectasis and pneumonia by promoting lung expansion and preventing pooling of respiratory secretions. It also aids in improving circulation, reducing the risk of deep vein thrombosis, and enhancing overall recovery. Instructing the client to exhale into an incentive spirometer (Choice A) is beneficial for lung expansion but is more focused on respiratory therapy rather than preventing complications. Repositioning the client every 8 hours (Choice B) is important for preventing pressure ulcers but is not directly related to preventing respiratory complications. Maintaining the client on bed rest for the first 48 hours (Choice D) can lead to complications such as atelectasis, pneumonia, and deep vein thrombosis due to decreased lung expansion and mobility.

3. A client reports difficulty sleeping at night, which interferes with daily functioning. Which intervention should the nurse suggest to this client?

• A. Avoid beverages containing caffeine
• B. Take a sleep medication regularly at bedtime
• C. Watch television for 30 minutes in bed to relax before falling asleep
• D. Advise the client to take several naps during the day

Correct answer: A

Rationale: The correct answer is A: Avoid beverages containing caffeine. Caffeine is a stimulant that can interfere with sleep, making it difficult for the client to fall asleep at night. Taking sleep medication regularly (choice B) may not address the root cause of the sleep difficulty and can lead to dependency. Watching television in bed (choice C) can actually stimulate the brain and hinder relaxation before sleep. Advising the client to take several naps during the day (choice D) can disrupt the sleep-wake cycle further. Therefore, recommending the avoidance of caffeine-containing beverages is the most appropriate intervention to help the client improve their ability to sleep at night and function better during the day.

4. A client has been prescribed enoxaparin. Which of the following instructions should the nurse include?

• A. You need to obtain routine blood tests to monitor the effects of this medication.
• B. You should administer the medication into your thigh.
• C. You should inject the medication once daily.
• D. You need to use a 1-inch needle to administer the medication.

Correct answer: C

Rationale: The correct instruction to include when educating a client prescribed enoxaparin is to inject the medication once daily. Enoxaparin is typically administered via subcutaneous injection once daily, usually in the abdomen, to prevent blood clots.

5. A client with renal calculi is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should increase my intake of calcium-rich foods.
• B. I should decrease my intake of calcium-rich foods.
• C. I should increase my intake of sodium-rich foods.
• D. I should decrease my intake of potassium-rich foods.

Correct answer: B

Rationale: The correct answer is B because decreasing the intake of calcium-rich foods can help manage and prevent the formation of renal calculi. Excessive calcium intake can contribute to the formation of these stones, so reducing calcium-rich foods is a key dietary modification for individuals with renal calculi. Choice A is incorrect as increasing calcium-rich foods can exacerbate the condition. Choice C is incorrect because increasing sodium-rich foods can lead to more stone formation due to increased calcium excretion. Choice D is incorrect as potassium-rich foods do not directly contribute to the formation of renal calculi.

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