Nursing Elites

1. A nurse is preparing to administer heparin subcutaneously to a client. Which of the following actions should the nurse take?

• A. Use a 21-gauge needle for injection.
• B. Inject the medication into the client's deltoid muscle.
• C. Administer the medication within 5 cm (2 in) of the umbilicus.
• D. Massage the injection site after administration.

Correct answer: C

Rationale: The correct action the nurse should take when preparing to administer heparin subcutaneously is to administer the medication within 5 cm (2 in) of the umbilicus. This practice ensures proper subcutaneous delivery of the medication. Choice A is incorrect because a smaller gauge needle, typically 25-26 gauge, is used for subcutaneous injections. Choice B is incorrect as heparin should not be injected into the deltoid muscle but rather into fatty tissue. Choice D is incorrect as massaging the injection site after administration can lead to tissue irritation or bruising.

2. A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy. Which of the following information should the charge nurse include?

• A. The proxy should make health care decisions for the client regardless of the client's ability to do so
• B. The proxy can make financial decisions if the need arises
• C. The proxy can make treatment decisions if the client is under anesthesia
• D. The proxy should manage legal issues for the client

Correct answer: C

Rationale: The correct answer is C because the health care proxy can make treatment decisions for the client if the client is under anesthesia. This aligns with the concept of durable power of attorney for health care, where the proxy is authorized to make health care decisions when the client is unable to do so. Choices A, B, and D are incorrect. Choice A is incorrect because the proxy should make health care decisions only when the client is unable to do so. Choice B is incorrect as financial decisions are not typically within the scope of a health care proxy. Choice D is incorrect as managing legal issues is not the primary role of a health care proxy.

3. A client with type 1 diabetes mellitus is being taught self-administration of insulin by a nurse. Which of the following instructions should the nurse include?

• A. Inject air into the vial before withdrawing the insulin.
• B. Draw up the short-acting insulin first, then the long-acting insulin.
• C. Store unopened insulin vials in the freezer.
• D. Rotate injection sites within the same anatomical region.

Correct answer: D

Rationale: The correct instruction the nurse should include is to rotate injection sites within the same anatomical region. This practice helps reduce the risk of lipodystrophy, a condition characterized by fatty tissue changes due to repeated insulin injections in the same spot. By rotating sites, the client ensures better insulin absorption and prevents localized skin changes. Injecting air into the vial before withdrawing insulin (Choice A) is unnecessary and not recommended. Drawing up short-acting insulin before long-acting insulin (Choice B) is not a standard practice and can lead to errors in dosing. Storing unopened insulin vials in the freezer (Choice C) is incorrect as insulin should be stored in the refrigerator, not the freezer, to maintain its effectiveness.

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

• A. Take this medication with meals to prevent nausea.
• B. Avoid drinking alcohol while taking this medication.
• C. Avoid eating foods high in potassium.
• D. Monitor for signs of infection.

Correct answer: D

Rationale: The correct answer is D: 'Monitor for signs of infection.' Clopidogrel affects platelet levels, increasing the risk of bleeding. Therefore, it is essential for clients taking clopidogrel to monitor for signs of infection, which could indicate a lowered immune response. Choices A, B, and C are incorrect because they do not directly relate to the specific monitoring needs associated with clopidogrel therapy.

5. A nurse is caring for a newborn who is 1-day-old and receiving phototherapy for jaundice. Which of the following actions should the nurse take?

• A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
• B. Keep the infant's head covered with a cap.
• C. Ensure that the newborn wears a diaper.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to ensure that the newborn wears a diaper. This is important to prevent skin irritation during phototherapy. Choice A is incorrect as newborns should be breastfed or formula-fed, not given glucose water. Choice B is unnecessary and may interfere with the effectiveness of phototherapy. Choice D is inappropriate as lotions can interfere with the phototherapy and increase the risk of skin damage.

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