Nursing Elites

1. A healthcare professional is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the healthcare professional take?

• A. Use a 25-gauge needle.
• B. Select a site on the client’s abdomen.
• C. Use the Z-track technique to displace the skin on the injection site.
• D. Observe for bleb formation to confirm proper placement.

Correct answer: B

Rationale: For subcutaneous injections like heparin, a 25-27 gauge needle is recommended, making choice A incorrect. The abdomen is a commonly used site for heparin injection due to its consistent absorption and convenience, making choice B the correct answer. The Z-track technique is not necessary for subcutaneous injections, making choice C unnecessary. Observing for bleb formation is not a standard practice for confirming proper placement of subcutaneous heparin, making choice D incorrect. Therefore, the correct action is to select a site on the client's abdomen for the injection.

2. A client is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?

• A. Monitor the client for pain in the suprapubic region.
• B. Ensure the client is free of metal objects.
• C. Administer 240 mL (8 oz) of oral contrast before the procedure.
• D. Assist the client with a bowel cleansing.

Correct answer: B

Rationale: The correct action for the nurse to include before an intravenous pyelogram is ensuring the client is free of metal objects. Metal objects can interfere with the imaging procedure and may need to be removed to prevent artifacts. Monitoring for pain in the suprapubic region (choice A) is not directly related to the procedure and is not a standard pre-procedure action. Administering oral contrast (choice C) is more common for other imaging studies like a CT scan, not an intravenous pyelogram. Assisting with a bowel cleansing (choice D) is not typically required before an intravenous pyelogram.

3. The healthcare provider is caring for a client with a suspected deep vein thrombosis (DVT). Which assessment finding should the healthcare provider report to the healthcare provider?

• A. Swelling and redness in the affected leg
• B. Pain in the affected leg
• C. Warmth and tenderness in the affected leg
• D. A positive Homans' sign

Correct answer: D

Rationale: A positive Homans' sign is a classic sign associated with deep vein thrombosis (DVT) and indicates the presence of a blood clot. This finding is crucial to report to the healthcare provider promptly for further evaluation and treatment. Swelling, redness, pain, warmth, and tenderness in the affected leg are common signs of DVT, but a positive Homans' sign specifically points towards a potential blood clot, making it the priority finding to be reported. Reporting other symptoms may also be important, but a positive Homans' sign is more specific to DVT and requires immediate attention.

4. A healthcare professional is reviewing a client's health record and notes a new prescription for lisinopril 10 mg PO once daily. The healthcare professional should identify this as which of the following types of prescription?

• A. Single
• B. Stat
• C. Routine
• D. Now

Correct answer: C

Rationale: A routine prescription, such as lisinopril 10 mg PO once daily, is administered on a regular schedule with or without a termination date. It is a standard, ongoing prescription for maintenance therapy. Choice A, 'Single,' would typically refer to a one-time prescription. Choice B, 'Stat,' is used for prescriptions that are needed immediately or in emergency situations. Choice D, 'Now,' is not a common prescription type designation and is not applicable in this context.

5. An assistive personnel says to the nurse, “This client is incontinent of stool three or four times a day. I get angry, and I think that the client is doing it just to get attention. I think we should put adult diapers on her.” Which is the appropriate nursing response?

• A. You should report this to the supervisor
• B. It is very upsetting to see an adult client regress
• C. Diapers are the best solution
• D. The client’s condition is not your concern

Correct answer: B

Rationale: The correct response is 'It is very upsetting to see an adult client regress.' In this situation, the nurse should acknowledge the emotional impact of caregiving on the assistive personnel and address it professionally. Choice A is incorrect because reporting to the supervisor may not directly address the emotional concerns raised. Choice C is incorrect because immediately resorting to diapers without further assessment or intervention is not the most appropriate solution. Choice D is incorrect as the client's well-being and care are a shared responsibility among healthcare team members.

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