Nursing Elites

1. A client with iron-deficiency anemia asks a nurse why the Z-track method is necessary for administering iron dextran. Which response should the nurse provide?

• A. It decreases the risk of injecting medication into a blood vessel.
• B. It delays medication absorption.
• C. It minimizes tissue irritation.
• D. It accelerates medication excretion.

Correct answer: C

Rationale: The Z-track method is used to minimize tissue irritation by sealing the medication in the muscle. This technique helps prevent leakage of the medication into subcutaneous tissue, reducing the risk of irritation and staining at the injection site. Option A about decreasing the risk of injecting medication into a blood vessel is not correct as the primary purpose of the Z-track method is to prevent tissue irritation. Option B stating it delays medication absorption is incorrect as the Z-track method does not affect the rate of medication absorption. Option D mentioning it accelerates medication excretion is incorrect as the Z-track method does not impact medication excretion but rather focuses on minimizing tissue irritation.

2. What advice should the client be given if they are feeling dizzy upon standing after taking a diuretic for hypertension?

• A. Avoid standing up too quickly.
• B. Increase fluid intake to stay hydrated.
• C. Eat more salt to help retain fluids.
• D. Wear compression stockings during the day.

Correct answer: A

Rationale: The correct advice for a client feeling dizzy upon standing after taking a diuretic for hypertension is to avoid standing up too quickly. Diuretics can lead to orthostatic hypotension, causing dizziness upon sudden position changes. Increasing fluid intake can exacerbate the issue by further lowering blood pressure. Eating more salt might counteract the diuretic's effects but is not the primary intervention for orthostatic hypotension. Compression stockings are more relevant for venous insufficiency than for orthostatic hypotension.

3. The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurse observe?

• A. Tops of the ears
• B. Bridge of the nose
• C. Around the nostrils
• D. Over the cheeks

Correct answer: A

Rationale: When a client is using a nasal cannula for oxygen therapy, the areas prone to skin damage are the tops of the ears and around the nostrils. The pressure exerted by the cannula on these areas can lead to skin breakdown, so it is important for the nurse to observe these sites for any signs of damage. The correct answer is 'Tops of the ears.' Choices 'Bridge of the nose' and 'Over the cheeks' are not typically areas where skin damage related to the cannula would occur, making them incorrect choices.

4. While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding?

• A. Complete the intermittent suction of the nasopharynx.
• B. Reposition the pulse oximeter clip to obtain a new reading.
• C. Stop suctioning until the pulse oximeter reading is above 95%.
• D. Apply an oxygen mask over the client's nose and mouth.

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to complete the intermittent suction of the nasopharynx. Since the oxygen saturation remains stable at 94%, which was the initial reading, it indicates that the procedure is not causing a significant drop in oxygen levels. Stopping the suctioning or applying oxygen may not be necessary as the saturation level is within an acceptable range. Repositioning the pulse oximeter clip is unlikely to change the reading significantly. Therefore, completing the procedure maintains care consistency and effectiveness, ensuring proper airway management without unnecessary interventions. Choices B, C, and D are incorrect because repositioning the pulse oximeter clip, stopping suctioning until a higher reading is achieved, and applying oxygen are not warranted based on the stable oxygen saturation level of 94% throughout the procedure.

5. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

• A. The client's comfort level is increased when the nurse maintains eye contact while typing notes into the record
• B. The interview process is hindered by electronic documentation and may disrupt the flow of conversation
• C. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically
• D. Completing the electronic record during an interview is optional and not a legal obligation of the examining nurse

Correct answer: C

Rationale: The most accurate statement is that the nurse has a limited ability to observe nonverbal communication while entering the assessment electronically. This is because the nurse's focus is on typing or inputting data, which may lead to missing important nonverbal cues from the client. Choices A and B are incorrect as they do not address the limitation of observing nonverbal cues. Choice A is incorrect because breaking eye contact to type notes may hinder the client's comfort level. Choice B is incorrect because it states that electronic documentation enhances the interview process, which may not always be the case. Choice D is incorrect as completing the electronic record during an interview is typically a standard practice but not a legal obligation.

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