Nursing Elites

1. A client is receiving a new prescription for enoxaparin. Which of the following instructions should the nurse include?

• A. Rub the injection site after administration.
• B. Pinch the skin while administering the injection.
• C. Aspirate before administering the medication.
• D. Avoid taking aspirin while using this medication.

Correct answer: D

Rationale: The correct answer is D: 'Avoid taking aspirin while using this medication.' Enoxaparin is an anticoagulant medication, and taking aspirin concurrently can increase the risk of bleeding. Choices A, B, and C are incorrect. A nurse should not instruct the client to rub the injection site after administration as it may cause irritation. Pinching the skin while administering the injection is not recommended for enoxaparin injections. Aspirating before administering the medication is also unnecessary as enoxaparin is administered subcutaneously, not intramuscularly.

2. A client has Clostridium difficile infection. Which of the following actions should the nurse take?

• A. Wash hands with an alcohol-based hand rub.
• B. Place the client on contact precautions.
• C. Wear a mask when entering the client's room.
• D. Double-bag all linens before removing them from the room.

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with Clostridium difficile infection is to place the client on contact precautions. This helps prevent the spread of the infection to other clients. Washing hands with an alcohol-based hand rub is important for infection control but is not specific to preventing the spread of Clostridium difficile. Wearing a mask may be necessary for airborne precautions but is not the priority for Clostridium difficile infection. Double-bagging linens is not a standard practice for preventing the spread of Clostridium difficile.

3. A client is receiving intermittent enteral tube feedings and is experiencing dumping syndrome. Which of the following actions should the nurse take?

• A. Administer a refrigerated feeding.
• B. Increase the amount of water used to flush the tubing.
• C. Decrease the rate of the client's feedings.
• D. Instruct the client to move onto their right side.

Correct answer: C

Rationale: Dumping syndrome is a condition that occurs when food moves too quickly from the stomach into the small intestine. Symptoms can include abdominal cramping, diarrhea, and sweating. To manage dumping syndrome in a client receiving enteral tube feedings, the nurse should decrease the rate of the feedings. This intervention helps slow down the movement of food through the gastrointestinal tract, reducing the symptoms. Administering a refrigerated feeding (choice A) or increasing the amount of water used to flush the tubing (choice B) are not appropriate actions for addressing dumping syndrome. Instructing the client to move onto their right side (choice D) is not a relevant intervention for managing dumping syndrome in this scenario.

4. A client is receiving chemotherapy and is being taught about preventing infection. Which of the following instructions should the nurse include?

• A. Take your temperature daily.
• B. Avoid fresh fruits and vegetables.
• C. Limit your intake of high-protein foods.
• D. Increase your intake of high-fat foods.

Correct answer: B

Rationale: Clients receiving chemotherapy are instructed to avoid fresh fruits and vegetables to lower the risk of infection. Fresh produce may harbor bacteria or other pathogens that could be harmful to individuals with compromised immune systems. Taking the temperature daily may be important but is not directly related to preventing infection. Limiting high-protein foods is not necessary unless there are specific dietary restrictions due to the treatment plan. Increasing the intake of high-fat foods is not recommended during chemotherapy as a high-fat diet may lead to other health issues.

5. A patient is being cared for by a nurse who has a history of angina and is experiencing chest pain. Which of the following actions should the nurse take first?

• A. Administer oxygen at 2 L/min via nasal cannula.
• B. Administer nitroglycerin sublingually.
• C. Obtain a 12-lead ECG.
• D. Notify the healthcare provider.

Correct answer: C

Rationale: In a patient with a history of angina experiencing chest pain, the priority action for the nurse is to obtain a 12-lead ECG. This helps in assessing for myocardial infarction, a serious condition that requires immediate attention. Administering oxygen, nitroglycerin, or notifying the healthcare provider can be important interventions but obtaining the ECG comes first to determine the presence of myocardial infarction and guide further management.

Similar Questions