Nursing Elites

1. An antibiotic IM injection for a 2-year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to

• A. administer the medication in 2 separate injections
• B. give the medication in the ventrogluteal site
• C. call to get a smaller volume ordered
• D. check with the pharmacy for a liquid form of the medication

Correct answer: A

Rationale: Administering the medication in 2 separate injections is the correct action. When the total volume of an injection is relatively large for a specific site, dividing it into smaller volumes and administering them separately is a safer practice to prevent discomfort, tissue damage, or absorption issues. Giving the medication in the ventrogluteal site can be appropriate for IM injections but does not address the issue of the total volume being too high for a single injection. Calling to get a smaller volume ordered may delay treatment and is not necessary when a safe administration method is available. Checking with the pharmacy for a liquid form of the medication does not directly address the issue of the total volume being too high for a single injection, and changing the formulation may not be necessary if the correct administration technique can be applied.

2. A client with hypertension taking a potassium-wasting diuretic is being educated about nutrition by a nurse. Which of the following dietary instructions should the nurse include in the teaching?

• A. Increase consumption of tuna and salmon.
• B. Limit intake of dried fruits.
• C. Avoid cow's milk.
• D. Consume organs and bananas

Correct answer: D

Rationale: The correct answer is D: 'Consume organs and bananas.' When a client is taking a potassium-wasting diuretic, they are at risk of potassium loss. Consuming foods high in potassium, such as organs and bananas, can help counteract this loss. Choice A is incorrect because tuna and salmon are not particularly high in potassium. Choice B is incorrect because dried fruits are good sources of potassium. Choice C is incorrect as cow's milk is also a good source of potassium, which could be beneficial for a client taking a potassium-wasting diuretic.

3. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?

• A. Sensory perceptual alterations related to decreased vision
• B. Alteration in mobility related to fatigue
• C. Impaired gas exchange related to retained secretions
• D. Altered patterns of urinary elimination related to nocturia

Correct answer: D

Rationale: The correct answer is D: Altered patterns of urinary elimination related to nocturia. Nocturia increases the risk of falls in elderly clients due to frequent nighttime trips to the bathroom. Choice A is incorrect because while decreased vision can contribute to falls, nocturia poses a more direct risk. Choice B is incorrect as fatigue may affect mobility but is not as directly linked to falls as nocturia. Choice C is incorrect as impaired gas exchange is not typically associated with an increased risk of falls.

4. A 60-year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void?

• A. Have him drink several glasses of water
• B. Crede the bladder from the bottom to the top
• C. Assist him to stand by the side of the bed to void
• D. Wait 2 hours and have him try to void again

Correct answer: C

Rationale: Assisting the client to stand by the side of the bed to void is the most appropriate action. This position can help stimulate voiding due to gravity and normal positioning. Having the client drink water (Choice A) may help, but assisting him to stand is more effective. Crede maneuver (Choice B) is not recommended as it can increase the risk of bladder trauma. Waiting for 2 hours (Choice D) without taking any action is not proactive in addressing the client's inability to void.

5. The healthcare provider is assessing a client who has just returned from surgery. Which of these findings requires the most immediate attention?

• A. Respiratory rate of 16 breaths per minute
• B. Blood pressure of 120/80 mm Hg
• C. Temperature of 99.5 degrees Fahrenheit
• D. Heart rate of 80 beats per minute

Correct answer: C

Rationale: A temperature of 99.5 degrees Fahrenheit is slightly elevated but not immediately critical. In a postoperative patient, an elevated temperature could indicate an infection, which requires prompt attention to prevent complications. The respiratory rate, blood pressure, and heart rate within normal ranges are important to monitor but do not indicate an immediate need for intervention as an elevated temperature does.

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