Nursing Elites

1. Based on the documentation in the medical record, which action should the nurse implement next?

• A. Administer the rubella vaccine subcutaneously
• B. Observe the mother breastfeeding her infant
• C. Call the nursery for the infant's blood type result
• D. Administer Vicodin one tablet for pain

Correct answer: B

Rationale: The correct answer is to observe the mother breastfeeding her infant. This action is essential to ensure that the infant is feeding well and to assess maternal-infant bonding. Administering the rubella vaccine subcutaneously (Option A) is not the immediate priority in this scenario as assessing breastfeeding is more crucial. Calling the nursery for the infant's blood type result (Option C) is premature and not the next appropriate step, as it does not address the immediate needs of the newborn. Administering Vicodin one tablet for pain (Option D) is not indicated without further assessment or indication of pain, making it an incorrect choice at this time.

2. The healthcare provider is assessing a client who has just undergone a thyroidectomy. Which assessment finding is most concerning?

• A. Hoarseness of the voice
• B. Slight swelling at the incision site
• C. Tingling around the mouth
• D. Mild fever

Correct answer: C

Rationale: Tingling around the mouth is the most concerning finding as it may indicate hypocalcemia, a potential complication after thyroidectomy. Hoarseness of the voice is common due to surgical manipulation, slight swelling at the incision site is expected postoperatively, and mild fever can be a normal inflammatory response. Hypocalcemia after thyroidectomy can lead to serious complications and should be addressed promptly to prevent further issues.

3. The healthcare provider is preparing to administer an intramuscular injection to an adult client. Which site is the preferred location for this injection?

• A. Deltoid muscle.
• B. Vastus lateralis muscle.
• C. Ventrogluteal muscle.
• D. Dorsogluteal muscle.

Correct answer: C

Rationale: The ventrogluteal site is preferred for intramuscular injections in adults due to its muscle mass and lower risk of nerve injury. The deltoid muscle is more commonly used for vaccines in adults, the vastus lateralis muscle is preferred in infants and young children, and the dorsogluteal muscle is associated with a higher risk of nerve injury and is no longer recommended for intramuscular injections.

4. When teaching a diabetic client about foot care, what information is most important?

• A. Inspect feet daily
• B. Wear cotton socks
• C. Use lukewarm water to wash feet
• D. Cut nails straight across

Correct answer: A

Rationale: Inspecting feet daily is crucial for diabetic clients as it can help prevent complications like infections and ulcers. This practice allows for early detection of any foot issues, enabling timely intervention. While wearing cotton socks (choice B) is beneficial as they absorb moisture and reduce the risk of fungal infections, it is not as critical as daily foot inspection. Using lukewarm water to wash feet (choice C) is important to prevent burns or skin damage in diabetic clients with decreased sensation, but it is not as crucial as daily foot inspection. Cutting nails straight across (choice D) is essential to prevent ingrown nails, but it is not the most important information when educating diabetic clients about foot care.

5. A client with a diagnosis of osteoporosis is prescribed alendronate (Fosamax). What is the most important instruction the nurse should provide?

• A. Take the medication in the morning on an empty stomach.
• B. Take the medication at bedtime.
• C. Remain upright for at least 30 minutes after taking the medication.
• D. Take the medication with a full glass of water.

Correct answer: D

Rationale: The most important instruction the nurse should provide to a client prescribed alendronate (Fosamax) for osteoporosis is to take the medication with a full glass of water. This is crucial to help prevent esophageal irritation. Option A is correct as alendronate should be taken in the morning on an empty stomach. Option C is incorrect because the client should remain upright for at least 30 minutes after taking the medication, not lie down. Option B is incorrect and a duplicate of Option A.

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