Nursing Elites

1. The nurse is administering an intradermal injection for a tuberculosis skin test. Which technique should the nurse use?

• A. Use a 25-gauge needle at a 90-degree angle
• B. Use a 27-gauge needle at a 15-degree angle
• C. Use a 22-gauge needle at a 45-degree angle
• D. Use a 20-gauge needle at a 90-degree angle

Correct answer: B

Rationale: An intradermal injection for a tuberculosis skin test should be administered using a 27-gauge needle at a 15-degree angle. This technique ensures that the medication is delivered into the dermis layer of the skin. Choice A is incorrect because a 25-gauge needle is too large for an intradermal injection. Choice C is incorrect as a 22-gauge needle is also too large and the angle is too steep for an intradermal injection. Choice D is incorrect as a 20-gauge needle is too large for an intradermal injection, and a 90-degree angle would not deliver the medication accurately into the dermis.

2. A client who is bedridden after a stroke is at risk for developing pressure ulcers. Which nursing intervention is most important in preventing this complication?

• A. Apply lotion to the skin every 4 hours.
• B. Reposition the client every 2 hours.
• C. Elevate the head of the bed 30 degrees.
• D. Massage the skin at least twice a day.

Correct answer: B

Rationale: Repositioning the client every 2 hours is crucial in preventing pressure ulcers in bedridden clients. This intervention helps in relieving pressure on specific areas of the body, promoting circulation, and reducing the risk of tissue damage. Applying lotion every 4 hours (Choice A) may not address the root cause of pressure ulcers. Elevating the head of the bed (Choice C) is beneficial for some conditions but not specifically targeted at preventing pressure ulcers. Massaging the skin at least twice a day (Choice D) can actually increase the risk of skin breakdown in individuals at risk for pressure ulcers by causing friction and shearing forces on the skin.

3. In the critical care unit, which client should receive the most care hours by a registered nurse (RN)?

• A. A client with a newly inserted Foley catheter and Alzheimer's disease
• B. A 55-year-old with chronic kidney disease
• C. An 82-year-old client with a newly fractured femur and soft wrist restraints
• D. A 72-year-old with pneumonia and sepsis on antibiotics

Correct answer: C

Rationale: The client with a newly fractured femur and soft wrist restraints should receive the most care hours as they have physical limitations due to the fracture and mental limitations due to being restrained. This client requires continuous monitoring, support, and frequent assessments to prevent complications. Choices A, B, and D do not have the same level of physical and mental care needs as the client with the newly fractured femur and soft wrist restraints.

4. A client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. Which finding indicates that the treatment is effective?

• A. Potassium level of 4.0 mEq/L.
• B. Blood glucose level of 180 mg/dL.
• C. Urine output of 50 mL/hour.
• D. Absence of ketones in the urine.

Correct answer: D

Rationale: The correct answer is D: Absence of ketones in the urine. In a client with diabetic ketoacidosis (DKA) receiving an insulin infusion, the absence of ketones in the urine indicates that ketoacidosis is resolving. This is a crucial finding as it shows that the insulin therapy is effectively addressing the metabolic imbalance causing DKA. Choices A, B, and C are incorrect: A potassium level of 4.0 mEq/L is within normal range but does not directly reflect the resolution of DKA; a blood glucose level of 180 mg/dL, while improved, is still high and does not specifically indicate the resolution of ketoacidosis; urine output of 50 mL/hour is within normal limits but does not directly point to the resolution of DKA.

5. At 42-weeks gestation, a client refuses induction and desires a natural delivery. What is the most important action for the nurse to take?

• A. Discuss alternative ways to support her birth plan.
• B. Explain the indications for induction in post-term pregnancy.
• C. Discuss the differences between labor with oxytocin and natural labor.
• D. Ask the healthcare provider to discuss the issue with the client.

Correct answer: A

Rationale: The correct answer is to discuss alternative ways to support her birth plan. It is crucial to respect the client's autonomy and desires while ensuring their safety and well-being. Choice B is incorrect because while educating the client about the indications for induction is important, it is not the most immediate action to take in this scenario. Choice C is incorrect as it focuses on comparing labor types rather than supporting the client's birth plan. Choice D is incorrect as the nurse should first engage with the client directly before involving the healthcare provider.

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