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 with type 1 diabetes is admitted to the emergency room with abdominal pain, polyuria, and confusion. What should the nurse implement first?

• A. Administer intravenous insulin.
• B. Start an intravenous fluid bolus.
• C. Obtain a blood glucose level.
• D. Administer an antiemetic.

Correct answer: B

Rationale: In this scenario, the nurse should first start an intravenous fluid bolus. This intervention is crucial in addressing severe dehydration associated with diabetic ketoacidosis, a life-threatening complication of type 1 diabetes. Administering intravenous insulin (Choice A) is important but should follow fluid resuscitation. Obtaining a blood glucose level (Choice C) is necessary but not as urgent as addressing the dehydration. Administering an antiemetic (Choice D) is not the priority in this situation.

3. What might be suggested to a client with fibrocystic breasts in an attempt to help relieve symptoms?

• A. Increase intake of high-calcium foods in your diet
• B. Wear a supportive bra during the day and at night
• C. Take over-the-counter pain relievers
• D. Perform regular breast massage

Correct answer: B

Rationale: The correct answer is B: 'Wear a supportive bra during the day and at night.' Wearing a supportive bra is essential for individuals with fibrocystic breasts as it helps relieve discomfort by providing necessary support to reduce strain on breast tissue. Option A is incorrect as high-calcium foods are not directly related to symptom relief in fibrocystic breasts. Option C is not the first-line recommendation and may not address the underlying issue. Option D, performing regular breast massage, is not typically recommended and may not provide significant relief for fibrocystic breast symptoms.

4. The nurse is preparing an older adult for discharge following cataract extraction. What is the most important instruction?

• A. Avoid straining, bending, or lifting heavy objects.
• B. Limit exposure to sunlight for the first 2 weeks.
• C. Use direct lighting when reading for 6 weeks.
• D. Irrigate the conjunctiva with saline before applying ointment.

Correct answer: A

Rationale: The most important instruction for a patient following cataract extraction is to avoid straining, bending, or lifting heavy objects. These activities can increase intraocular pressure and potentially lead to complications such as bleeding or dislocation of the intraocular lens. Choices B, C, and D are not as critical in the immediate post-operative period. Limiting sunlight exposure and using direct lighting when reading are important but not as crucial as avoiding activities that can increase intraocular pressure. Irrigating the conjunctiva with saline before applying ointment is not a standard post-cataract surgery instruction.

5. A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. Which action should the nurse take?

• A. Instruct the client to use a moisturizer immediately after the bath
• B. Advise the client to take shorter baths with less water
• C. Suggest taking antihistamines for the pruritus
• D. Encourage the client to use cooler water and apply calamine lotion after soaking

Correct answer: D

Rationale: In this situation, the client's pruritus (itching) is likely exacerbated by hot baths, which can worsen the itching sensation. Using cooler water will help soothe the skin and reduce pruritus. Additionally, applying calamine lotion after soaking can provide further relief. Instructing the client to use a moisturizer immediately after the bath (Choice A) may not address the root cause of pruritus aggravated by hot baths. Advising the client to take shorter baths with less water (Choice B) might not be as effective in relieving the itching sensation caused by cirrhosis. Suggesting antihistamines for the pruritus (Choice C) may not directly address the impact of hot baths on the client's discomfort.

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