Nursing Elites

1. The nurse is caring for a client postoperatively following a thyroidectomy. Which assessment finding should be reported to the healthcare provider immediately?

• 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 should be reported to the healthcare provider immediately as it may indicate hypocalcemia, a potential complication after thyroidectomy. Hoarseness of the voice is common postoperatively due to surgical manipulation, slight swelling at the incision site is a normal response, and a mild fever can be expected after surgery. However, tingling around the mouth suggests a potential calcium imbalance, which requires prompt attention to prevent serious complications.

2. A client with type 1 diabetes mellitus is learning to administer insulin. What is the best site for the nurse to recommend for insulin injection?

• A. Abdomen
• B. Thigh
• C. Upper arm
• D. Buttock

Correct answer: A

Rationale: The correct answer is the abdomen. The abdomen is the recommended site for insulin injection due to its faster absorption rate compared to other sites. Insulin injected into the abdomen is absorbed more quickly, leading to better glycemic control. The thigh and upper arm are also common sites for insulin injection, but they have slower absorption rates than the abdomen. The buttock is not a preferred site for insulin injection due to inconsistent absorption and potential risk of injecting into muscle instead of fatty tissue.

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. A client is diagnosed with type 1 diabetes mellitus. Which instruction about insulin administration should the nurse emphasize?

• A. Rotate injection sites to prevent tissue damage
• B. Inject insulin into the same site to increase absorption
• C. Only use insulin pens
• D. Mix different types of insulin in the same syringe

Correct answer: C

Rationale: The correct answer is to only use insulin pens. This is because insulin pens provide a convenient and accurate way to administer insulin. Rotating injection sites is important to prevent tissue damage and promote consistent insulin absorption, making choice A incorrect. Injecting insulin into the same site can lead to lipodystrophy and is not recommended, making choice B incorrect. Mixing different types of insulin in the same syringe can alter their action profiles and is generally not recommended, making choice D incorrect.

5. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which laboratory finding is most indicative of this condition?

• A. Serum glucose of 180 mg/dL
• B. Blood pH of 7.30
• C. Positive urine ketones
• D. Serum bicarbonate of 25 mEq/L

Correct answer: C

Rationale: The correct answer is C: Positive urine ketones. In diabetic ketoacidosis (DKA), the body breaks down fat for energy due to a lack of insulin, leading to ketone production. Positive urine ketones are a hallmark laboratory finding in DKA as they directly reflect the presence of ketosis. Choice A, serum glucose of 180 mg/dL, may be elevated in DKA, but it is not specific to this condition. Choice B, blood pH of 7.30, often shows acidosis in DKA, but urine ketones are more specific to the presence of ketosis. Choice D, serum bicarbonate of 25 mEq/L, would typically be low in DKA due to acidosis rather than elevated.

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