Nursing Elites

1. The healthcare provider is preparing to administer an IM 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 the preferred site for IM injections in adults due to its muscle mass and low risk of nerve injury. The deltoid muscle, although commonly used for vaccines in adults due to easy accessibility, has a smaller muscle mass making it less ideal for IM injections. The vastus lateralis muscle is typically used in infants and young children, not in adults. The dorsogluteal site has a higher risk of injury to the sciatic nerve and is no longer recommended for IM injections in any age group.

2. A client with a chronic illness expresses frustration over their condition. What is the nurse's best response to support the client?

• A. Encourage joining a support group for emotional support
• B. Discuss the possibility of a cure in the future
• C. Suggest focusing on positive aspects of their life
• D. Validate their feelings and listen to their concerns

Correct answer: D

Rationale: The best response for the nurse to support a client expressing frustration over their chronic illness is to validate their feelings and listen to their concerns (Option D). This approach helps acknowledge the client's emotions, demonstrates empathy, and establishes a therapeutic relationship. By validating the client's feelings and actively listening to their concerns, the nurse offers a supportive environment for the client to express their frustrations. Choices A, B, and C are not the best responses in this situation. While joining a support group, discussing a cure, or focusing on positive aspects can be beneficial interventions, the immediate priority is to validate the client's feelings and provide a space for them to express their frustrations.

3. 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.

4. A client who has just been diagnosed with tuberculosis (TB) is being discharged home. Which instruction is most important for the nurse to provide?

• A. Avoid close contact with others until treatment is complete
• B. Take all prescribed medications as directed
• C. Schedule a follow-up appointment with the healthcare provider
• D. Wear a mask when in public places

Correct answer: B

Rationale: The correct answer is B: 'Take all prescribed medications as directed.' This instruction is the most important because adherence to the prescribed medication regimen is crucial in treating tuberculosis effectively and preventing the development of drug-resistant TB. While choice A is important for infection control, ensuring treatment adherence through proper medication intake takes precedence. Choice C is also essential for monitoring progress but is not as critical as ensuring medication compliance. Choice D is relevant for preventing transmission but is not as crucial as ensuring proper treatment by taking medications as directed.

5. Based on the Nursing diagnosis of 'Potential for infection related to second and third degree burns,' which intervention has the highest priority?

• A. Application of topical antibacterial cream
• B. Use of careful hand washing technique
• C. Administration of plasma expanders
• D. Limiting visitors to the burned client

Correct answer: B

Rationale: The highest priority intervention in this scenario is B, the use of careful hand washing technique. Proper hand hygiene is essential in preventing infection, especially in individuals with compromised skin integrity like those with burns. By practicing careful hand washing, healthcare providers reduce the risk of introducing harmful pathogens to the burn wound, thus lowering the chances of infections. Choice A, application of topical antibacterial cream, is important but should follow ensuring proper hand hygiene. Choice C, administration of plasma expanders, is not directly associated with preventing burn-related infections. Choice D, limiting visitors, is significant for infection control, but ensuring proper hand hygiene outweighs this intervention in terms of priority.

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