Nursing Elites

1. The nurse is preparing to administer an intramuscular injection to a client with muscle wasting in the gluteal region. What is the most appropriate site for the injection?

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

Correct answer: D

Rationale: The vastus lateralis site is the most appropriate for an IM injection in a client with muscle wasting in the gluteal region. Administering the injection in the vastus lateralis ensures effective medication delivery due to muscle wasting in the gluteal region, preventing potential complications associated with the dorsogluteal or ventrogluteal sites, which may not be suitable in this specific client case. The deltoid site is mainly used for smaller volumes of medication and may not be ideal for this scenario.

2. A client with cirrhosis is admitted with jaundice and ascites. Which assessment finding requires immediate intervention?

• A. Peripheral edema
• B. Confusion and altered mental status
• C. Yellowing of the skin
• D. Increased abdominal girth

Correct answer: B

Rationale: Confusion and altered mental status are the most critical assessment findings in a client with cirrhosis. These symptoms may indicate hepatic encephalopathy, a serious complication that requires immediate intervention. Yellowing of the skin (jaundice) is a common manifestation of cirrhosis and does not necessitate immediate intervention. Peripheral edema and increased abdominal girth are associated with fluid retention in cirrhosis but are not as urgent as addressing altered mental status and confusion.

3. The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation?

• A. Recommend weight-bearing physical activity.
• B. Encourage a diet high in dairy products.
• C. Suggest vitamin D supplementation.
• D. Advise avoiding caffeine and alcohol.

Correct answer: A

Rationale: The correct answer is A: Recommend weight-bearing physical activity. Weight-bearing exercises are effective in maintaining bone density and preventing osteoporosis by promoting bone formation. Encouraging a diet high in dairy products (choice B) can provide calcium, but it's not as directly related to bone formation as physical activity. While vitamin D supplementation (choice C) is important for calcium absorption and bone health, it is not directly involved in promoting bone formation. Advising to avoid caffeine and alcohol (choice D) can be beneficial for bone health, but it is not as directly related to promoting bone formation as weight-bearing physical activity.

4. Which class of drugs is the only source of a cure for septic shock?

• A. Antihypertensives
• B. Anti-infectives
• C. Antihistamines
• D. Anticholesteremics

Correct answer: B

Rationale: The correct answer is B: Anti-infectives. Anti-infective agents, such as antibiotics, are essential in treating septic shock as they can eliminate bacteria and halt the progression of the condition by stopping the production of endotoxins. Antihypertensives (Choice A) are used to lower blood pressure, antihistamines (Choice C) are used to treat allergic reactions, and anticholesteremics (Choice D) are used to lower cholesterol levels. However, none of these drug classes directly address the bacterial infection that underlies septic shock.

5. A client with a history of hypertension is prescribed a beta-blocker. Which client statement indicates that further teaching is needed?

• A. ‘I will take my medication in the morning before breakfast.’
• B. ‘I should avoid eating foods high in potassium.’
• C. ‘I should change positions slowly to avoid dizziness.’
• D. ‘I should avoid abrupt discontinuation of the medication.’

Correct answer: B

Rationale: The correct answer is B: ‘I should avoid eating foods high in potassium.’ This statement indicates a misunderstanding as beta-blockers do not typically affect potassium levels. The other choices (A, C, and D) are all appropriate statements for a client prescribed a beta-blocker. Choice A shows understanding of the timing of medication administration, choice C addresses orthostatic hypotension concerns, and choice D highlights the importance of not abruptly stopping the medication to prevent adverse effects.

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