Nursing Elites

1. The nurse is preparing to administer an intramuscular injection to an adult client. Which site should the nurse select?

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

Correct answer: B

Rationale: The ventrogluteal site is preferred for intramuscular injections in adults because it is free from major blood vessels and nerves, reducing the risk of injury. The deltoid muscle can be used for smaller volumes of medication, primarily vaccines. The vastus lateralis muscle is commonly used in infants, toddlers, and young children. The dorsogluteal muscle site is discouraged due to its proximity to the sciatic nerve, increasing the risk of injury or nerve damage.

2. Prior to administering warfarin to a client with a history of atrial fibrillation, what lab result should the nurse review?

• A. White blood cell count.
• B. Prothrombin time (PT) and International Normalized Ratio (INR).
• C. Hemoglobin and hematocrit.
• D. Blood urea nitrogen (BUN) and creatinine.

Correct answer: B

Rationale: The correct answer is B: Prothrombin time (PT) and International Normalized Ratio (INR). These lab values are crucial for monitoring the effectiveness of warfarin, an anticoagulant medication. PT measures the time it takes for blood to clot, while INR standardizes these results. Ensuring the client's PT/INR levels are within the therapeutic range is essential to prevent clotting or excessive bleeding. Choices A, C, and D are incorrect as they are not directly related to monitoring warfarin therapy in a client with atrial fibrillation.

3. A client with hypothyroidism is experiencing severe lethargy and cold intolerance. What action should the nurse take?

• A. Increase the dose of levothyroxine.
• B. Administer a PRN dose of antipyretic medication.
• C. Provide a warm blanket and increase the room temperature.
• D. Increase the client's fluid intake to avoid dehydration.

Correct answer: A

Rationale: The correct answer is to increase the dose of levothyroxine. In hypothyroidism, the body does not produce enough thyroid hormone, leading to symptoms like lethargy and cold intolerance. Increasing the dose of levothyroxine, which is a synthetic thyroid hormone replacement, helps correct the deficiency and alleviates the symptoms. Choice B, administering antipyretic medication, is incorrect as antipyretics are used to reduce fever, not treat hypothyroidism symptoms. Choice C, providing a warm blanket and increasing room temperature, may provide temporary comfort but does not address the underlying hormonal deficiency. Choice D, increasing fluid intake, is important for overall health but does not directly address the symptoms of hypothyroidism.

4. 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.

5. Which intervention should be included in the long-term plan of care for a client with COPD?

• A. Administer high-flow oxygen during sleep.
• B. Reduce risk factors for infection.
• C. Limit fluid intake to reduce secretions.
• D. Use diaphragmatic breathing to achieve better exhalation.

Correct answer: D

Rationale: The correct answer is D: 'Use diaphragmatic breathing to achieve better exhalation.' Diaphragmatic breathing is an essential intervention for clients with COPD as it helps improve exhalation and lung function, ultimately reducing symptoms over the long term. Option A is incorrect because high-flow oxygen during sleep is more relevant for clients with conditions like sleep apnea rather than COPD. Option B, 'Reduce risk factors for infection,' is important but not as specific to the long-term management of COPD as diaphragmatic breathing. Option C, 'Limit fluid intake to reduce secretions,' is not a recommended intervention for clients with COPD, as adequate hydration is crucial for maintaining respiratory health.

Similar Questions