Nursing Elites

1. The nurse is preparing to administer the 0800 dose of 20 units of Humulin R to an 8-year-old girl diagnosed with Type 1 diabetes. The mother comments that her daughter is a very picky eater and many times does not eat meals. Which intervention should the nurse implement first?

• A. Administer the 20 Units of Humulin R subcutaneously as prescribed
• B. Ask the girl if she will be eating her breakfast this morning
• C. Discuss changing the insulin prescription to Lispro with the healthcare provider
• D. Explain to the mother the importance of eating the scheduled meals

Correct answer: B

Rationale: The correct answer is to ask the girl if she will be eating her breakfast this morning. This is important to determine if the child will be consuming food, which is crucial information before administering insulin. If the child does not plan to eat, administering the full dose of insulin may lead to hypoglycemia. Choice A is incorrect as administering the insulin without knowing if the child will eat can be dangerous. Choice C is not the first intervention because the immediate concern is the child's meal intake. Choice D, while important, is not the first step in this situation.

2. A nurse is preparing to administer an intramuscular injection to a client. Which action should the nurse take to reduce the client's risk of injury?

• A. Use a 1-inch needle
• B. Select a large muscle for the injection
• C. Aspirate for blood return before injecting
• D. Massage the injection site

Correct answer: C

Rationale: The correct answer is to aspirate for blood return before injecting. This action helps ensure that the needle is not in a blood vessel, reducing the risk of injury. Using a 1-inch needle (Choice A) is a standard length for intramuscular injections but does not directly reduce the risk of injury. Selecting a large muscle for the injection (Choice B) is important for proper medication absorption but does not directly reduce the risk of injury. Massaging the injection site (Choice D) can help with medication absorption but does not reduce the risk of injury.

3. An angry client screams at the emergency department triage nurse, 'I've been waiting here for two hours! You and the staff are incompetent.' What is the best response for the nurse to make?

• A. The emergency department is very busy at this time.
• B. I'll let you see the doctor next because you've waited so long.
• C. I'm doing the best I can for the sickest clients first.
• D. I understand you are frustrated with the wait time.

Correct answer: D

Rationale: The correct response for the nurse is to choose option D, 'I understand you are frustrated with the wait time.' This response acknowledges the client's emotions, shows empathy, and validates their feelings of frustration. Option A justifies the situation but does not address the client's emotional state. Option B is unfair to other patients and may not be based on urgency. Option C focuses on the nurse's actions rather than addressing the client's emotions, making it less effective than option D.

4. The nurse is caring for a laboring 22-year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority?

• A. Raising the side rails and placing the call bell within reach
• B. Teaching the client how to push effectively to decrease the length of the second stage of labor
• C. Timing and recording uterine contractions
• D. Positioning the client for proper distribution of anesthesia

Correct answer: A

Rationale: The highest priority nursing intervention for a laboring client following administration of regional anesthesia is to ensure safety by raising the side rails and placing the call bell within reach. This is crucial to prevent falls and to ensure that the client can call for assistance if needed. Teaching the client how to push effectively (Choice B) is important but not the highest priority at this moment. Timing and recording uterine contractions (Choice C) are essential but not as immediate as ensuring safety post-anesthesia. Positioning the client for proper distribution of anesthesia (Choice D) is important but ensuring immediate safety takes precedence in this situation.

5. A client who has had three spontaneous abortions is requesting information about possible causes. The nurse's response should be based on which information?

• A. Chromosomal abnormalities are the most common cause of early spontaneous abortions
• B. Incompetent cervix can cause spontaneous abortions
• C. An infection can cause spontaneous abortions
• D. Nutritional deficiencies are the most common cause of early spontaneous abortions

Correct answer: A

Rationale: The correct answer is A: Chromosomal abnormalities are the most common cause of early spontaneous abortions. Spontaneous abortions, also known as miscarriages, often occur due to chromosomal abnormalities in the fetus. These abnormalities are a common cause of early pregnancy loss. Choice B is incorrect because an incompetent cervix typically leads to late miscarriages, not early spontaneous abortions. Choice C is incorrect as while infections can be a cause of spontaneous abortions, they are not the most common cause. Choice D is incorrect as nutritional deficiencies are not the most common cause of early spontaneous abortions.

Similar Questions