Nursing Elites

1. The nurse is teaching a client about the administration of a subcutaneous injection. Which site is most appropriate for this type of injection?

• A. Deltoid muscle
• B. Dorsogluteal muscle
• C. Ventrogluteal muscle
• D. Abdomen

Correct answer: D

Rationale: The abdomen is a common site for subcutaneous injections due to its accessibility and ample subcutaneous tissue. Subcutaneous injections are typically given in areas with a layer of fat between the skin and muscle, such as the abdomen, to allow for slow and consistent absorption of the medication. The deltoid muscle is more appropriate for intramuscular injections, not subcutaneous. The dorsogluteal muscle and ventrogluteal muscle are also more suited for intramuscular injections, not subcutaneous.

2. When providing care for a client receiving palliative care for terminal cancer, what should the nurse prioritize?

• A. Pain management
• B. Arranging family visits
• C. Discussing advance directives
• D. Providing nutritional support

Correct answer: A

Rationale: When caring for a client receiving palliative care for terminal cancer, the nurse should prioritize pain management. Effective pain management is crucial in enhancing the quality of life for terminally ill patients. While arranging family visits and discussing advance directives are important aspects of care, pain management takes precedence in providing comfort and alleviating suffering. Nutritional support is essential but may be of lesser priority compared to pain management in this context.

3. The nurse is assessing a client who has been diagnosed with chronic obstructive pulmonary disease (COPD). Which clinical finding is characteristic of this condition?

• A. Pursed-lip breathing
• B. Hyperresonance on percussion
• C. Bradycardia
• D. High-pitched inspiratory crackles

Correct answer: A

Rationale: Pursed-lip breathing is a characteristic finding in clients with COPD. It helps keep the airways open during exhalation, acting as a compensatory mechanism to prevent airway collapse, which is common in COPD. Hyperresonance on percussion is typically found in conditions like emphysema, which is a component of COPD but not characteristic of the overall disease. Bradycardia is not typical in COPD; instead, clients often exhibit tachycardia due to chronic hypoxemia. High-pitched inspiratory crackles are more commonly associated with conditions like pneumonia, not COPD.

4. During a routine prenatal visit, a nurse measures a client’s fundal height. The client is 26 weeks pregnant. What should the fundal height be?

• A. Approximately 26 cm
• B. Between 24 to 28 cm
• C. Above the umbilicus by two finger widths
• D. Below the xiphoid process

Correct answer: B

Rationale: The correct answer is B: Between 24 to 28 cm. Fundal height corresponds to the weeks of gestation, so at 26 weeks of pregnancy, the fundal height should range between 24 to 28 cm. This measurement is a quick way to assess fetal growth and amniotic fluid volume. Choice A is incorrect because fundal height may vary and not always match the exact weeks of pregnancy. Choice C, measuring above the umbilicus by two finger widths, is not a standard method for fundal height measurement. Choice D, below the xiphoid process, is too high and not relevant for assessing fundal height during pregnancy.

5. The nurse is caring for a client with a diagnosis of bipolar disorder who is taking lithium. What is the most important information the nurse should provide?

• A. Take the medication on an empty stomach.
• B. Monitor sodium intake.
• C. Report any signs of weight gain.
• D. Avoid excessive caffeine intake.

Correct answer: B

Rationale: The correct answer is B: 'Monitor sodium intake.' Sodium levels can affect lithium levels in the body, so it is crucial to maintain a consistent sodium intake to prevent toxicity or subtherapeutic levels. Option A is incorrect because lithium is usually recommended to be taken on an empty stomach to enhance absorption. Option C, reporting signs of weight gain, is relevant but not as critical as monitoring sodium intake. Option D, avoiding excessive caffeine intake, is important for some individuals but not as essential as monitoring sodium levels when taking lithium.

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