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. How should the nurse respond to an older male client who states that his religion does not permit him to bathe daily?

• A. Review the importance of hygienic measures for improved health
• B. State that the healthcare provider has prescribed a bath today
• C. Offer the client several choices of times to bathe during the day
• D. Request that the client clarify his religious beliefs about bathing

Correct answer: C

Rationale: The correct response is to offer the client several choices of times to bathe during the day. This approach respects the client's religious beliefs while ensuring that hygienic practices are still maintained. By providing options, the nurse can work together with the client to find a solution that aligns with both his beliefs and his health needs. Choice A is incorrect because solely reviewing the importance of hygiene may not address the client's specific religious concerns. Choice B is inappropriate as it disregards the client's beliefs and autonomy. Choice D is not the best approach as it may come off as confrontational or dismissive of the client's beliefs, rather than working collaboratively to find a suitable solution.

3. The nurse is caring for a client with acute pancreatitis. Which intervention should be included in the plan of care?

• A. Provide a high-protein diet
• B. Encourage oral fluids
• C. Administer intravenous fluids as prescribed
• D. Monitor for signs of hyperglycemia

Correct answer: C

Rationale: The correct intervention to include in the plan of care for a client with acute pancreatitis is to administer intravenous fluids as prescribed. Intravenous fluids are crucial to maintain hydration and electrolyte balance in clients with acute pancreatitis. Providing a high-protein diet (Choice A) is not recommended initially for clients with acute pancreatitis, as they may need to be kept NPO (nothing by mouth) to rest the pancreas. Encouraging oral fluids (Choice B) may not be appropriate if the client is experiencing severe symptoms and requires intravenous fluids. Monitoring for signs of hyperglycemia (Choice D) is important but not the immediate intervention needed to address the fluid and electrolyte imbalances associated with acute pancreatitis.

4. A client admitted to the hospital with advanced liver failure related to chronic alcoholism is exhibiting ascites and edema. Which pathophysiological mechanisms should the nurse identify as responsible for the third spacing symptoms? (Select all that apply.)

• A. Portal hypertension.
• B. Sodium and water retention.
• C. Decreased serum albumin.
• D. All of the above

Correct answer: D

Rationale: In advanced liver failure related to chronic alcoholism, ascites and edema occur due to multiple pathophysiological mechanisms. Portal hypertension contributes to the development of ascites by increasing pressure in the portal venous system. Sodium and water retention exacerbate fluid accumulation in the third space. Decreased serum albumin levels lead to reduced oncotic pressure, contributing to the movement of fluid into the interstitial spaces. Abnormal protein metabolism further disrupts fluid balance. Therefore, all of the options (A, B, and C) are correct in this scenario, making choice D the correct answer. Choices A, B, and C alone do not fully explain the comprehensive pathophysiological mechanisms involved in the development of ascites and edema in this clinical context.

5. In a community health setting, which individual is at highest risk for contracting an HIV infection?

• A. 17-year-old who is sexually active with numerous partners
• B. 34-year-old homosexual in a monogamous relationship
• C. 30-year-old cocaine user who inhales and smokes drugs
• D. 45-year-old who has received two blood transfusions in the past 6 months

Correct answer: C

Rationale: The correct answer is C. Substance abuse, particularly using shared inhalation equipment like needles and pipes for drug inhalation, significantly increases the risk of contracting HIV. Choice A, the 17-year-old with multiple sexual partners, poses a risk of HIV transmission through sexual contact, but it is lower compared to the direct risk associated with sharing drug paraphernalia. Choice B, the 34-year-old homosexual in a monogamous relationship, is at lower risk since being in a monogamous relationship reduces exposure to HIV. Choice D, the 45-year-old who received blood transfusions, is also at lower risk as blood transfusions are now screened for HIV, decreasing the likelihood of transmission through this route.

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