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. The unlicensed assistive personnel (UAP) reports to the nurse that a client refused to bathe for the third consecutive day. What action is best for the nurse to take?

• A. Ask the client why the bath was refused
• B. Ask family members to encourage the client to bathe
• C. Explain the importance of good hygiene to the client
• D. Reschedule the bath for the following day

Correct answer: A

Rationale: The correct action for the nurse to take is to ask the client why the bath was refused. Understanding the client's reasons for refusal can guide appropriate interventions, respecting client autonomy while addressing any underlying issues. Choice B is not the best course of action as involving family members may not address the client's specific concerns. Choice C, while important, may not directly address the immediate refusal to bathe. Choice D does not address the underlying reasons for the refusal and may not lead to a resolution.

3. What is the primary purpose of a chest tube in a client's care?

• A. To drain air and fluid from the pleural space
• B. To prevent infection in the thoracic cavity
• C. To assist with lung expansion
• D. To monitor intrathoracic pressure

Correct answer: A

Rationale: The correct answer is A: To drain air and fluid from the pleural space. A chest tube is primarily used to remove accumulated air or fluid in the pleural space, preventing lung collapse or compromise of lung function. This intervention aims to re-expand the lung and enhance respiratory function. Choice B is incorrect because preventing infection is not the primary purpose of a chest tube. Choice C is incorrect as lung expansion is a result of draining the pleural space, not the primary goal. Choice D is incorrect as monitoring intrathoracic pressure is not the main objective of a chest tube insertion.

4. The nurse is assessing a client with a suspected pulmonary embolism (PE). Which symptom is most indicative of this condition?

• A. Bilateral leg swelling.
• B. Sudden onset of chest pain.
• C. Gradual onset of dyspnea.
• D. Decreased breath sounds on auscultation.

Correct answer: C

Rationale: The correct answer is C: 'Gradual onset of dyspnea.' While pulmonary embolism can present with various symptoms, the most common include sudden onset of dyspnea, chest pain (often pleuritic in nature), tachypnea, and tachycardia. Bilateral leg swelling is more commonly associated with conditions like deep vein thrombosis, not pulmonary embolism. Decreased breath sounds on auscultation may be seen in conditions like pneumothorax, not typically in pulmonary embolism. Therefore, the gradual onset of dyspnea is the most indicative symptom of pulmonary embolism in this scenario.

5. 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.

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