Nursing Elites

1. The client is being taught how to self-administer a subcutaneous injection. To ensure sterility of the procedure, which subject is most important for the instructor to include in the teaching plan?

• A. Hand washing before preparing the injection.
• B. Technique for drawing medication from a vial.
• C. Selection and rotation of injection sites.
• D. Proper disposal of injection equipment.

Correct answer: B

Rationale: To maintain the sterility of the procedure, it is crucial to teach the client the correct technique for drawing medication from a vial. This ensures that the medication remains sterile during preparation and administration. While hand washing, injection site selection, and equipment disposal are important aspects of injection safety, the key focus should be on maintaining the sterility of the medication itself to prevent infections and ensure the effectiveness of the treatment.

2. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most beneficial?

• A. Ask the wife how she would like to participate in the client’s care.
• B. Provide the wife with information about hospice.
• C. Encourage the wife to visit during and after painful treatments are completed.
• D. Refer the wife to a support group for family members of those dying of cancer.

Correct answer: A

Rationale: During this challenging time of dealing with a terminal cancer diagnosis, involving the wife in the care process can be highly beneficial. By asking the wife how she would like to participate in the client’s care, it allows her to feel more in control and connected. This approach fosters a collaborative care environment, ensuring that the wife's preferences and needs are taken into consideration. Providing information about hospice (choice B) may be premature at this stage and could potentially overwhelm the family. Encouraging the wife to visit during and after painful treatments (choice C) may not address her need for involvement in decision-making. Referring the wife to a support group (choice D) is helpful but may not directly involve her in the care process of her husband.

3. A postoperative client has three different PRN analgesics prescribed for varying levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What action should the nurse take first?

• A. Assess for side effects of the medication.
• B. Document the client’s responses.
• C. Complete a medication error report.
• D. Determine if the pain was relieved.

Correct answer: A

Rationale: In the scenario where a nurse administers a medication outside the prescribed parameters, the immediate action should be to assess the client for any potential side effects of the medication. This is crucial to ensure the client's safety and well-being. By promptly assessing for side effects, the nurse can address any adverse reactions promptly and provide necessary interventions. Once the client's safety is ensured, documenting the client's responses, completing a medication error report, and assessing pain relief can follow as part of the broader response to the medication error. Choice B is not the first priority because the immediate concern is the potential harm from the incorrect dose. Choice C is also important but comes after ensuring the client's safety. Choice D focuses on the outcome rather than the immediate need to address any side effects of the medication.

4. While the nurse is discharging an adult woman who was hospitalized for 6 days for treatment of pneumonia and reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement?

• A. Instruct the client to repeat the medication plan
• B. Encourage the client to take a PRN antianxiety drug
• C. Provide written instructions that are easy to follow
• D. Include a family member in the teaching session

Correct answer: A

Rationale: In this situation, the most important action for the nurse to implement is to instruct the client to repeat the medication plan. By using the teach-back method, the nurse can ensure the client's understanding of the prescribed medications and address any concerns or anxieties the client may have. This approach promotes patient engagement, active participation, and retention of important information, ultimately enhancing medication adherence and safety.

5. During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report?

• A. The occurrence of any episodes of sleep apnea
• B. The child's blood pressure, pulse, and respirations
• C. Length of rapid eye movement (REM) sleep that the child is experiencing
• D. Description of the family's home environment

Correct answer: D

Rationale: In response to the mother's report, the nurse should assess the family's home environment first to identify any factors that may hinder the establishment of bedtime routines conducive to sleep. Factors such as noise, light, distractions, or other environmental aspects could be contributing to the child's difficulty falling asleep at a reasonable hour and waking up in the morning.

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