Nursing Elites

1. When giving an intramuscular injection to an infant, which of the following sites is preferred?

• A. Ventrogluteal region
• B. Deltoid
• C. Vastus lateralis
• D. Dorsogluteal region

Correct answer: C

Rationale: The correct answer is the Vastus lateralis when giving an intramuscular injection to an infant. The Vastus lateralis muscle, located in the thigh, is the preferred site for infants as it has a larger muscle mass and is well-developed, making it suitable for injections. The Ventrogluteal region and Dorsogluteal region are not recommended for infants due to their smaller muscle mass and potential risk of damaging nearby structures. The Deltoid muscle is typically used for older children and adults, not infants.

2. The client is preparing to undergo a total hysterectomy for advanced cervical cancer. The client is crying and says that she wants to have more children and is unsure if she should have the procedure. What should the nurse do?

• A. Allow the client to honestly discuss her fears and encourage her to talk more with her physician.
• B. Tell her the good things that she will be able to do without more children and encourage her to make a list of positive things.
• C. Explain to the client that her ovaries can be frozen for egg harvesting at a later time and she can find a surrogate.
• D. Advise the client to put off having the surgery until she is sure that she wants to undergo the procedure and notify the surgeon of the decision.

Correct answer: A

Rationale: In this situation, the most appropriate action for the nurse is to allow the client to express her fears and concerns openly. By encouraging her to talk more with her physician, the nurse is promoting effective communication and ensuring that the client receives adequate information to make an informed decision. Option A is correct because it acknowledges the client's emotions and empowers her to seek clarification and support from her healthcare provider. Options B and C do not address the client's emotional needs or provide a solution to her concerns regarding fertility. Option D is not appropriate as it does not prioritize the client's emotional well-being and delays necessary medical treatment for advanced cervical cancer.

3. A high school nurse observes a 14-year-old female rubbing her scalp excessively in the gym. What is the most appropriate course of action for the nurse?

• A. Request the female’s parents for a private evaluation of her scalp
• B. Contact the female’s parents regarding the observations
• C. Observe the hairline and scalp for possible signs of lice
• D. Inform the student’s physician about the situation

Correct answer: C

Rationale: The most appropriate course of action for the nurse is to observe the hairline and scalp for possible signs of lice. The student's behavior of excessively rubbing her scalp raises concerns about a potential infestation, making it necessary to look for signs firsthand. Contacting the parents or the physician should be considered after observing for signs of lice to provide more information and take appropriate action. Requesting a private evaluation from the parents may not be required initially, as lice infestation is a common concern among children and observing for signs is the immediate step to address the situation.

4. Is head lag expected to be resolved by 4 months of age? Continuing head lag at 6 months of age may indicate?

• A. Dizziness and orthostatic hypotension.
• B. Nausea, vomiting, diarrhea, or constipation, and stomach cramps.
• C. Drowsiness, lethargy, and fatigue.
• D. Neuropathy and tingling in the extremities.

Correct answer: B

Rationale: Head lag is a developmental milestone that should be resolved by 4 months of age. Continuing head lag at 6 months of age may indicate potential developmental delays or muscle weakness. The correct answer, 'Nausea, vomiting, diarrhea, or constipation, and stomach cramps,' reflects symptoms that could be associated with developmental delays or underlying health conditions. Dizziness and orthostatic hypotension (Choice A) are unlikely to be directly related to head lag. Choices C and D present symptoms that are unrelated to the issue of continued head lag at 6 months of age.

5. On morning rounds, the nurse finds a somnolent client with a Blood glucose of 89 mg/dL. A sulfonurea and a proton pump inhibitor are scheduled to be administered. What is the nurse's best action?

• A. Give the proton pump inhibitor and hold the sulfonurea until the client eats
• B. Hold medications and notify the physician
• C. Arouse the client and give some orange juice with sugar packets added
• D. Give the medications as ordered and re-check blood sugar in one hour

Correct answer: A

Rationale: The correct action is to give the proton pump inhibitor and hold the sulfonurea until the client eats. Sulfonureas should be held for blood glucose levels below 100 mg/dL until the client has food to prevent hypoglycemia. Giving the proton pump inhibitor is appropriate and does not need to be delayed. Option B is incorrect because holding both medications without taking appropriate action may lead to further complications. Option C is not the best choice as it does not address the need to hold the sulfonurea until the client eats. Option D is incorrect because administering the medications without ensuring the client eats may lead to hypoglycemia.

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