Nursing Elites

1. When a client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer, which of the following should take priority in planning care?

• A. Esophagitis
• B. Leukopenia
• C. Fatigue
• D. Skin irritation

Correct answer: B

Rationale: Leukopenia should take priority in planning care for a client receiving external beam radiation to the mediastinum for bronchial cancer because it is a serious side effect that increases the risk of infection. Monitoring leukopenia is crucial to prevent complications. Esophagitis, fatigue, and skin irritation are also potential side effects of radiation therapy, but leukopenia poses a higher risk of life-threatening infections, requiring immediate attention.

2. A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to

• A. have the client identify coping methods
• B. get the description of the location and intensity of the pain
• C. accept the client's report of pain
• D. determine the client's status of pain

Correct answer: B

Rationale: The correct answer is B: 'get the description of the location and intensity of the pain.' When a client complains of pain, the initial step in pain assessment is to gather information about the location and intensity of the pain. This helps the nurse understand the nature of the pain and lays the groundwork for further assessment and management. Choice A is incorrect because identifying coping methods comes later in the assessment process. Choice C is incorrect as accepting the client's report of pain is important, but not the first step. Choice D is incorrect as determining the client's pain status also comes after gathering information about the pain.

3. What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?

• A. Presence of blood in stools
• B. Oozing liquid stool
• C. Continuous rumbling flatulence
• D. Absence of bowel movements

Correct answer: B

Rationale: The correct answer is B: 'Oozing liquid stool.' In a paralyzed client, oozing liquid stool is a common sign of fecal impaction. This occurrence requires prompt intervention to prevent complications. Choice A, 'Presence of blood in stools,' is more indicative of gastrointestinal bleeding rather than fecal impaction. Choice C, 'Continuous rumbling flatulence,' is associated with gas movement in the intestines and not specifically linked to fecal impaction. Choice D, 'Absence of bowel movements,' could be a sign of constipation but does not directly point towards fecal impaction.

4. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these?

• A. Apply appropriate signs outside and inside the room
• B. Apply a mask with a shield if there is a risk of fluid splash
• C. Wear a gown to change soiled linens from incontinence
• D. Have gloves on while handling bedpans with feces

Correct answer: D

Rationale: The correct answer is to have gloves on while handling bedpans with feces. Hepatitis A is transmitted through the fecal-oral route, and using gloves during such direct contact with feces is crucial in preventing the transmission of the infection. Choice A is not directly related to infection control for hepatitis A. Choice B is more relevant to preventing droplet transmission rather than fecal-oral transmission. Choice C is important for preventing contact transmission from soiled linens but is not as directly related to the mode of transmission of hepatitis A as using gloves when handling feces.

5. Which bed position is preferred for use with a client in an extended care facility on a falls risk prevention protocol?

• A. All 4 side rails up, wheels locked, bed closest to door
• B. Lower side rails up, bed facing the doorway
• C. Knees bent, head slightly elevated, bed in the lowest position
• D. Bed in the lowest position, wheels locked, place bed against the wall

Correct answer: D

Rationale: The correct answer is D. Placing the bed in the lowest position, ensuring wheels are locked, and positioning it against the wall is the preferred bed position for a client in an extended care facility on a falls risk prevention protocol. This setup helps minimize the risk of falls by providing a stable and secure environment. Choices A, B, and C do not address key factors such as having the bed in the lowest position and placing it against the wall, which are crucial in preventing falls in such a setting.

Similar Questions