a client is receiving external radiation therapy for lung cancer which intervention is most important for the nurse to include in the clients plan of
Logo

Nursing Elites

HESI RN

HESI Fundamentals

1. A client is receiving external radiation therapy for lung cancer. Which intervention is most important for the nurse to include in the client's plan of care?

Correct answer: C

Rationale: Instructing the client to avoid using deodorant on the skin near the radiation site (C) is crucial to prevent skin irritation and potential adverse reactions during external radiation therapy. Sunscreen (A), heating pad (B), and dietary changes (D) are less pertinent in this situation.

2. When is the first dose of Hepatitis B vaccine typically administered?

Correct answer: A

Rationale: The first dose of the Hepatitis B vaccine is usually administered at birth in the hospital to provide early protection against the virus. Giving the vaccine at birth helps prevent perinatal transmission of Hepatitis B from an infected mother to her newborn. This early administration is crucial in establishing immunity in infants, as delaying the vaccine increases the risk of infection. Options B, C, and D are incorrect because delaying the administration of the Hepatitis B vaccine can leave infants vulnerable to the virus during the critical early months of life when they are most susceptible.

3. In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible?

Correct answer: A

Rationale: The correct answer is A: Daily black, sticky stool. Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the health care provider promptly. This finding indicates the presence of digested blood in the stool. Choices B, C, and D describe variations of normal stool color and consistency, which do not raise immediate concerns related to gastrointestinal bleeding.

4. 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?

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.

5. The healthcare professional is monitoring a client receiving IV potassium chloride. Which assessment finding should prompt the healthcare professional to immediately stop the infusion?

Correct answer: B

Rationale: An irregular heart rate is a critical sign of hyperkalemia, a serious condition that can lead to life-threatening cardiac arrhythmias. Stopping the infusion promptly is crucial to prevent further complications. The healthcare professional should inform the healthcare provider immediately for further evaluation and management. Choice A is incorrect because pain at the IV site is common and may not necessitate stopping the infusion. Choice C is incorrect as swelling at the IV site may indicate a local reaction but is not a reason to stop the infusion. Choice D is incorrect as an elevated blood pressure alone is not a direct indication to stop the infusion of IV potassium chloride.

Similar Questions

The healthcare provider is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition?
Upon admission, a female client with breast cancer, liver, and spine metastases presents with constant, severe pain despite the continuous use of oxycodone (Percodan) and amitriptyline (Elavil) at home for pain management. What information is most crucial for the nurse to gather during the admission assessment?
An adult has a coagulation time of 20 minutes. The nurse should observe the client for which of the following?
You are assigned to teach a student how to suction an adult patient with a tracheostomy. Which of the following actions by the student would be incorrect?
A client with chronic kidney disease is receiving peritoneal dialysis. Which assessment finding should the nurse report to the healthcare provider immediately?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses