Nursing Elites

1. A nurse is caring for a client receiving radiation treatments for cancer. The client states he is experiencing dryness, redness, and scaling at the treatment area. Which of the following should the nurse instruct the client to do?

• A. Sit in the sun for 15 minutes per day.
• B. Apply moist heat to the area twice daily.
• C. Liberally apply prescribed lotion to the area.
• D. Wash the affected area daily with antimicrobial soap.

Correct answer: C

Rationale: The nurse should instruct the client to liberally apply prescribed lotion to the treatment area. Prescribed hydrating lotions help soothe and protect irradiated skin, reducing dryness, redness, and scaling. Sitting in the sun can further damage the skin. Applying moist heat may exacerbate the skin condition. Washing the area with antimicrobial soap can be too harsh and further irritate the skin.

2. A nurse is assessing a client 2 hours after a vaginal delivery and notes that the client's uterus is boggy and displaced to the right. Which of the following interventions should the nurse perform first?

• A. Assist the client to void
• B. Massage the uterus
• C. Administer oxytocin
• D. Encourage breastfeeding

Correct answer: A

Rationale: A boggy and displaced uterus is often a sign of bladder distention, which can prevent the uterus from contracting effectively. The priority intervention is to assist the client to void. By emptying the bladder, the uterus can return to midline and become firm. Massaging the uterus or administering oxytocin may be necessary but should come after addressing the bladder distention. Encouraging breastfeeding is important for uterine contraction but is not the priority in this situation.

3. A nurse is planning a staff education session regarding biological weapons of mass destruction. What should the nurse include in the session?

• A. Rabies, cholera, meningitis
• B. Smallpox, anthrax, botulism
• C. Ebola, hepatitis B, tetanus
• D. Tuberculosis, influenza, measles

Correct answer: B

Rationale: The correct answer is B: Smallpox, anthrax, botulism. These are known biological weapons that can be used in mass casualty situations. Rabies, cholera, and meningitis (Choice A) are not typically used as biological weapons. Ebola, hepatitis B, and tetanus (Choice C) are serious diseases but are not commonly associated with biological warfare. Tuberculosis, influenza, and measles (Choice D) are infectious diseases but are not typically used as biological weapons of mass destruction.

4. A nurse is caring for a client in preterm labor who is receiving magnesium sulfate. Which of the following is an indication of magnesium toxicity?

• A. Blood glucose of 160 mg/dL
• B. Urine output of 20 mL/hour
• C. Systolic BP of 140 mm Hg
• D. Respiratory rate of 20/min

Correct answer: B

Rationale: The correct answer is B: Urine output of 20 mL/hour. Urine output below 30 mL/hour is a sign of magnesium toxicity due to the risk of accumulation in the body. Choices A, C, and D are not indicative of magnesium toxicity. Elevated blood glucose, systolic blood pressure, and normal respiratory rate are not specific signs of magnesium toxicity.

5. A client has been prescribed phenytoin. Which of the following should the nurse monitor to prevent toxicity?

• A. Blood pressure
• B. Complete blood count
• C. Serum phenytoin levels
• D. Liver function tests

Correct answer: C

Rationale: Corrected Rationale: Serum phenytoin levels should be regularly monitored to prevent toxicity because the therapeutic range is narrow. Monitoring blood pressure (choice A), complete blood count (choice B), and liver function tests (choice D) are not directly related to preventing phenytoin toxicity.

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