Nursing Elites

1. A nurse is caring for a client who is receiving radiation therapy. Which of the following side effects should the nurse monitor for?

• A. Fatigue
• B. Hair loss
• C. Nausea
• D. Dry mouth

Correct answer: D

Rationale: The correct answer is D, dry mouth. Dry mouth is a common side effect of radiation therapy due to damage to the salivary glands. It is essential for the nurse to monitor for this condition as it can lead to oral health issues and discomfort. Fatigue (choice A) is a common side effect of radiation therapy, but in this case, dry mouth is a more specific side effect to monitor for. Hair loss (choice B) is more commonly associated with chemotherapy rather than radiation therapy. Nausea (choice C) is also a common side effect of radiation therapy, but dry mouth is a more direct effect of the treatment that the nurse should focus on monitoring.

2. A client with heart failure is receiving a continuous IV infusion of milrinone. Which of the following actions should the nurse take?

• A. Monitor the client's blood pressure continuously
• B. Weigh the client daily
• C. Monitor the infusion site for signs of infiltration
• D. Measure the client's intake and output every 2 hours

Correct answer: D

Rationale: Measuring the client's intake and output every 2 hours is essential when caring for a client receiving a continuous IV infusion of milrinone. Milrinone is a medication that affects fluid balance, and monitoring intake and output helps assess the client's response to the medication. Continuous monitoring of blood pressure may not be necessary unless there is a specific indication. While weighing the client daily is important for overall assessment, measuring intake and output more frequently provides more real-time data for fluid balance evaluation. Monitoring the infusion site is crucial for detecting infiltration but is not directly related to managing fluid balance in this situation.

3. A nurse is reviewing the medical record of a client who has thrombocytopenia. Which of the following actions should the nurse include in the care plan?

• A. Encourage the client to floss daily.
• B. Remove fresh flowers from the client's room.
• C. Provide the client with a stool softener.
• D. Avoid serving raw vegetables.

Correct answer: C

Rationale: The correct action the nurse should include in the care plan for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is a condition characterized by a low platelet count, which can lead to increased risk of bleeding. Stool softeners help prevent straining during bowel movements, which can reduce the risk of bleeding in individuals with thrombocytopenia. Encouraging the client to floss daily (Choice A) is unrelated to managing thrombocytopenia. Removing fresh flowers from the client's room (Choice B) is more related to infection control rather than managing thrombocytopenia. Avoiding serving raw vegetables (Choice D) is more about reducing the risk of infection rather than managing thrombocytopenia.

4. A nurse is planning to administer a blood transfusion to a client. Which of the following should the nurse do to prevent an adverse transfusion reaction?

• A. Verify the client's blood type with the provider's prescription
• B. Ensure the client's consent for the transfusion is on file
• C. Administer a diuretic prior to starting the transfusion
• D. Check the client's temperature prior to the transfusion

Correct answer: A

Rationale: The correct answer is to verify the client's blood type with the provider's prescription. This is crucial to prevent an adverse transfusion reaction due to incompatibility. Ensuring the blood type matches before starting the transfusion is a standard safety practice. Option B, ensuring client consent, is important but not directly related to preventing a transfusion reaction. Option C, administering a diuretic, is unnecessary and can be harmful in this context. Option D, checking the client's temperature, is important for general assessment but not specifically focused on preventing a transfusion reaction.

5. A client is prescribed furosemide and needs to consume potassium-rich foods. Which of the following foods should the client be advised to include in the diet?

• A. Grapes.
• B. Apples.
• C. Bananas.
• D. Rice.

Correct answer: C

Rationale: The correct answer is C: Bananas. Bananas are rich in potassium and should be included in the diet of clients taking furosemide, a potassium-wasting diuretic. Grapes, apples, and rice are not as high in potassium as bananas and would not be as effective in replenishing potassium levels in clients taking furosemide.

Similar Questions