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 has a new prescription for levothyroxine. Which of the following statements should the nurse include?

• A. Take this medication with food to prevent nausea.
• B. Take this medication in the morning to prevent insomnia.
• C. You should store this medication in the refrigerator.
• D. Take this medication with a full glass of water before breakfast.

Correct answer: D

Rationale: The correct statement the nurse should include is to take levothyroxine with a full glass of water before breakfast. This helps improve absorption and prevents gastrointestinal side effects. Choice A is incorrect because levothyroxine should be taken on an empty stomach. Choice B is incorrect as insomnia is not a common side effect of levothyroxine. Choice C is also incorrect as levothyroxine does not need to be refrigerated.

3. A client has Clostridium difficile infection. Which of the following actions should the nurse take?

• A. Wash hands with an alcohol-based hand rub.
• B. Place the client on contact precautions.
• C. Wear a mask when entering the client's room.
• D. Double-bag all linens before removing them from the room.

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with Clostridium difficile infection is to place the client on contact precautions. This helps prevent the spread of the infection to other clients. Washing hands with an alcohol-based hand rub is important for infection control but is not specific to preventing the spread of Clostridium difficile. Wearing a mask may be necessary for airborne precautions but is not the priority for Clostridium difficile infection. Double-bagging linens is not a standard practice for preventing the spread of Clostridium difficile.

4. During a change-of-shift report, a nurse is receiving information about an adult female client who is postoperative. Which of the following client information should the nurse report?

• A. The client's oxygen saturation is 95%
• B. The client's blood pressure is 110/70 mm Hg
• C. The client has a temperature of 36.8°C (98.2°F)
• D. The client's heart rate is 88/min

Correct answer: B

Rationale: The correct answer is B because a blood pressure of 110/70 mm Hg is within the normal range and stable. Reporting this information is crucial to monitor the client's condition postoperatively. Oxygen saturation of 95% is acceptable, a temperature of 36.8°C (98.2°F) is normal, and a heart rate of 88/min is within the expected range for an adult female client, so these values do not raise concerns that require immediate reporting.

5. A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?

• A. Clamp the chest tube for 15 minutes every 2 hours.
• B. Empty the drainage collection chamber when it is half full.
• C. Keep the drainage system below the level of the client's chest.
• D. Strip the chest tube every 2 hours to maintain patency.

Correct answer: C

Rationale: The correct action the nurse should take when caring for a client with a chest tube is to keep the drainage system below the level of the client's chest. This positioning helps prevent fluid from flowing back into the pleural space, ensuring proper drainage and effective functioning of the chest tube. Clamping the chest tube intermittently or stripping it frequently can lead to complications and should be avoided. Emptying the drainage collection chamber at specific intervals may vary based on institutional protocols, but it should be done when it is no more than two-thirds full to prevent backflow and maintain accurate monitoring of drainage output.

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