Nursing Elites

1. A client is undergoing radiation therapy. Which of the following actions should the nurse take to prevent skin irritation?

• A. Apply heat packs to the area
• B. Use perfumed soap to cleanse the area
• C. Keep the area moist with lotion
• D. Avoid sun exposure to the treated area

Correct answer: D

Rationale: Avoiding sun exposure is crucial to prevent skin irritation and burns in clients undergoing radiation therapy. Radiation therapy makes the skin more sensitive to sunlight, increasing the risk of skin damage. Applying heat packs (choice A) can exacerbate skin irritation as heat can further irritate the skin that is already sensitive due to radiation. Using perfumed soap (choice B) can further irritate the skin due to its harsh chemicals, potentially worsening skin reactions. While keeping the area moist with lotion (choice C) may seem beneficial, some lotions contain ingredients that can worsen skin reactions during radiation therapy. Therefore, avoiding sun exposure to the treated area (choice D) is the most appropriate action to prevent skin irritation and damage during radiation therapy.

2. A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?

• A. Offer small amounts of clear liquids 6 hr following surgery.
• B. Give cromolyn nebulizer solution every 6 hr.
• C. Apply a warm compress to the operative site every 4 hr.
• D. Administer analgesics on a scheduled basis for the first 24 hr.

Correct answer: D

Rationale: Administering analgesics on a scheduled basis for the first 24 hours is crucial to ensure adequate pain control in the immediate postoperative period. Choice A is incorrect because clear liquids are typically initiated gradually and advanced as tolerated but not specifically at 6 hours post-surgery. Choice B is incorrect as cromolyn nebulizer solution is not indicated for postoperative pain management in this scenario. Choice C is incorrect as applying a warm compress may not be appropriate for the operative site after appendicitis surgery and can potentially increase the risk of infection.

3. What is the correct procedure for taking a telephone order from a provider?

• A. State patient name, drug, dose, route, frequency, and read back the order
• B. State the medication and ask for a witness to listen to the order
• C. Write down the order and verify with the provider within 12 hours
• D. Have the provider verify the order during the next in-person visit

Correct answer: A

Rationale: The correct procedure for taking a telephone order from a provider is to state the patient's name, drug, dose, route, frequency, and then read back the order to ensure accuracy. This process helps in preventing errors and ensures that all relevant information is correctly documented. Choice B is incorrect because having a witness listen to the order is not a standard practice and may not guarantee accuracy. Choice C is incorrect as verifying the order within 12 hours may lead to delays in patient care. Choice D is incorrect because waiting for the provider to verify the order during the next in-person visit could result in a significant delay in administering necessary medication.

4. A healthcare provider is collecting data from a client who has multiple sclerosis. Which of the following findings should the healthcare provider expect?

• A. Fever
• B. Ataxia
• C. Nystagmus
• D. Fatigue

Correct answer: B

Rationale: Ataxia, which refers to difficulty with coordination, is a common symptom seen in individuals with multiple sclerosis. Nystagmus, the involuntary eye movement, can also occur in multiple sclerosis but is not as common as ataxia. Fatigue is a common symptom in multiple sclerosis, but ataxia is more specific. Fever is not a typical finding associated with multiple sclerosis.

5. A client has a history of oliguria, hypertension, and peripheral edema. Current lab values are: BUN - 25, K+ - 4.0 mEq/L. Which nutrient should be restricted in the client's diet?

• A. Protein
• B. Fats
• C. Carbohydrates
• D. Magnesium

Correct answer: A

Rationale: In clients with oliguria, hypertension, and peripheral edema, protein should be restricted in the diet to reduce the workload on the kidneys. Excessive protein intake can lead to increased BUN levels, which can further stress the kidneys. Restricting protein can help prevent further kidney damage. Fats, carbohydrates, and magnesium do not directly impact kidney function in the same way as protein does, making them incorrect choices in this scenario.

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