Nursing Elites

1. A patient is receiving discharge teaching for esophageal cancer and starting radiation therapy. What instruction should the healthcare provider include?

• A. Remove dye markings after each radiation treatment
• B. Apply a warm compress to the irradiated site
• C. Wear clothing over the area of radiation treatment
• D. Use a washcloth to bathe the treatment area

Correct answer: C

Rationale: The correct instruction for a patient starting radiation therapy for esophageal cancer is to wear clothing over the area of radiation treatment. This helps to prevent irritation and protect the skin. Removing dye markings after each treatment (choice A) is unnecessary and not typically part of the patient's self-care. Applying a warm compress (choice B) can exacerbate skin irritation caused by radiation. Using a washcloth to bathe the treatment area (choice D) can potentially irritate the skin further, making it important to avoid.

2. A client is found on the floor of their room experiencing a seizure. Which action is the nurse's priority?

• A. Restrain the client
• B. Place the client on their side with their head forward
• C. Perform a neurological assessment
• D. Monitor the client's vitals every 2 minutes

Correct answer: B

Rationale: During a seizure, the priority action for the nurse is to place the client on their side with their head forward. This position helps maintain an open airway and prevents aspiration of fluids or secretions. Restraint should never be used during a seizure as it can cause harm to the client. Performing a neurological assessment is important but not the immediate priority during an active seizure. While monitoring vitals is essential, ensuring the client's airway is clear takes precedence.

3. A client has been prescribed albuterol. Which of the following is a priority adverse effect the nurse should monitor?

• A. Tachycardia
• B. Bradycardia
• C. Dizziness
• D. Hypertension

Correct answer: A

Rationale: Corrected Rationale: Albuterol, a beta-2 adrenergic agonist, can lead to tachycardia due to its stimulant effect on beta-2 receptors in the heart. Monitoring for tachycardia is crucial as it can be a sign of excessive sympathetic stimulation and may lead to severe complications. Bradycardia, dizziness, and hypertension are less likely adverse effects of albuterol, making them lower priority for monitoring in this context.

4. A client receiving IV moderate (conscious) sedation with midazolam has a respiratory rate of 9/min and is not responding to commands. Which of the following is an appropriate action by the nurse?

• A. Place the client in a prone position
• B. Implement positive pressure ventilation
• C. Perform nasopharyngeal suctioning
• D. Administer flumazenil

Correct answer: D

Rationale: In this scenario, the client is showing signs of respiratory depression and central nervous system depression due to midazolam sedation. Administering flumazenil is the correct action as it is the antidote for midazolam, a benzodiazepine, and can reverse the sedative effects to restore respiratory function. Placing the client in a prone position (choice A) may worsen respiratory compromise. Implementing positive pressure ventilation (choice B) is not the first-line intervention for sedation-related respiratory depression. Performing nasopharyngeal suctioning (choice C) is not indicated as there are no signs of airway obstruction requiring suctioning.

5. A nurse is caring for a client receiving anticoagulation therapy. Which of the following should the nurse monitor?

• A. INR levels
• B. Blood glucose
• C. Serum creatinine
• D. Liver function

Correct answer: A

Rationale: Corrected Rationale: When caring for a client receiving anticoagulation therapy, the nurse should monitor the INR levels. INR (International Normalized Ratio) reflects the blood's ability to clot properly. It is crucial to monitor INR levels to ensure the anticoagulation therapy is within the therapeutic range and to prevent bleeding complications. Monitoring blood glucose levels (Choice B) is more relevant for clients with diabetes or those on medications affecting blood sugar. Serum creatinine (Choice C) is typically monitored to assess kidney function. Liver function (Choice D) is assessed through tests like AST, ALT, and bilirubin levels, and it is more relevant for assessing liver health rather than monitoring anticoagulation therapy.

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