Nursing Elites

1. A nurse is providing teaching to a client who has a new prescription for nitroglycerin transdermal patches. Which of the following instructions should the nurse include?

• A. Apply the patch to your upper arm.
• B. You should remove the patch before showering.
• C. Rotate the patch site each time you apply it.
• D. Apply the patch to your lower abdomen.

Correct answer: C

Rationale: The correct answer is to instruct the client to rotate the patch site each time they apply it. This practice helps prevent skin irritation and ensures the effectiveness of nitroglycerin transdermal patches. Applying the patch to the same site each time can lead to skin irritation and decreased patch efficacy. Choices A, B, and D are incorrect because applying the patch to the upper arm, removing it before showering, and placing it on the lower abdomen do not promote proper rotation of patch sites, which is essential for optimal outcomes.

2. A client is receiving radiation therapy to the head and neck. Which of the following interventions should the nurse include?

• A. Instruct the client to use an alcohol-free mouthwash.
• B. Apply heat packs to the radiation site.
• C. Provide a diet low in carbohydrates.
• D. Avoid exposure to direct sunlight during treatment.

Correct answer: D

Rationale: The correct intervention for a client receiving radiation therapy to the head and neck is to avoid exposure to direct sunlight. Direct sunlight should be avoided to protect the skin from further irritation and damage caused by the radiation therapy. Instructing the client to use an alcohol-free mouthwash is important to prevent irritation and maintain oral hygiene, making choice A incorrect. Applying heat packs to the radiation site is contraindicated as heat can further aggravate the skin, making choice B incorrect. Providing a diet low in carbohydrates is not directly related to radiation therapy to the head and neck, so choice C is also incorrect.

3. A nurse is planning care for a client who has a new prescription for a peripheral intravenous (IV) catheter. Which of the following actions should the nurse take to prevent infection?

• A. Shave the hair at the insertion site.
• B. Cleanse the site with povidone-iodine.
• C. Wear sterile gloves when changing the dressing.
• D. Change the IV site every 48 to 72 hours.

Correct answer: D

Rationale: The correct action to prevent infection when caring for a client with a new peripheral IV catheter is to change the IV site every 48 to 72 hours. Shaving the hair at the insertion site can actually increase the risk of infection by causing microabrasions in the skin. While cleansing the site with povidone-iodine is important before insertion, it is not necessary to continue doing so once the IV is in place. Wearing sterile gloves when changing the dressing is crucial for maintaining aseptic technique but does not directly prevent infection related to the IV site itself.

4. What is the initial step when a patient is experiencing chest pain?

• A. Administer oxygen
• B. Reposition the patient
• C. Provide pain relief
• D. Provide nitroglycerin

Correct answer: A

Rationale: Administering oxygen is the initial step in managing chest pain. Oxygen helps improve oxygenation levels in the blood, which is crucial in cases of chest pain. Repositioning the patient, providing pain relief, or administering nitroglycerin may be necessary steps depending on the underlying cause, but administering oxygen takes precedence as it addresses the primary concern of oxygen supply to the body during chest pain.

5. A client has thrombocytopenia. What action should the nurse include?

• 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 for the nurse when caring for a client with thrombocytopenia is to provide the client with a stool softener. Thrombocytopenia is characterized by a low platelet count, leading to increased bleeding tendencies. Providing a stool softener helps prevent constipation, reducing the likelihood of straining during bowel movements and subsequent bleeding. Encouraging the client to floss daily (choice A) is unrelated to managing thrombocytopenia. Removing fresh flowers from the client's room (choice B) pertains more to infection control than addressing thrombocytopenia. Avoiding serving raw vegetables (choice D) is not directly associated with managing thrombocytopenia symptoms.

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