Nursing Elites

1. A nurse is reviewing the plan of care for a client undergoing radiation therapy for cancer. Which of the following instructions should the nurse reinforce with the client?

• A. Apply sunscreen before going outside
• B. Avoid using perfumed lotions
• C. Massage the area daily
• D. Take vitamin supplements with food

Correct answer: B

Rationale: The correct instruction the nurse should reinforce with the client undergoing radiation therapy is to avoid using perfumed lotions. This is essential to reduce the risk of skin irritation, as perfumed lotions can exacerbate skin reactions during radiation therapy. Applying sunscreen before going outside is generally a good practice but not specifically related to radiation therapy. Massaging the area daily is contraindicated during radiation therapy as it can further irritate the skin. Taking vitamin supplements with food is important for overall health but is not a specific instruction related to radiation therapy.

2. What advice should be given to a client experiencing constipation?

• A. Encourage the client to drink water frequently
• B. Increase dietary fiber to relieve constipation
• C. Administer a laxative to relieve discomfort
• D. Encourage the client to increase physical activity

Correct answer: B

Rationale: The correct advice to give to a client experiencing constipation is to increase dietary fiber. Dietary fiber helps relieve constipation by promoting regular bowel movements. Encouraging the client to drink water frequently (Choice A) is also important for overall bowel health, but increasing dietary fiber is more directly related to relieving constipation. Administering a laxative (Choice C) should not be the first-line recommendation and should only be considered if dietary and lifestyle changes do not work. Encouraging the client to increase physical activity (Choice D) can be beneficial for overall health but may not directly address the issue of constipation.

3. A client is receiving furosemide. Which of the following laboratory values should the nurse monitor?

• A. Sodium
• B. Potassium
• C. Calcium
• D. Magnesium

Correct answer: B

Rationale: The correct answer is B: Potassium. Furosemide is a loop diuretic that can cause potassium depletion through increased urinary excretion. Monitoring potassium levels is crucial to prevent hypokalemia, which can lead to cardiac dysrhythmias, muscle weakness, and other serious complications. Monitoring sodium, calcium, and magnesium levels is not typically associated with furosemide therapy, making choices A, C, and D incorrect.

4. A nurse has administered medications to a group of clients. For which of the following client situations should the nurse complete an incident report?

• A. Administering acetaminophen to an NPO client
• B. Administering insulin lispro to an NPO client
• C. Administering medication to the incorrect client
• D. Administering anticoagulants without checking INR

Correct answer: B

Rationale: The correct answer is B because administering insulin lispro to an NPO client can lead to hypoglycemia due to the lack of food to balance the medication. This situation poses a serious risk to the client's safety and should be documented in an incident report. Choice A is not as critical as insulin administration for an NPO client. Choice C is also serious but does not pose an immediate risk to the client's health. Choice D, administering anticoagulants without checking the INR, is important but does not require an incident report unless adverse effects occur, as it may not immediately endanger the client's life.

5. 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.

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