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. How should a healthcare professional assess a patient with fluid overload?

• A. Monitor weight and assess for edema
• B. Monitor blood pressure and auscultate lung sounds
• C. Assess for jugular venous distention
• D. Monitor oxygen saturation and check for fluid retention

Correct answer: A

Rationale: The correct way to assess a patient with fluid overload is by monitoring weight and assessing for edema. Weight monitoring helps in detecting fluid retention, and edema is a visible sign of excess fluid accumulation. Although monitoring blood pressure and auscultating lung sounds are important assessments in heart failure, they are not specific to fluid overload. Assessing for jugular venous distention is more indicative of right-sided heart failure rather than fluid overload. Monitoring oxygen saturation and checking for fluid retention are not primary assessments for fluid overload.

3. How should a healthcare provider manage a patient with pneumonia?

• A. Administer antibiotics and provide oxygen therapy
• B. Provide bronchodilators and encourage deep breathing
• C. Administer fluids and encourage bed rest
• D. Monitor for chest pain and provide pain relief

Correct answer: A

Rationale: Correct answer: Administering antibiotics and providing oxygen therapy are essential in managing pneumonia. Antibiotics help treat the infection caused by bacteria, while oxygen therapy improves lung function. Choice B is incorrect because bronchodilators may not be the primary treatment for pneumonia. Choice C is not the priority in pneumonia management, although fluids and rest are important for recovery. Choice D is also not a primary intervention in pneumonia management.

4. What are the early signs of heart failure in a patient?

• A. Shortness of breath and weight gain
• B. Fatigue and chest pain
• C. Nausea and vomiting
• D. Cough and elevated blood pressure

Correct answer: A

Rationale: The correct answer is A: Shortness of breath and weight gain. Early signs of heart failure typically manifest as shortness of breath due to fluid accumulation in the lungs and weight gain due to fluid retention in the body. Choices B, C, and D are incorrect. Fatigue and chest pain are symptoms commonly associated with heart conditions but are not specific early signs of heart failure. Nausea and vomiting are not typically early signs of heart failure. Cough can be a symptom of heart failure, but it is usually associated with other symptoms like shortness of breath rather than being an isolated early sign. Elevated blood pressure is not an early sign of heart failure; in fact, heart failure is more commonly associated with low blood pressure.

5. While performing assessments on newborns in the nursery, which finding should the nurse report to the provider?

• A. A two-day old newborn with a respiratory rate of 70.
• B. A 16-hour old newborn who has not passed meconium yet.
• C. A two-day old newborn with a small amount of blood-tinged vaginal discharge.
• D. A 16-hour old newborn with a blood glucose of 45 mg/dL.

Correct answer: A

Rationale: A respiratory rate of 70 in a two-day old newborn is above the normal range and should be reported to the provider. This finding may indicate respiratory distress or another underlying issue that needs prompt attention. Choices B, C, and D are within normal limits for newborns and do not require immediate reporting to the provider.

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