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. A client with dementia is at risk of falling. What is the best intervention to prevent injury?

• A. Place the client in a room close to the nurses' station
• B. Use a bed exit alarm
• C. Encourage family members to stay with the client at all times
• D. Raise all four side rails

Correct answer: B

Rationale: Using a bed exit alarm is the best intervention to prevent injury in a client with dementia at risk of falling. This device alerts staff when the client attempts to leave the bed, allowing for timely assistance and reducing the risk of falls. Placing the client in a room close to the nurses' station may help with supervision but does not provide immediate alerts like a bed exit alarm. Encouraging family members to stay with the client at all times may not be feasible, and raising all four side rails can lead to restraint issues and is not recommended unless necessary for the client's safety.

3. A nurse is caring for a client who has multiple fractures following a motor-vehicle crash. For which of the following client statements should the nurse recommend a referral to an occupational therapist?

• A. I can't brush my teeth properly
• B. I am so frustrated I can't open my milk carton
• C. I can't hold a pencil
• D. I can't write anymore

Correct answer: B

Rationale: The correct answer is B. The client's frustration with opening a milk carton indicates difficulty with activities of daily living, which is a common concern addressed by occupational therapists. Choices A, C, and D are related to fine motor skills, which may also be addressed by an occupational therapist but are not as directly linked to activities of daily living as struggling with tasks like opening containers.

4. What is the first intervention for a patient in shock?

• A. Administer fluids
• B. Monitor blood pressure
• C. Provide oxygen
• D. Call for assistance

Correct answer: A

Rationale: The correct answer is to administer fluids. In a patient experiencing shock, the priority is to address inadequate perfusion by restoring circulating blood volume. Administering fluids helps improve perfusion and oxygen delivery to vital organs. Monitoring blood pressure, providing oxygen, and calling for assistance are important steps but administering fluids is the initial and most critical intervention in the management of shock.

5. A nurse is caring for a client who is postoperative following a thyroidectomy and reports tingling and numbness in the hands. The nurse should expect to administer which of the following medications?

• A. Sodium bicarbonate.
• B. Calcium gluconate.
• C. Potassium chloride.
• D. Magnesium sulfate.

Correct answer: B

Rationale: Tingling and numbness in the hands can indicate hypocalcemia, a common complication following a thyroidectomy. Hypocalcemia requires immediate intervention to prevent severe complications like tetany and seizures. Calcium gluconate is the drug of choice for rapidly raising serum calcium levels in hypocalcemic patients. Sodium bicarbonate is not indicated for treating hypocalcemia or related symptoms. Potassium chloride is used to correct potassium imbalances, not calcium. Magnesium sulfate is not the appropriate treatment for hypocalcemia; it is commonly used for conditions like preeclampsia or eclampsia.

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