Nursing Elites

1. A client undergoing radiation therapy is being taught about skin care by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will use a heating pad to soothe the skin
• B. I will avoid using perfumed lotions on the treated area
• C. I will apply cold compresses to the area
• D. I will scrub the area daily with soap and water

Correct answer: B

Rationale: The correct answer is B because avoiding perfumed lotions is important to prevent skin irritation after radiation therapy. Using a heating pad (A) can further damage the skin, applying cold compresses (C) may not be recommended, and scrubbing the area daily with soap and water (D) can be too harsh on the skin, leading to further irritation and damage.

2. A nurse is teaching a client who has heart failure about fluid restrictions. Which of the following instructions should the nurse include?

• A. Limit fluid intake to 3 liters per day
• B. Limit fluid intake to 1-2 liters per day
• C. Drink 4 liters of water per day
• D. Restrict water intake to 1 liter per day

Correct answer: B

Rationale: The correct answer is B: 'Limit fluid intake to 1-2 liters per day.' For clients with heart failure, fluid restriction is essential to prevent fluid overload. Restricting fluid intake to 1-2 liters per day helps maintain fluid balance and prevents exacerbation of heart failure symptoms. Choices A, C, and D are incorrect because consuming 3 liters, 4 liters, or limiting water intake to 1 liter per day, respectively, can lead to fluid overload in clients with heart failure.

3. A healthcare professional is contributing to the plan of care for a client who is receiving mechanical ventilation. Which of the following interventions should the healthcare professional recommend?

• A. Suction the airway every hour
• B. Keep the head of the bed at 30 degrees
• C. Change the ventilator tubing every day
• D. Administer a bronchodilator every 2 hours

Correct answer: B

Rationale: The correct answer is to keep the head of the bed at 30 degrees. This position helps reduce the risk of aspiration and improves ventilation. Suctioning the airway every hour may lead to mucosal damage and increase the risk of infection. Changing the ventilator tubing every day is not necessary unless there are specific indications to do so, as it can increase the risk of contamination and infection. Administering a bronchodilator every 2 hours is not a standard practice and should be done based on the client's individualized treatment plan.

4. What are the primary differences between left-sided and right-sided heart failure?

• A. Left-sided: Pulmonary congestion; Right-sided: Systemic edema
• B. Right-sided: Pulmonary congestion; Left-sided: Systemic edema
• C. Left-sided: Systemic edema; Right-sided: Pulmonary congestion
• D. Right-sided: Pulmonary congestion; Left-sided: Heart failure

Correct answer: A

Rationale: The correct answer is A: "Left-sided: Pulmonary congestion; Right-sided: Systemic edema." Left-sided heart failure primarily affects the lungs, leading to pulmonary congestion, which manifests as symptoms like shortness of breath and cough. On the other hand, right-sided heart failure causes systemic congestion and edema, often presenting as swelling in the legs and abdomen due to fluid retention. Choice B is incorrect because it swaps the features of left-sided and right-sided heart failure. Choice C is incorrect as it also incorrectly switches the characteristics of the two types of heart failure. Choice D is incorrect because it inaccurately associates left-sided heart failure with pulmonary congestion and right-sided heart failure with heart failure itself, which is not a distinguishing feature.

5. A client at 20 weeks of gestation is being taught by a nurse about an alpha-fetoprotein (AFP) test. Which of the following information should the nurse include?

• A. This test is used to confirm pregnancy
• B. This test is used to detect neural tube defects
• C. This test will determine the baby's lung maturity
• D. This test will check for gestational diabetes

Correct answer: B

Rationale: The correct answer is B: 'This test is used to detect neural tube defects.' An alpha-fetoprotein test is essential for screening neural tube defects in the fetus, not for confirming pregnancy, determining lung maturity, or checking for gestational diabetes. Detecting neural tube defects is crucial for early intervention and management of potential health issues in the baby.

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