Nursing Elites

1. A nurse works on an oncology unit and delegates personal hygiene to assistive personnel (AP). What action by the AP requires intervention from the nurse?

• A. Allowing a very tired client to skip oral hygiene and sleep.
• B. Assisting clients with washing the perianal area every 12 hours.
• C. Helping the client use a soft-bristled toothbrush for oral care.
• D. Reminding the client to rinse the mouth with water or saline.

Correct answer: A

Rationale: Skipping oral hygiene is not appropriate for a client, even if they are tired, as it increases the risk of infection.

2. Nurse Joy is caring for a client with an internal radiation implant. When caring for the client, the nurse should observe which of the following principles?

• A. Limit the time with the client to 1 hour per shift
• B. Do not allow pregnant women into the client’s room
• C. Remove the dosimeter badge when entering the client’s room
• D. Individuals younger than 16 years old may be allowed to go in the room as long as they are 6 feet away from the client

Correct answer: B

Rationale: Clients with internal radiation implants (also known as brachytherapy) emit a small amount of radiation, which can pose a risk to others. Pregnant women are particularly vulnerable to the harmful effects of radiation because it can affect both the mother and the developing fetus. Radiation exposure can lead to birth defects, miscarriage, or other developmental issues, so pregnant women should avoid any exposure by not entering the client's room.

3. A client is admitted to the hospital with a suspected diagnosis of Hodgkin’s disease. Which assessment finding would the nurse expect to note specifically in the client?

• A. Fatigue
• B. Weakness
• C. Weight gain
• D. Enlarged lymph nodes

Correct answer: D

Rationale: Hodgkin’s disease (Hodgkin’s lymphoma) is a type of cancer that originates in the lymphatic system, particularly affecting the lymph nodes. A hallmark sign of Hodgkin’s disease is the painless enlargement of lymph nodes, often in the neck, armpit, or groin. These enlarged lymph nodes are typically firm and rubbery to the touch. This is one of the most distinctive and common early signs that healthcare providers look for when diagnosing the disease.

4. The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which is a late sign of this oncological emergency?

• A. Headache
• B. Dysphagia
• C. Constipation
• D. Electrocardiographic changes

Correct answer: D

Rationale: The correct answer is D, Electrocardiographic changes. In clients with metastatic prostate cancer, hypercalcemia can lead to various signs and symptoms. Electrocardiographic changes are considered a late sign of hypercalcemia, indicating severe electrolyte imbalance. Headache (choice A), dysphagia (choice B), and constipation (choice C) are earlier signs of hypercalcemia and may precede the development of more severe symptoms like electrocardiographic changes.

5. Nurse Lisa is assessing a client who has just completed radiation therapy to the neck area. Which of the following findings is most concerning?

• A. Erythema in the treated area
• B. Difficulty swallowing
• C. Dry, peeling skin
• D. Hoarseness

Correct answer: B

Rationale: Difficulty swallowing (dysphagia) following radiation therapy to the neck area is a significant concern because it can indicate serious complications such as esophageal stricture, inflammation, or damage to the surrounding tissues, including the esophagus. This can lead to malnutrition, dehydration, or aspiration, all of which require prompt intervention. Radiation therapy can cause irritation and scarring in the esophageal and throat tissues, which may progressively worsen if not treated. Therefore, dysphagia should be addressed immediately to prevent further complications.

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