Nursing Elites

1. The nurse is planning care for a client who is receiving radiation therapy for breast cancer. Which intervention is most important for the nurse to include?

• A. Encourage the client to use sunscreen
• B. Apply lotion to the radiated area
• C. Keep the area dry and clean
• D. Encourage the client to exercise the arm

Correct answer: C

Rationale: Keeping the radiated area dry and clean is crucial to prevent skin irritation and infection. Radiation therapy can cause skin changes, making it susceptible to irritation and infection. Using sunscreen (Choice A) is not usually recommended on the radiated area as it can further irritate the skin. Applying lotion (Choice B) may not be suitable as it can trap moisture and cause skin breakdown. While encouraging exercise (Choice D) is important, keeping the area dry and clean takes precedence to prevent complications during radiation therapy.

2. The nurse is caring for a client with a diagnosis of pneumonia who has been febrile for 24 hours. Which data is most important for the nurse to obtain in determining the client's fluid status?

• A. Daily intake and output
• B. Skin turgor
• C. Daily weight
• D. Vital signs every 4 hours

Correct answer: C

Rationale: Daily weight is the most important data for the nurse to obtain in determining the client's fluid status in this scenario. During febrile episodes, assessing daily weight is crucial as it can indicate fluid retention or loss. While monitoring intake and output is important for assessing fluid balance, daily weight provides a more comprehensive picture of fluid status over time. Skin turgor is more indicative of hydration status than overall fluid status, and vital signs, although essential, do not directly assess fluid status as effectively as daily weight.

3. A 20-year-old male client is diagnosed with Ewing's sarcoma following examination for a knee injury. Which instruction is most important for the nurse to provide the client?

• A. Take analgesics regularly to reduce the pain
• B. Notify the healthcare provider if the swelling worsens
• C. Avoid weight-bearing until the injury heals
• D. Seek treatment for the sarcoma immediately

Correct answer: D

Rationale: The correct answer is to instruct the client to seek treatment for the sarcoma immediately. Ewing's sarcoma is an aggressive cancer, and prompt treatment is crucial for improving prognosis. Option A is incorrect because while pain management is important, addressing the underlying cause (sarcoma) is the priority. Option B is not as critical as seeking treatment for the sarcoma itself. Option C is not the most important instruction as the primary concern is addressing the cancer diagnosis.

4. The nurse is planning discharge teaching for a client with chronic kidney disease. Which information is most important for the nurse to provide this client?

• A. Monitor daily weights
• B. Limit fluid intake to prevent fluid overload
• C. Report any weight gain of more than 2 pounds in a day
• D. Increase protein intake to promote healing

Correct answer: C

Rationale: The most important information for the nurse to provide a client with chronic kidney disease is to report any weight gain of more than 2 pounds in a day. This is crucial because sudden weight gain can indicate fluid retention, which is a common issue in kidney disease. Monitoring daily weights, as in option A, is important but not as critical as reporting sudden weight gain. Option B, limiting fluid intake, is a general recommendation for kidney disease but not the most important aspect in this scenario. Option D, increasing protein intake, is not appropriate as excessive protein intake can be harmful for clients with kidney disease.

5. A male client with diabetes mellitus takes Novolin 70/30 insulin before meals and azithromycin (Zithromax) PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of the Zithromax an hour before breakfast as instructed. What action should the nurse implement?

• A. Offer to obtain a new breakfast tray in an hour so the client can take the Zithromax
• B. Instruct the client to eat his breakfast and take the Zithromax two hours after eating
• C. Tell the client to skip that day's dose and resume taking the Zithromax the next day
• D. Provide a PRN dose of an antacid to take with the Zithromax right after breakfast

Correct answer: B

Rationale: To ensure the effectiveness of the antibiotic and manage blood glucose levels, the client should take the Zithromax two hours after eating. Option A is incorrect because obtaining a new breakfast tray is not necessary to administer the missed dose. Option C is incorrect as skipping a dose can lead to decreased effectiveness of the antibiotic. Option D is incorrect because providing an antacid is not indicated in this situation.

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