Nursing Elites

1. The patient is being treated for cancer with weekly radiation therapy to the head and intravenous chemotherapy treatments. Which assessment is the priority?

• A. Feet
• B. Nail beds
• C. Perineum
• D. Oral cavity

Correct answer: D

Rationale: The correct answer is the oral cavity. During cancer treatment involving radiation to the head and intravenous chemotherapy, the oral cavity is a priority assessment area. Radiation can reduce salivary flow and lower the pH of saliva, which can lead to stomatitis and tooth decay. Assessing the oral cavity allows for the early identification and management of potential complications. Choice A, assessing the feet, is not the priority in this scenario as it is not directly impacted by the described cancer treatments. Choice B, assessing the nail beds, is not the priority compared to the oral cavity. Nail bed assessment may be relevant for certain conditions, but in this case, the oral cavity is of higher priority due to the specific treatment effects. Choice C, assessing the perineum, is also not the priority in this situation as it is not directly affected by the described cancer treatments, unlike the oral cavity.

2. A client returning from the surgical suite following a vaginal hysterectomy is awake and asking for something to drink. Her post-op diet prescription reads: 'clear liquids, advance diet as tolerated.' Which of the following is appropriate for the nurse to tell the patient?

• A. ''I am going to listen to your abdomen.''
• B. ''You need to wait until the surgeon evaluates your condition.''
• C. ''You can have clear liquids, but let me check with the surgeon first.''
• D. ''It is best to start with small sips of clear liquids and observe how you feel.''

Correct answer: A

Rationale: The correct answer is A: ''I am going to listen to your abdomen.'' Listening to the abdomen helps assess bowel sounds and ensure that the client’s gastrointestinal system is ready for oral intake. Choice B is incorrect because the client does not necessarily need to wait for the surgeon to evaluate before starting with clear liquids. Choice C is incorrect because unless there are specific contraindications, clear liquids are usually allowed after surgery. Choice D is incorrect as it does not address the immediate assessment needed before initiating oral intake post-operatively.

3. A mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse?

• A. Folic acid should be taken before and after conception.
• B. Multivitamin supplements are recommended during pregnancy.
• C. A well-balanced diet promotes normal fetal development.
• D. Increased dietary iron improves the health of mother and fetus.

Correct answer: A

Rationale: The correct answer is A: 'Folic acid should be taken before and after conception.' Folic acid supplementation before and during early pregnancy has been shown to significantly reduce the risk of neural tube defects. Choice B is incorrect because while multivitamin supplements are beneficial during pregnancy, the specific focus for preventing neural tube defects is on folic acid. Choice C is a general statement about a well-balanced diet and does not specifically address neural tube defects. Choice D is incorrect as it focuses on dietary iron, which is important for overall health but not specifically proven to prevent neural tube defects.

4. The UAPs working on a chronic neuro unit ask the LPN/LVN to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client?

• A. Place the chair at a right angle to the bed on the client's left side before moving.
• B. Assist the client to a standing position, then place the right hand on the armrest.
• C. Have the client place the left foot next to the chair and pivot to the left before sitting.
• D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.

Correct answer: D

Rationale: The correct method for transferring an elderly client with left-sided weakness from the bed to the chair involves moving the chair parallel to the right side of the bed and standing the client on the right foot. This technique provides a stable and safe transfer by utilizing the stronger side of the client to support the transfer. Choices A, B, and C are incorrect because placing the chair at a right angle to the bed on the client's left side, assisting the client to a standing position and placing the right hand on the armrest, and having the client pivot to the left before sitting do not address the client's left-sided weakness and may increase the risk of falls or injuries.

5. During a change-of-shift report at a long-term care facility, a nurse discusses an older adult client with shingles with an oncoming nurse. What information should the nurse include in the report?

• A. The location of the client's breakfast.
• B. The schedule for administering routine vital signs.
• C. The specific transmission-based precautions in place.
• D. The type of transmission-based precautions in place.

Correct answer: D

Rationale: The correct answer is to include the type of transmission-based precautions in the report. This information is crucial for infection control when caring for a client with shingles, as it helps prevent the spread of the virus to other clients and healthcare workers. Choices A, B, and C are not directly related to managing a client with shingles. Option A about the location of breakfast is irrelevant to the client's condition. Option B about vital sign measurements, though important, is not the priority when discussing a client with shingles. Option C mentions 'specific times the client had visitors,' which is not as crucial as knowing the specific precautions in place to prevent transmission of the virus.

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