Nursing Elites

1. A client is receiving high-dose brachytherapy as a form of cancer treatment. What type of teaching must the nurse include when educating this client about safety?

• A. The client must remain in isolation under airborne precautions
• B. The client should stay in a private room at the hospital
• C. The client may need to limit visits from friends and family
• D. Both B and C

Correct answer: D

Rationale: A client undergoing high-dose brachytherapy has a radiation implant placed for cancer treatment. To ensure safety, the client should be in a private hospital room to prevent radiation exposure to others. Limiting visits from friends and family is necessary to prevent overexposure. Option A is incorrect as isolation under airborne precautions is not required for brachytherapy. Option B and C are the correct choices as they focus on minimizing radiation exposure to others, ensuring safety during treatment.

2. A client is complaining of pain that starts in the shoulder and travels down the length of his arm. This type of pain is referred to as:

• A. Referred pain
• B. Superficial pain
• C. Radiating pain
• D. Precipitating pain

Correct answer: C

Rationale: Radiating pain is the correct term for pain that originates in one part of the body and extends to other related areas. In this scenario, the pain starting in the shoulder and traveling down the arm describes radiating pain. Referred pain (Choice A) is pain felt at a site different from the actual origin of the pain. Superficial pain (Choice B) is pain that arises from the skin or tissues just beneath it. Precipitating pain (Choice D) refers to pain that is triggered by specific actions or events, not the characteristic described in the question.

3. When auscultating the blood pressure of a 25-year-old patient, the nurse notices that the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure?

• A. 200/92
• B. 200/100
• C. 100/200/92
• D. 200/100/92

Correct answer: A

Rationale: When auscultating blood pressure, it is crucial to note the points at which Korotkoff sounds change. In adults, the last audible sound indicates the diastolic pressure. In this case, the Korotkoff sounds muffle at 100 mm Hg and disappear at 92 mm Hg. Therefore, the blood pressure should be recorded as systolic/diastolic, which is 200/92. Choices B, C, and D are incorrect because they do not reflect the correct points where the Korotkoff sounds change during blood pressure measurement.

4. You are working the 4 pm to 12 midnight evening shift. You are taking care of a group of patients. The supervising RN identifies 5 patients who get a medication at 'HS'. When will you give this medication?

• A. After the dinner meal
• B. Whenever requested
• C. At the patient's bedtime
• D. Before the end of the shift

Correct answer: C

Rationale: The correct answer is to give the medication at the patient's bedtime. 'HS' is a medical abbreviation that stands for 'hora somni,' which translates to 'at bedtime' or 'at the hours of sleep.' This timing ensures that the medication is administered appropriately to align with the patient's sleep schedule and maximize its effectiveness. Choices A, B, and D are incorrect because giving the medication after dinner, whenever requested, or before the end of the shift may not coincide with the intended purpose of the medication, potentially affecting its efficacy and patient outcomes.

5. A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, 'I'm tired of being sick. I wish I could end it all.' What is the most accurate and informative way to record this data in a nursing progress note?

• A. Client appears to be depressed, possibly suicidal
• B. Client reports being tired of being ill and wants to die
• C. Client does not want to live any longer and is tired of being ill
• D. Client states, 'I'm tired of being sick. I wish I could end it all.'

Correct answer: D

Rationale: Subjective data includes thoughts, beliefs, feelings, perceptions, and sensations that are apparent only to the person affected and cannot be measured, seen, or felt by the nurse. This information should be documented using the client's exact words in quotes. The other options indicate that the nurse has drawn the conclusion that the client no longer wishes to live. From the data provided, the cues do not support this assumption. A more complete assessment should be conducted to determine if the client is suicidal.

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