Nursing Elites

1. A client undergoing chemotherapy expresses concern about hair loss. What should the nurse suggest?

• A. Encourage the client to cut their hair short before chemotherapy.
• B. Provide resources for wigs or hairpieces.
• C. Assure the client that hair loss will be minimal.
• D. Offer the client medication to reduce the chances of hair loss.

Correct answer: B

Rationale: The correct answer is B: Providing wigs and other coping resources helps clients manage the emotional effects of chemotherapy-related hair loss. Encouraging the client to cut their hair short before chemotherapy (Choice A) is not necessary as hair loss may still occur. Assuring the client that hair loss will be minimal (Choice C) may provide false hope as hair loss is a common side effect of chemotherapy. Offering medication to reduce hair loss (Choice D) is not a typical approach as chemotherapy-related hair loss is often an expected side effect that cannot be entirely prevented with medication.

2. A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following statements indicates an understanding of the teaching?

• A. I should avoid taking acetaminophen while taking this medication
• B. I will take this medication at the same time each day
• C. I will need to get my blood tested regularly while taking this medication
• D. I should increase my intake of leafy green vegetables

Correct answer: C

Rationale: The correct answer is C. Warfarin therapy requires regular blood testing to monitor INR levels and ensure therapeutic dosing. Option A is incorrect because acetaminophen can be taken with warfarin. Option B is not specific to warfarin administration. Option D is incorrect as it does not address the key monitoring requirement of blood testing while on warfarin.

3. A patient is experiencing shortness of breath. What is the nurse's immediate action?

• A. Assist the patient into a high Fowler's position.
• B. Administer oxygen at 2 liters per minute via nasal cannula.
• C. Encourage the patient to take deep breaths and cough.
• D. Assess the patient's lung sounds.

Correct answer: B

Rationale: Administering oxygen at 2 liters per minute via nasal cannula is the immediate action for a patient experiencing shortness of breath. This intervention helps to improve oxygenation and relieve respiratory distress promptly. Placing the patient in a high Fowler's position (choice A) may also be beneficial but providing oxygen takes precedence in this scenario to address the underlying hypoxemia. Encouraging deep breaths and coughing (choice C) may not be appropriate as the first action, especially without assessing the patient first. Assessing lung sounds (choice D) is essential but should follow the initial intervention of administering oxygen.

4. A nurse manager notes that a nurse is not following safety protocols. What should the manager do first?

• A. Confront the nurse about the behavior.
• B. Notify the hospital's safety committee.
• C. Document the observation without addressing it.
• D. Follow up with the nurse at a later time.

Correct answer: B

Rationale: The correct first step for the nurse manager is to notify the hospital's safety committee. This action is crucial to ensure that the appropriate measures are taken promptly to address the non-compliance with safety protocols. Confronting the nurse directly may not be the best initial approach as involving the safety committee can provide a systematic and comprehensive response to the issue. Documenting the observation without addressing it or following up at a later time may delay the necessary actions to maintain a safe environment, making these choices less effective as the first course of action.

5. When administering IV fluids to a dehydrated patient, what is the nurse's priority assessment?

• A. Monitor the patient's electrolyte levels.
• B. Assess the patient's blood pressure regularly.
• C. Monitor the patient's heart rate every 4 hours.
• D. Check the patient's urine output hourly.

Correct answer: B

Rationale: The correct answer is to assess the patient's blood pressure regularly. Monitoring blood pressure is crucial when administering IV fluids to a dehydrated patient as it helps in evaluating the patient's fluid status. Changes in blood pressure can indicate the effectiveness of the fluid therapy, the patient's response to treatment, and the possibility of complications such as fluid overload or hypovolemia. Monitoring electrolyte levels (Choice A) is essential but not the priority when assessing a dehydrated patient receiving IV fluids. Heart rate (Choice C) should be monitored more frequently than every 4 hours in such a situation. Checking urine output (Choice D) is important but not as critical as assessing blood pressure in this scenario.

Similar Questions