Nursing Elites

1. A nurse is caring for a client receiving radiation treatments for cancer. The client states he is experiencing dryness, redness, and scaling at the treatment area. Which of the following should the nurse instruct the client to do?

• A. Sit in the sun for 15 minutes per day.
• B. Apply moist heat to the area twice daily.
• C. Liberally apply prescribed lotion to the area.
• D. Wash the affected area daily with antimicrobial soap.

Correct answer: C

Rationale: The nurse should instruct the client to liberally apply prescribed lotion to the treatment area. Prescribed hydrating lotions help soothe and protect irradiated skin, reducing dryness, redness, and scaling. Sitting in the sun can further damage the skin. Applying moist heat may exacerbate the skin condition. Washing the area with antimicrobial soap can be too harsh and further irritate the skin.

2. A client with osteoporosis is being taught by a nurse about dietary changes. Which of the following food choices should the nurse recommend to promote bone health?

• A. Leafy green vegetables
• B. Red meat
• C. Fortified orange juice
• D. Whole grains

Correct answer: C

Rationale: The correct answer is C: Fortified orange juice. Fortified orange juice is often supplemented with calcium and vitamin D, both of which are essential for bone health and the prevention of osteoporosis. Leafy green vegetables (choice A) are good for overall health but may not provide sufficient calcium for bone health. Red meat (choice B) is a source of protein but is not a primary source of calcium. Whole grains (choice D) are beneficial for fiber intake but do not contain significant amounts of calcium or vitamin D necessary for bone health.

3. A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client's risk for falls?

• A. Using a night-light
• B. Demonstrating how to use the call light
• C. Placing the bedside table in close proximity
• D. Hourly rounding by the nurse

Correct answer: D

Rationale: Hourly rounding by the nurse is the most effective intervention to reduce the risk of falls in older adult clients with delirium. This intervention ensures that the nurse regularly checks on the client, assesses their needs, and assists them with any activities, thereby minimizing the chances of falls. Using a night-light (choice A) may help improve visibility but does not provide continuous assistance and monitoring. Demonstrating how to use the call light (choice B) is important but may not prevent falls directly. Placing the bedside table in close proximity (choice C) is helpful for convenience but does not address the continuous monitoring and assistance needed to prevent falls in this case.

4. A nurse receives a change-of-shift report. Which of the following clients should the nurse attend to first?

• A. A client who reports tingling in the fingers following a thyroidectomy
• B. A client who has dark, foul-smelling urine with a urine output of 320 mL in the last 8 hr
• C. A client who is in a long leg cast and reports cool feet bilaterally
• D. A client who has a productive cough and an oral temperature of 36°C (96.8°F)

Correct answer: C

Rationale: The correct answer is C. Cool feet bilaterally in a client with a long leg cast may indicate compromised circulation, which is a medical emergency that requires immediate intervention. Choices A, B, and D do not present immediate life-threatening conditions. Tingling in the fingers following a thyroidectomy may indicate hypocalcemia but does not require immediate attention. Dark, foul-smelling urine with decreased urine output indicates a possible urinary tract infection or dehydration but can be addressed after attending to the client with compromised circulation. A productive cough and a normal oral temperature do not suggest an urgent condition compared to compromised circulation in a client with a long leg cast.

5. During triage following a mass casualty event, which client should be prioritized?

• A. A client with massive head trauma
• B. A client with full-thickness burns to the face and trunk
• C. A client showing signs of hypovolemic shock
• D. A client with an open fracture of the lower extremity

Correct answer: C

Rationale: During triage after a mass casualty event, the client showing signs of hypovolemic shock should be prioritized. Hypovolemic shock is a life-threatening condition that requires immediate attention to restore circulation and prevent death. While clients with head trauma, burns, and fractures also need urgent care, hypovolemic shock poses an immediate threat to life and must be addressed first to stabilize the client's condition.

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