Nursing Elites

1. A client receiving radiation therapy for breast cancer may experience which of the following side effects that the nurse should monitor for?

• A. Fatigue
• B. Nausea
• C. Skin irritation
• D. Weight gain

Correct answer: C

Rationale: During radiation therapy for breast cancer, one common side effect is skin irritation due to the impact of radiation on the skin cells. This side effect should be closely monitored by the nurse. Fatigue may also occur as a side effect of radiation therapy, but skin irritation is more specific to the treatment area and is a priority in this case. Nausea and weight gain are not typically associated with radiation therapy for breast cancer, making them incorrect choices.

2. A nurse is caring for a client who is at risk for developing a deep vein thrombosis (DVT). Which of the following interventions should the nurse implement?

• A. Massage the client's legs every 2 hours.
• B. Instruct the client to sit with the legs crossed.
• C. Administer prophylactic antibiotics.
• D. Apply sequential compression devices to the client's legs.

Correct answer: D

Rationale: The correct answer is D: Apply sequential compression devices to the client's legs. Sequential compression devices help prevent venous stasis and reduce the risk of DVT by promoting blood flow in the legs. Massaging the client's legs every 2 hours (choice A) may dislodge a clot if present, leading to a higher risk of embolism. Instructing the client to sit with the legs crossed (choice B) can impede blood flow and increase the risk of DVT. Administering prophylactic antibiotics (choice C) is not indicated for preventing DVT, as antibiotics are used to treat infections caused by bacteria, not to prevent blood clots.

3. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

• A. Place the cap from the solution sterile side up on a clean surface.
• B. Open the outermost flap of the sterile kit away from the body.
• C. Place the sterile dressing within 1.25 cm of the edge of the sterile field.
• D. Set up the sterile field 5 cm below waist level.

Correct answer: B

Rationale: When setting up a sterile field for a dressing change, the nurse should open the outermost flap of the sterile kit away from the body. This action helps maintain the sterility of the field by minimizing the risk of contamination. Option A is incorrect because the cap from the solution should be placed sterile side down to prevent contamination. Option C is incorrect because the sterile dressing should be placed at least 1.25 cm away from the edge of the sterile field to maintain its sterility. Option D is incorrect because the sterile field should be set up above waist level to prevent potential contamination from reaching the field.

4. A nurse in the emergency department is caring for a client who reports intimate partner violence. Which of the following interventions is the nurse's priority?

• A. Develop a safety plan with the client.
• B. Refer the client to a community support group.
• C. Determine if the client has any injuries.
• D. Contact the client's family about the incident.

Correct answer: A

Rationale: The correct answer is to develop a safety plan with the client. In cases of intimate partner violence, the priority is to ensure the client's immediate safety. While referring the client to a community support group (choice B) and determining if the client has any injuries (choice C) are important interventions, ensuring the client's safety through a safety plan takes precedence. Contacting the client's family about the incident (choice D) may not be appropriate as it can further endanger the client.

5. A nurse is assessing a client who has a history of urinary incontinence. Which of the following findings should the nurse report to the provider?

• A. Urine output of 50 mL in 2 hours
• B. Presence of an indwelling urinary catheter
• C. Frequent urination at night
• D. Dark-colored urine

Correct answer: D

Rationale: The correct answer is D, dark-colored urine. Dark-colored urine can indicate various issues such as dehydration, liver problems, or blood in the urine, which could be concerning and require further evaluation by the provider. Choices A, B, and C are not necessarily findings that would need immediate reporting to the provider. A urine output of 50 mL in 2 hours might be low but could be influenced by various factors and might not always require immediate action. The presence of an indwelling urinary catheter is a known history and not a new finding. Frequent urination at night could be a symptom related to various conditions but may not be an urgent concern unless accompanied by other significant symptoms.

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