Nursing Elites

1. A nurse is caring for a client who is receiving radiation therapy for breast cancer. Which of the following skin care instructions should the nurse provide?

• A. Wear loose clothing over the radiation site.
• B. Use scented lotions to moisturize the skin.
• C. Apply ice packs to the radiation site for pain relief.
• D. Expose the radiation site to sunlight for 20 minutes daily.

Correct answer: A

Rationale: The correct answer is A: Wear loose clothing over the radiation site. Clients receiving radiation therapy should wear loose clothing over the treatment area to prevent irritation and promote healing. Choice B is incorrect as scented lotions can irritate the skin during radiation therapy. Choice C is incorrect because ice packs should not be applied to the radiation site as they can exacerbate skin reactions. Choice D is incorrect as exposing the radiation site to sunlight can increase skin damage and should be avoided.

2. A client with Parkinson's disease is receiving physical therapy. Which statement by the client indicates the need for a referral to physical therapy?

• A. I have been experiencing more tremors in my left arm than before
• B. I noticed that I am having a harder time holding onto my toothbrush
• C. Lately, I feel like my feet are freezing up, as they are stuck to the ground
• D. Sometimes, I feel I am making a chewing motion when I'm not eating

Correct answer: C

Rationale: The correct answer is C because freezing of feet while walking is a sign of impaired mobility, indicating the need for physical therapy in clients with Parkinson's disease. Choices A, B, and D are symptoms commonly associated with Parkinson's disease but do not specifically indicate the need for immediate referral to physical therapy.

3. A healthcare professional is caring for a client who has a prescription for enoxaparin. Which of the following laboratory tests should the healthcare professional review before administering the medication?

• A. Prothrombin time (PT)
• B. INR
• C. Platelet count
• D. Potassium levels

Correct answer: D

Rationale: Corrected Rationale: Before administering enoxaparin, it is essential to review potassium levels to monitor for potential imbalances. Enoxaparin, a type of anticoagulant, does not directly affect PT, INR, or platelet count. Monitoring potassium levels is crucial to ensure the safety and effectiveness of the medication. PT and INR are typically used to monitor warfarin therapy, while platelet count is essential for assessing clotting function but is not directly related to enoxaparin administration.

4. What is the most important assessment for a patient with suspected pneumonia?

• A. Monitor lung sounds
• B. Check oxygen saturation
• C. Assess for cough
• D. Assess for fever

Correct answer: A

Rationale: The most important assessment for a patient with suspected pneumonia is to monitor lung sounds. Lung sounds provide crucial information about the severity of pneumonia, such as crackles or decreased air entry. This assessment helps in evaluating the effectiveness of ventilation and oxygenation. While checking oxygen saturation is important, monitoring lung sounds gives more direct information about the lung involvement in pneumonia. Assessing for cough and fever are also relevant but do not provide as direct and critical information as monitoring lung sounds in the context of suspected pneumonia.

5. A nurse is assessing a client who is receiving opioid analgesics for pain management. Which of the following findings should the nurse report to the provider?

• A. Respiratory rate of 20/min
• B. Blood pressure of 118/76 mm Hg
• C. Heart rate of 88/min
• D. Oxygen saturation of 94%

Correct answer: C

Rationale: The correct answer is C. A heart rate of 88/min is a normal finding; therefore, it does not require immediate reporting to the provider. The respiratory rate of 20/min, blood pressure of 118/76 mm Hg, and oxygen saturation of 94% are also within normal ranges and do not indicate any immediate concerns. However, a serum potassium level of 3.0 mEq/L indicates hypokalemia, which can be a serious issue and should be reported to the provider for further evaluation and management.

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