Nursing Elites

1. A nurse is caring for a client who is receiving radiation therapy. Which of the following side effects should the nurse monitor for?

• A. Fatigue
• B. Hair loss
• C. Nausea
• D. Dry mouth

Correct answer: D

Rationale: The correct answer is D, dry mouth. Dry mouth is a common side effect of radiation therapy due to damage to the salivary glands. It is essential for the nurse to monitor for this condition as it can lead to oral health issues and discomfort. Fatigue (choice A) is a common side effect of radiation therapy, but in this case, dry mouth is a more specific side effect to monitor for. Hair loss (choice B) is more commonly associated with chemotherapy rather than radiation therapy. Nausea (choice C) is also a common side effect of radiation therapy, but dry mouth is a more direct effect of the treatment that the nurse should focus on monitoring.

2. When administering an incorrect dose of medication, which facts related to the incident report should the nurse document in the client's medical record?

• A. Time the medication was given
• B. The client's response to the medication
• C. The dose that was administered
• D. Reason for the error

Correct answer: A

Rationale: The nurse should document the time the medication was given in the client's medical record when administering an incorrect dose. This information is crucial for tracking the sequence of events leading to the error. Choice B, the client's response to the medication, is important for monitoring the client's condition post-administration but may not be directly linked to the incident report. Choice C, documenting the dose that was administered, is relevant but does not provide insights into the timing of events. Choice D, detailing the reason for the error, should be included in the incident report but may not need to be documented in the client's medical record.

3. Which medication is used to treat opioid overdose?

• A. Naloxone
• B. Epinephrine
• C. Lidocaine
• D. Atropine

Correct answer: A

Rationale: Naloxone is the correct answer. Naloxone is the standard medication for reversing opioid overdose by blocking opioid receptors. Choice B, Epinephrine, is used to treat severe allergic reactions (anaphylaxis) and cardiac arrest, not opioid overdose. Choice C, Lidocaine, is a local anesthetic used for numbing purposes and managing certain types of arrhythmias, not for opioid overdose. Choice D, Atropine, is used to treat bradycardia, organophosphate poisoning, and nerve agent toxicity, not opioid overdose.

4. What is the initial step in managing a suspected pulmonary embolism in a patient?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer anticoagulants
• D. Administer IV fluids

Correct answer: A

Rationale: Administering oxygen is the initial step in managing a suspected pulmonary embolism. Oxygen therapy is crucial to improve oxygenation levels in the blood when there is a suspected blockage in the pulmonary artery. Administering anticoagulants, although important in the treatment of pulmonary embolism, is not the first step as ensuring adequate oxygen supply takes precedence. Repositioning the patient or administering IV fluids are not the primary interventions for a suspected pulmonary embolism and are not as essential as providing oxygen support.

5. A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include?

• A. Remove the client's restraint every 4 hours.
• B. Document the client's condition every 15 minutes.
• C. Attach the restraint to the bed's side rails.
• D. Request a PRN restraint prescription for clients who are aggressive.

Correct answer: B

Rationale: The correct answer is B. When updating protocols for the use of belt restraints, it is essential to document the client's condition every 15 minutes. This frequent documentation helps ensure the client's safety and allows for timely assessment of the need for continued restraint use. Choice A is incorrect because restraints should be removed and reassessed more frequently than every 4 hours. Choice C is incorrect as restraints should not be attached to the bed's side rails due to entrapment risks. Choice D is also incorrect as restraints should not be used as needed (PRN) but rather based on a specific prescription and assessment indicating the need for restraint use.

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