Nursing Elites

1. A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for one week. Which of the following should the nurse include in the plan of care?

• A. Remove dirty linens from the room after double-bagging them
• B. Wear a dosimeter film badge while in the client’s room
• C. Limit each visitor to one hour per day
• D. Ensure family members remain at least 3 feet from the client

Correct answer: B

Rationale: The correct answer is to wear a dosimeter film badge while in the client's room. Wearing a dosimeter helps monitor the cumulative radiation exposure of healthcare workers, ensuring their safety during care. Removing dirty linens, limiting visitor time, and maintaining a distance from the client are not directly related to radiation safety measures and are not necessary in this scenario.

2. A nurse is planning care for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority?

• A. Administer IV pain medication to a client who reports pain as a 6 on a scale of 0 to 10
• B. Administer oxygen to a client who has an oxygen saturation of 91%
• C. Instruct a client who is 1 hr postoperative about coughing and deep breathing exercises
• D. Initiate an infusion of 0.9% sodium chloride for a client who has just had abdominal surgery

Correct answer: B

Rationale: When using the ABC approach to client care, the nurse should identify that the priority intervention is administering oxygen. In this scenario, the client's oxygen saturation is only 91%, which is below the normal range of 95% and above. Oxygen is essential for adequate tissue perfusion and oxygenation of vital organs. Administering oxygen takes precedence over other interventions to ensure the client's physiological needs are met first. Choice A can be addressed after ensuring adequate oxygenation. Choice C is important for preventing postoperative complications but is not as urgent as addressing oxygen saturation. Choice D is a common postoperative intervention, but in this case, ensuring adequate oxygenation is the priority over IV fluid administration.

3. A client receiving chemotherapy is experiencing neutropenia. Which of the following should the nurse include in this client's education?

• A. Track oral temperature weekly
• B. Gardening is a good form of mild exercise
• C. Avoid crowded events
• D. Eat plenty of fresh fruits and vegetables

Correct answer: C

Rationale: Clients with neutropenia have a weakened immune system, making them susceptible to infections. Avoiding crowded events helps reduce the risk of exposure to pathogens, thereby minimizing the chance of infections. Tracking oral temperature is important for detecting fever early, which is a sign of infection and requires immediate medical attention. While gardening can be a good form of exercise, clients with neutropenia should avoid it due to the risk of exposure to bacteria and fungi present in soil. Eating fresh fruits and vegetables is generally encouraged for overall health but may carry a risk of bacterial contamination, which could be harmful to a client with neutropenia.

4. A healthcare professional is assessing a client with heart failure. Which of the following signs should the healthcare professional monitor for?

• A. Peripheral edema
• B. Tachycardia
• C. Bradycardia
• D. Hypotension

Correct answer: A

Rationale: In heart failure, the accumulation of fluid can lead to peripheral edema, which is swelling in the extremities. This is a common sign that healthcare professionals should monitor for. While tachycardia (increased heart rate), bradycardia (decreased heart rate), and hypotension (low blood pressure) can also occur in heart failure, they are not the primary signs typically associated with this condition. Therefore, peripheral edema is the most relevant sign to monitor in this case.

5. A nurse is caring for a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?

• A. Lip-smacking
• B. Agranulocytosis
• C. Clang association
• D. Alopecia

Correct answer: A

Rationale: Lip-smacking is a symptom of tardive dyskinesia, a long-term side effect of antipsychotic medications like haloperidol, characterized by involuntary movements of the face and jaw. Agranulocytosis (Choice B) is a rare but serious side effect of some medications, characterized by a dangerously low white blood cell count. Clang association (Choice C) is a thought disorder characterized by the association of words based on sound rather than meaning. Alopecia (Choice D) refers to hair loss, which is not a known long-term side effect of haloperidol.

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