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 providing teaching to a client who has tuberculosis (TB) and is prescribed rifampin. Which of the following statements should the nurse include in the teaching?

• A. This medication can cause your urine to turn a reddish-orange color.
• B. You should expect to take this medication for at least 6 months.
• C. You should avoid eating dairy products while on this medication.
• D. This medication can cause sensitivity to sunlight.

Correct answer: A

Rationale: The correct answer is A. Rifampin can cause harmless red-orange discoloration of bodily fluids, including urine, sweat, and tears. Clients should be informed about this side effect. Choice B is incorrect because the duration of rifampin therapy for TB is typically longer than 6 months. Choice C is incorrect as there is no need to avoid dairy products while on rifampin. Choice D is incorrect as rifampin does not cause sensitivity to sunlight.

3. A nurse is using Naegele’s rule to calculate the expected delivery date for a client whose last menstrual period was in October. What is the expected date?

• A. 711
• B. 1011
• C. 411
• D. 1211

Correct answer: A

Rationale: Using Naegele’s rule, to calculate the expected delivery date, you add one year, subtract three months, and add seven days to the first day of the last menstrual period. If the last menstrual period was in October, adding one year gives October of the following year. Subtracting three months gives July, and adding seven days gives the expected delivery date of July 11th. Therefore, the correct answer is 711. Choice B (1011) is incorrect as it doesn't follow Naegele’s rule calculations. Choices C (411) and D (1211) are also incorrect as they do not align with the correct application of Naegele’s rule.

4. A nurse is caring for a client receiving oxytocin IV for labor augmentation. The client’s contractions are occurring every 45 seconds and lasting 90 seconds. What action should the nurse take?

• A. Discontinue the oxytocin infusion
• B. Increase the oxytocin infusion
• C. Decrease the oxytocin infusion
• D. Maintain the oxytocin infusion

Correct answer: A

Rationale: In this scenario, the client is experiencing uterine hyperstimulation with contractions every 45 seconds lasting 90 seconds. This frequency and duration of contractions can lead to fetal distress. The appropriate nursing action is to discontinue the oxytocin infusion immediately to prevent complications. Increasing or maintaining the oxytocin infusion would exacerbate the situation, while decreasing it may not be sufficient to address the issue effectively.

5. During a change-of-shift assessment, a nurse is evaluating four clients. Which finding should the nurse report to the provider first?

• A. Client with cystic fibrosis who has a thick productive cough and reports thirst
• B. Client with gastroenteritis who is lethargic and confused
• C. Client with diabetes mellitus who has a morning fasting glucose of 185 mg/dL
• D. Client with sickle cell anemia who reports pain 15 minutes after receiving analgesic

Correct answer: B

Rationale: The nurse should report the client with gastroenteritis who is lethargic and confused to the provider first. Lethargy and confusion in a client with gastroenteritis may indicate dehydration or electrolyte imbalance, both of which can be life-threatening if not addressed promptly. The other options indicate important assessments that require intervention but do not pose an immediate life-threatening risk compared to the client with signs of dehydration and electrolyte imbalance.

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