Nursing Elites

1. A client is receiving radiation therapy to the head and neck. Which of the following interventions should the nurse include?

• A. Instruct the client to use an alcohol-free mouthwash.
• B. Apply heat packs to the radiation site.
• C. Provide a diet low in carbohydrates.
• D. Avoid exposure to direct sunlight during treatment.

Correct answer: D

Rationale: The correct intervention for a client receiving radiation therapy to the head and neck is to avoid exposure to direct sunlight. Direct sunlight should be avoided to protect the skin from further irritation and damage caused by the radiation therapy. Instructing the client to use an alcohol-free mouthwash is important to prevent irritation and maintain oral hygiene, making choice A incorrect. Applying heat packs to the radiation site is contraindicated as heat can further aggravate the skin, making choice B incorrect. Providing a diet low in carbohydrates is not directly related to radiation therapy to the head and neck, so choice C is also incorrect.

2. A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect?

• A. Increased creatinine
• B. Increased hemoglobin
• C. Increased bicarbonate
• D. Increased calcium

Correct answer: A

Rationale: The correct answer is A: Increased creatinine. In chronic kidney disease, the kidneys are unable to filter waste effectively, leading to a buildup of creatinine in the blood. This results in increased creatinine levels in laboratory tests. Choice B, increased hemoglobin, is not typically associated with chronic kidney disease. Choice C, increased bicarbonate, is also not a common finding in chronic kidney disease; in fact, metabolic acidosis with decreased bicarbonate levels is more common. Choice D, increased calcium, is not expected in chronic kidney disease; instead, calcium levels may be low due to impaired kidney function.

3. A nurse is preparing to mix NPH and regular insulin in the same syringe. Which of the following actions should the nurse take?

• A. Inject air into the NPH insulin vial.
• B. Withdraw the prescribed dose of regular insulin.
• C. Withdraw the prescribed dose of NPH insulin.
• D. Mix the two insulins in separate syringes.

Correct answer: A

Rationale: When mixing NPH and regular insulin in the same syringe, the nurse should first inject air into the NPH insulin vial. This action prevents contamination by allowing an easier withdrawal of the correct dose of NPH insulin after withdrawing the regular insulin. Withdrawing the prescribed dose of regular insulin (Choice B) is incorrect as it does not address the initial step of injecting air into the NPH vial. Similarly, withdrawing the prescribed dose of NPH insulin (Choice C) is incorrect as it skips the crucial first step. Mixing the two insulins in separate syringes (Choice D) is not ideal since combining them in one syringe is a common practice to reduce the number of injections for the patient.

4. A nurse is caring for a 1-day-old newborn who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take?

• A. Feed the infant 30 ml (1 oz) of glucose water every 2 hours.
• B. Keep the infant's head uncovered.
• C. Ensure that the newborn wears a diaper.
• D. Apply lotion to the newborn every 4 hours.

Correct answer: C

Rationale: The correct action for the nurse to take is to ensure that the newborn wears a diaper. This is important to prevent irritation during phototherapy, as exposure to light can increase the risk of skin breakdown. Feeding the infant glucose water is unnecessary and not indicated for jaundice treatment. Keeping the infant's head uncovered allows the light to reach the skin effectively. Applying lotion to the newborn every 4 hours can interfere with the effectiveness of phototherapy and is not recommended.

5. A nurse is providing discharge instructions for a client who has osteoporosis. Which of the following instructions should the nurse include to prevent injury?

• A. Perform weight-bearing exercises.
• B. Avoid crossing the legs beyond the midline.
• C. Avoid sitting in one position for prolonged periods.
• D. Splint the affected area.

Correct answer: A

Rationale: The correct answer is A: Perform weight-bearing exercises. Weight-bearing exercises are crucial for preventing bone density loss in clients with osteoporosis. These exercises help strengthen bones and reduce the risk of fractures. Option B, avoiding crossing the legs beyond the midline, is not directly related to preventing injury in osteoporosis. Option C, avoiding sitting in one position for prolonged periods, is important for preventing pressure ulcers but does not specifically address preventing injury in osteoporosis. Option D, splinting the affected area, is not a standard recommendation for preventing injury in osteoporosis.

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