Nursing Elites

1. A nurse is reviewing the plan of care for a client undergoing radiation therapy for cancer. Which of the following instructions should the nurse reinforce with the client?

• A. Apply sunscreen before going outside
• B. Avoid using perfumed lotions
• C. Massage the area daily
• D. Take vitamin supplements with food

Correct answer: B

Rationale: The correct instruction the nurse should reinforce with the client undergoing radiation therapy is to avoid using perfumed lotions. This is essential to reduce the risk of skin irritation, as perfumed lotions can exacerbate skin reactions during radiation therapy. Applying sunscreen before going outside is generally a good practice but not specifically related to radiation therapy. Massaging the area daily is contraindicated during radiation therapy as it can further irritate the skin. Taking vitamin supplements with food is important for overall health but is not a specific instruction related to radiation therapy.

2. What is a primary symptom of left-sided heart failure?

• A. Shortness of breath
• B. Edema
• C. Rapid heartbeat
• D. Confusion

Correct answer: A

Rationale: Shortness of breath is a primary symptom of left-sided heart failure. In this condition, the heart's inability to pump effectively leads to fluid backing up into the lungs, causing difficulty breathing. Edema (swelling), rapid heartbeat, and confusion are more commonly associated with other conditions or right-sided heart failure. Edema is often seen in right-sided heart failure due to fluid accumulation in the body, rapid heartbeat can be a general sign of heart issues, and confusion is more related to decreased brain perfusion in severe heart failure cases.

3. How should a healthcare professional manage a patient with fluid volume deficit?

• A. Encourage oral fluid intake
• B. Administer IV fluids as ordered
• C. Monitor urine output and check electrolyte levels
• D. Monitor skin turgor and capillary refill

Correct answer: A

Rationale: Encouraging oral fluid intake is a crucial nursing intervention in managing a patient with fluid volume deficit. By encouraging oral fluid intake, the patient can increase hydration levels, helping to correct the deficit. Administering IV fluids may be necessary in severe cases or when the patient is unable to tolerate oral intake. Monitoring urine output and checking electrolyte levels are essential aspects of assessing fluid volume status, but they are not direct interventions for correcting fluid volume deficit. Monitoring skin turgor and capillary refill are important assessments for fluid volume status but are not direct management strategies.

4. A client with an NG tube is reporting nausea and a decrease in gastric secretions. What is the nurse's first action?

• A. Increase the suction pressure
• B. Irrigate the NG tube with sterile water
• C. Turn the client onto their left side
• D. Replace the NG tube with a new one

Correct answer: B

Rationale: The correct first action for a client with an NG tube experiencing nausea and decreased gastric secretions is to irrigate the NG tube with sterile water. This helps alleviate blockages and can improve the client's symptoms. Increasing the suction pressure (Choice A) may exacerbate the issue and cause further discomfort. Turning the client onto their left side (Choice C) is not directly related to addressing the reported symptoms. Replacing the NG tube with a new one (Choice D) should be considered only after attempting initial interventions like irrigation.

5. A nurse is collecting data from a client who is in severe pain. Which of the following questions should the nurse ask first?

• A. When did your pain start?
• B. How severe is your pain?
• C. What makes your pain worse?
• D. Where is your pain located?

Correct answer: D

Rationale: The nurse should first ask the client where the pain is located because identifying the location of the pain is crucial in determining the cause and appropriate treatment. This information helps in further assessment and diagnosis. Asking when the pain started (Choice A) may be important but determining the location provides more immediate insights. Inquiring about the severity of pain (Choice B) and what worsens it (Choice C) are also important but come after identifying the location to provide a comprehensive understanding of the client's condition.

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