Nursing Elites

1. A client undergoing chemotherapy for cancer is being taught about potential adverse effects of the treatment. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will avoid drinking water before meals
• B. I might experience hair loss during treatment
• C. I might experience an increase in appetite
• D. I should expect my appetite to increase

Correct answer: B

Rationale: The correct answer is B because hair loss is a common adverse effect of chemotherapy. Options A, C, and D are incorrect. Avoiding drinking water before meals, experiencing an increase in appetite, or expecting appetite to increase are not related to the potential adverse effects of chemotherapy.

2. What are early indicators of dehydration?

• A. Dry mouth
• B. Increased thirst
• C. Decreased urine output
• D. Dizziness

Correct answer: A

Rationale: The correct answer is A, dry mouth, and B, increased thirst are early indicators of dehydration. Dry mouth occurs when the body is dehydrated, and increased thirst is the body's way of trying to increase fluid intake to combat dehydration. Choices C and D, decreased urine output and dizziness, can be signs of severe dehydration but are not typically considered early indicators.

3. What are the nursing considerations for a patient receiving anticoagulant therapy?

• A. Monitor INR levels and check for bleeding
• B. Educate patient on dietary restrictions
• C. Ensure adequate hydration and nutrition
• D. Ensure that the patient remains immobile

Correct answer: A

Rationale: The correct answer is A: 'Monitor INR levels and check for bleeding.' When a patient is receiving anticoagulant therapy, nurses must monitor the patient's INR levels to ensure that the anticoagulants are within the therapeutic range and also watch for signs of bleeding, which is a common side effect of anticoagulants. Option B is incorrect because while patient education is important, dietary restrictions are not a direct nursing consideration when administering anticoagulant therapy. Option C is not a specific nursing consideration related to anticoagulant therapy. Option D is incorrect as keeping the patient immobile is not a standard nursing practice for patients on anticoagulant therapy, as mobility is often encouraged to prevent complications like deep vein thrombosis.

4. A client is experiencing difficulty voiding following the removal of an indwelling catheter. What action should the nurse take to assist the client?

• A. Assess for bladder distention after 4 hours
• B. Pour warm water over the perineum
• C. Restrict the client's oral fluid intake
• D. Restrict movement for at least 12 hours

Correct answer: B

Rationale: The correct action for the nurse to assist the client who is experiencing difficulty voiding after the removal of an indwelling catheter is to pour warm water over the perineum. This technique can help stimulate urination by promoting relaxation of the perineal muscles and improving blood flow to the area. Assessing for bladder distention after 4 hours (Choice A) is important but not the immediate intervention needed to assist the client in voiding. Restricting the client's oral fluid intake (Choice C) can exacerbate the issue by reducing urine production. Restricting movement for at least 12 hours (Choice D) is unnecessary and may lead to discomfort and other complications.

5. A client with a sprained right ankle is learning to walk with a cane. What action demonstrates effective teaching?

• A. The client advances the cane 18 inches in front of the foot
• B. The client holds the cane in the left hand
• C. The client advances the cane and the right leg simultaneously
• D. The client holds the cane with the elbow flexed at 60°

Correct answer: B

Rationale: When a client has a sprained right ankle, they should hold the cane in the opposite hand (left hand) to the affected leg for better support and balance. This positioning helps to reduce the weight on the injured leg while providing stability. Option A is incorrect because advancing the cane too far in front can lead to loss of balance. Option C is incorrect as it does not provide the necessary support for the injured leg. Option D is incorrect as the elbow should be slightly flexed but not necessarily at a specific angle.

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