Nursing Elites

1. The nurse instructs the unlicensed nursing personnel (UAP) on how to provide oral hygiene for clients who cannot perform this task for themselves. Which of the following techniques should the nurse tell the UAP to incorporate into the client's daily care?

• A. Assess the oral cavity each time mouth care is given and record observations.
• B. Use a soft toothbrush to brush the client's teeth after each meal.
• C. Swab the client's tongue, gums, and lips with a soft foam applicator every 2 hours.
• D. Rinse the client's mouth with mouthwash several times a day.

Correct answer: B

Rationale: The correct technique to incorporate into the client's daily care for oral hygiene is to use a soft toothbrush to brush the client's teeth after each meal. This helps in maintaining oral hygiene for clients who cannot perform this task themselves. Choice A is incorrect because assessing the oral cavity each time mouth care is given is important but not the technique to incorporate into daily care. Choice C is incorrect as swabbing the tongue, gums, and lips every 2 hours may not be necessary for daily care. Choice D is incorrect as rinsing the client's mouth with mouthwash several times a day may not be suitable for all clients and is not a standard recommendation for daily oral care.

2. Which information about mammograms is most important to provide a post-menopausal female client?

• A. Breast self-examinations are not necessary if annual mammograms are obtained.
• B. Radiation exposure is minimized by shielding the abdomen with a lead-lined apron.
• C. Yearly mammograms should be done regardless of previous normal screenings.
• D. Women at high risk should have annual routine and ultrasound mammograms.

Correct answer: C

Rationale: The most important information to provide a post-menopausal female client regarding mammograms is that yearly mammograms should be done regardless of previous normal screenings. It is crucial for post-menopausal women to continue regular mammograms as they are at a higher risk for breast cancer. Option A is incorrect as breast self-examinations are still recommended in addition to mammograms. Option B is not the most important information compared to the importance of regular mammograms. Option D is not the most important advice for all post-menopausal females but specifically for those at high risk, indicating a more targeted approach.

3. The client is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?

• A. Protect the skin of the radiation portal site from sunlight exposure
• B. Apply moisturizing lotions daily to the radiation portal site
• C. Avoid washing the skin inside the radiation portal site
• D. Remove the ink marks of the portal after each radiation treatment

Correct answer: A

Rationale: Protecting the skin from sunlight exposure is crucial to prevent radiation burns and additional skin damage at the treatment site. Sun exposure can exacerbate skin reactions caused by radiation therapy. Applying moisturizing lotions daily may introduce foreign substances or irritants to the treated area, leading to potential complications. Washing the skin inside the radiation portal site is important for maintaining cleanliness and preventing infections. Removing the ink marks after each treatment is unnecessary and may cause unnecessary skin irritation and trauma.

4. A client with peripheral arterial disease (PAD) has cool and pale feet with diminished pulses. Which of the following interventions should the nurse implement?

• A. Keep the legs elevated above the level of the heart.
• B. Encourage the client to exercise daily.
• C. Apply warm compresses to the affected area.
• D. Apply ice packs to the affected area.

Correct answer: C

Rationale: In peripheral arterial disease (PAD), there is decreased blood flow to the extremities. Applying warm compresses helps dilate blood vessels, improve circulation, and relieve symptoms. Elevating the legs above the heart level may further compromise blood flow. Encouraging daily exercise is important in PAD management but may not be appropriate when the client has cool, pale feet with diminished pulses. Applying ice packs can worsen vasoconstriction and further reduce blood flow, exacerbating symptoms in PAD.

5. A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What action should the nurse implement?

• A. Determine if the client has also experienced breast tenderness and weight gain.
• B. Encourage the client to begin a regular, daily program of walking and exercise.
• C. Advise the client to notify the healthcare provider for immediate medical attention.
• D. Tell the client to stop taking the medication for a week to see if symptoms subside.

Correct answer: C

Rationale: Calf pain is indicative of thrombophlebitis, a serious, life-threatening complication associated with the use of oral contraceptives which requires further assessment and possibly immediate medical intervention.

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