Nursing Elites

1. The patient is being treated for cancer with weekly radiation therapy to the head and intravenous chemotherapy treatments. Which assessment is the priority?

• A. Feet
• B. Nail beds
• C. Perineum
• D. Oral cavity

Correct answer: D

Rationale: The correct answer is the oral cavity. During cancer treatment involving radiation to the head and intravenous chemotherapy, the oral cavity is a priority assessment area. Radiation can reduce salivary flow and lower the pH of saliva, which can lead to stomatitis and tooth decay. Assessing the oral cavity allows for the early identification and management of potential complications. Choice A, assessing the feet, is not the priority in this scenario as it is not directly impacted by the described cancer treatments. Choice B, assessing the nail beds, is not the priority compared to the oral cavity. Nail bed assessment may be relevant for certain conditions, but in this case, the oral cavity is of higher priority due to the specific treatment effects. Choice C, assessing the perineum, is also not the priority in this situation as it is not directly affected by the described cancer treatments, unlike the oral cavity.

2. When should discharge planning be initiated for a client experiencing an exacerbation of heart failure?

• A. During the admission process.
• B. After the client stabilizes.
• C. Only after the client requests it.
• D. At the time of discharge.

Correct answer: A

Rationale: Discharge planning should begin during the admission process for a client experiencing an exacerbation of heart failure. Initiating discharge planning early ensures timely and effective care transitions, which are crucial for managing the client's condition and preventing readmissions. Waiting until after the client stabilizes (choice B) could lead to delays in arranging necessary follow-up care and support services. Similarly, waiting for the client to request discharge planning (choice C) may result in missed opportunities for comprehensive care coordination. Planning at the time of discharge (choice D) is too late, as early intervention is key to promoting the client's well-being and recovery in the long term.

3. How should a healthcare professional care for a client approaching death with shortness of breath and noisy respirations?

• A. Turn the client every 2 hours
• B. Provide supplemental oxygen
• C. Use a fan to reduce the feeling of breathlessness
• D. Administer diuretics as prescribed

Correct answer: C

Rationale: In a palliative care setting, when caring for a client approaching death with symptoms of shortness of breath and noisy respirations, using a fan can help alleviate the sensation of breathlessness. This intervention can provide comfort by improving air circulation and reducing the perception of breathlessness. Turning the client every 2 hours may not directly address the respiratory distress caused by noisy respirations. Providing supplemental oxygen may not be indicated or effective in all cases, especially in end-of-life care where the focus is on comfort rather than aggressive interventions. Administering diuretics as prescribed would not be appropriate for addressing noisy respirations and shortness of breath in a dying client, as this may not be related to fluid overload or congestion. Therefore, the most appropriate action to help the client feel more comfortable in this situation is to use a fan to reduce the feeling of breathlessness.

4. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?

• A. Remove the safety pin from the extinguisher.
• B. Aim the extinguisher at the base of the fire.
• C. Squeeze the handle to release the extinguishing agent.
• D. Sweep the extinguisher from side to side.

Correct answer: A

Rationale: The correct first step in using a fire extinguisher is to remove the safety pin. This action enables the extinguisher to be activated and used effectively. Choice B, aiming the extinguisher at the base of the fire, comes after removing the safety pin. Choice C, squeezing the handle to release the extinguishing agent, and choice D, sweeping the extinguisher from side to side, are subsequent steps in using a fire extinguisher and should follow removing the safety pin.

5. A client who has been experiencing frequent tonic-clonic seizures is being admitted by a nurse. Which of the following actions should the nurse include in the client's plan of care?

• A. Wrap blankets around all four sides of the bed.
• B. Place the client in a padded room.
• C. Maintain the bed in the lowest position.
• D. Ensure the client has a soft mattress.

Correct answer: C

Rationale: Maintaining the bed in the lowest position is crucial in reducing the risk of injury during tonic-clonic seizures. This action helps prevent falls and minimizes potential harm to the client. Wrapping blankets around all four sides of the bed (Choice A) may restrict movement during a seizure and increase the risk of injury. Placing the client in a padded room (Choice B) is not a practical approach in a healthcare setting and may not be feasible. Ensuring the client has a soft mattress (Choice D) alone does not address the safety concerns during seizures, unlike keeping the bed in the lowest position.

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