Nursing Elites

1. What skin care measure should the nurse implement for a client who underwent external radiation treatment the previous day?

• A. Cleanse the radiated area with water and pat the skin dry
• B. Lightly massage the radiated skin with a lanolin-based lotion
• C. Rinse the site with normal saline and cover with a sterile towel
• D. Use a soft washcloth to gently remove the skin markings

Correct answer: A

Rationale: The correct measure for skin care after external radiation treatment is to cleanse the radiated area with water and pat the skin dry. This gentle cleansing without harsh chemicals or friction helps protect the integrity of radiated skin, preventing irritation or further damage. Choice B is incorrect because massaging radiated skin can cause further irritation, which should be avoided. Choice C is incorrect as rinsing with normal saline and covering with a sterile towel may not be necessary and could potentially introduce infection due to excessive moisture. Choice D is incorrect as using a soft washcloth to remove skin markings can be too abrasive for radiated skin, risking damage and irritation.

2. A terminally ill male client and his family request hospice care after discharge. What aspect of care should the nurse indicate is the focus of hospice?

• A. Enhance symptom management to improve end-of-life quality
• B. Facilitate assisted suicide with the client's consent
• C. Offer ways to postpone the death experience at home
• D. Provide training for family members to care for the client

Correct answer: A

Rationale: The correct answer is A. Hospice care focuses on enhancing symptom management to improve the end-of-life quality for terminally ill patients and their families. Hospice aims to provide comfort, dignity, and support during the end-of-life journey. Choice B is incorrect as hospice care does not involve assisted suicide but focuses on providing palliative care. Choice C is incorrect as hospice care does not aim to postpone the death experience but rather to provide support and comfort during this time. Choice D is incorrect as while hospice care may involve educating family members on caring for the client, the primary focus is on symptom management and quality of life.

3. When preparing to administer blood to a client, what is the most important action to ensure client safety during this procedure?

• A. Check the client’s blood type compatibility
• B. Monitor the client for signs of transfusion reaction
• C. Verify the correct client and blood product with another healthcare professional
• D. All of the above

Correct answer: D

Rationale: The most important action to ensure client safety during a blood transfusion is to implement multiple safety checks. Checking the client’s blood type compatibility is crucial as it helps prevent major transfusion reactions. Monitoring the client for signs of transfusion reaction is essential to detect any adverse reactions early. Verifying the correct client and blood product with another healthcare professional adds an extra layer of safety by ensuring the right blood is administered to the right patient. Choosing 'All of the above' (Option D) is the correct answer because each action plays a vital role in ensuring the safety and well-being of the client during a blood transfusion. Options A, B, and C are not exclusive; they complement each other to provide comprehensive safety measures.

4. After placement of a left subclavian central venous catheter (CVC), the nurse receives a report of the X-ray findings indicating that the CVC tip is in the client's superior vena cava. Which action should the nurse implement?

• A. Remove the catheter and apply direct pressure for 5 minutes.
• B. Initiate intravenous fluids as prescribed.
• C. Secure the catheter using aseptic technique.
• D. Notify the healthcare provider of the need to reposition the catheter.

Correct answer: B

Rationale: Initiating intravenous fluids as prescribed is the appropriate action when the CVC tip is correctly placed in the superior vena cava. Intravenous fluids can now be administered effectively through the central line. Removing the catheter and applying direct pressure is unnecessary and not indicated as the tip is in the correct position. Securing the catheter using aseptic technique is important for preventing infections but is not the immediate action needed in this situation. Notifying the healthcare provider of the need to reposition the catheter may delay necessary fluid administration, which is the priority at this time.

5. When caring for a client with a tracheostomy, what is the most important assessment to perform?

• A. Check the client's oxygen saturation
• B. Assess the tracheostomy site for signs of infection
• C. Monitor the client's respiratory rate
• D. Ensure the tracheostomy ties are secure

Correct answer: A

Rationale: The most important assessment to perform when caring for a client with a tracheostomy is to check the client's oxygen saturation. This assessment is crucial as it ensures that the client is receiving adequate oxygen through the tracheostomy. Monitoring oxygen saturation provides immediate information on the client's respiratory status and the effectiveness of the airway management. Assessing the tracheostomy site for signs of infection is important but not as critical as ensuring adequate oxygenation. Monitoring the respiratory rate is also essential but does not directly assess the effectiveness of oxygenation. Ensuring tracheostomy ties are secure is important for maintaining the device but does not directly evaluate the client's oxygenation status.

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