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A client is receiving external radiation therapy for lung cancer. Which intervention is most important for the nurse to include in the client's plan of care?
- A. Encourage the client to use sunscreen when outdoors.
- B. Apply a heating pad to the radiation site.
- C. Instruct the client to avoid using deodorant on the skin near the radiation site.
- D. Advise the client to increase intake of green leafy vegetables.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The client, who is newly diagnosed with arteriosclerosis and is obese, is being educated by the nurse on reducing the risk of a heart attack or stroke. Which health promotion brochure should the nurse provide to this client?
- A. Monitoring Your Blood Pressure at Home
- B. Smoking Cessation as a Lifelong Commitment
- C. Decreasing Cholesterol Levels Through Diet
- D. Stress Management for a Healthier You
Correct Answer: C
Rationale: The most significant risk factor contributing to arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. Therefore, the most crucial brochure for the nurse to provide to the client focuses on decreasing cholesterol levels through diet to help reduce the risk of heart attack or stroke.
The healthcare provider obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the healthcare provider implement first?
- A. Use an electronic sphygmomanometer to take the BP every 30 minutes.
- B. Retake the blood pressure in the same arm, deflating the cuff slowly.
- C. Ask another healthcare provider to recheck the blood pressure to compare results.
- D. Obtain another blood pressure cuff and retake the blood pressure.
Correct Answer: B
Rationale: The healthcare provider should first retake the blood pressure in the right arm, deflating the cuff slowly, because a low systolic and high diastolic blood pressure measurement is often the result of deflating the cuff too rapidly. Taking the BP in the same arm ensures consistency and accuracy of the measurement.
When assisting an older adult client in preparing to take a tub bath, which nursing action is most important?
- A. Check the bath water temperature.
- B. Shut the bathroom door.
- C. Ensure that the client has voided.
- D. Provide extra towels.
Correct Answer: A
Rationale: The most crucial nursing action when assisting an older adult client with a tub bath is to check the bath water temperature. This step is essential to prevent burns from hot water or chilling from water that is too cold. Ensuring the water temperature is safe is a critical aspect of promoting the client's safety and comfort during the bathing process.
The patient had a CVA and developed right-sided hemiplegia. Which action is least appropriate for the nurse to take?
- A. Performing ROM exercises during bathing.
- B. Changing the patient's position every two hours.
- C. Suctioning the patient supine and tightly pulling the bed sheets across their feet.
- D. Placing the patient in the prone position for one hour three times a day.
Correct Answer: C
Rationale: Suctioning the patient in a supine position and pulling the bed sheets tightly across their feet can lead to foot drop, which is harmful for a patient with right-sided hemiplegia. This action can exacerbate muscle weakness and impair circulation in the affected limb. It is crucial to avoid actions that may compromise the patient's safety and well-being, such as causing foot drop in this scenario.
While changing a client's post-operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given a positive MRSA result, what is the most important action for the nurse to take?
- A. Force oral fluids
- B. Request a nutrition consult
- C. Initiate contact precautions
- D. Limit visitors to immediate family only
Correct Answer: C
Rationale: Initiating contact precautions is crucial in this situation to prevent the spread of MRSA infection. MRSA is a highly contagious bacterium that can spread through direct contact with an infected wound or by touching contaminated surfaces. By implementing contact precautions, the nurse can help contain the infection and protect other patients, healthcare workers, and visitors from being exposed to MRSA.