Nokea
A client reports skin dryness, redness, and scaling after radiation. What should the nurse advise?
- A. Apply hydrating lotions.
- B. Scrub the area vigorously.
- C. Cover the area with adhesive bandages.
- D. Avoid moisturizing the skin.
Correct Answer: A
Rationale: The correct answer is A: Apply hydrating lotions. After radiation, skin can become dry and irritated. Hydrating lotions help to moisturize the skin and reduce dryness, redness, and scaling. They provide a protective barrier and promote skin healing. Advising the client to apply hydrating lotions is essential in maintaining skin integrity post-radiation.
Choice B: Scrubbing the area vigorously can further damage the skin and exacerbate irritation.
Choice C: Covering the area with adhesive bandages can trap moisture and lead to skin maceration.
Choice D: Avoiding moisturizing the skin can worsen dryness and discomfort.
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A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?
- A. As soon as the nurse can prepare the client and the administration set
- B. One hour after receiving the blood
- C. Two hours after receiving the blood
- D. Immediately after lunch break
Correct Answer: A
Rationale: The correct answer is A. The nurse should begin the infusion as soon as possible after receiving the packed RBCs to prevent bacterial growth and ensure the blood's optimal efficacy. Delaying the infusion could increase the risk of contamination. Choice B (one hour after receiving the blood) is incorrect because it unnecessarily delays the infusion. Choice C (two hours after receiving the blood) is also incorrect as it further prolongs the time before starting the infusion. Choice D (immediately after lunch break) is incorrect as it does not prioritize the immediate need to administer the blood. Starting the infusion promptly is crucial to prevent any adverse reactions or complications for the patient.
A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless, and apneic. Which of the following actions is the nurse's priority?
- A. Defibrillation
- B. Administer oxygen
- C. Call for help
- D. Start chest compressions
Correct Answer: A
Rationale: The correct answer is A: Defibrillation. Ventricular fibrillation is a life-threatening arrhythmia that requires immediate defibrillation to restore the heart's normal rhythm. Defibrillation is the priority as it is the most effective intervention to treat ventricular fibrillation and increase the chance of survival. Administering oxygen (B) is important but not the priority over defibrillation. Calling for help (C) should be done after initiating defibrillation. Starting chest compressions (D) should only be done if defibrillation is not immediately available or unsuccessful.
A nurse is caring for a client who has asthma and is taking fluticasone. The nurse should monitor the client for which of the following adverse effects?
- A. Oral candidiasis
- B. Hypertension
- C. Increased appetite
- D. Weight loss
Correct Answer: A
Rationale: The correct answer is A: Oral candidiasis. Fluticasone is a corticosteroid inhaler commonly used to manage asthma. Corticosteroids can suppress the immune system locally, leading to oral candidiasis. The nurse should monitor for white patches in the mouth. Hypertension (B), increased appetite (C), and weight loss (D) are not commonly associated with fluticasone use.
A nurse is teaching a newly licensed nurse about gynecological examination. Which of the following information should the nurse include in the teaching?
- A. The urethral orifice is assessed by separating the labia minora.
- B. The cervix should be palpated first.
- C. The external genitalia should not be inspected.
- D. The perineum should be assessed after the vaginal examination.
Correct Answer: A
Rationale: The correct answer is A because the urethral orifice is located between the clitoris and the vaginal opening, so separating the labia minora allows for proper visualization and assessment. This step ensures accurate examination of the urethral opening for signs of infection or abnormalities. Palpating the cervix first (B) is incorrect as it should be done after inspecting the external genitalia. Choosing not to inspect the external genitalia (C) is incorrect as it is an essential part of the gynecological examination. Assessing the perineum after the vaginal examination (D) is incorrect as the perineum should be assessed before the vaginal examination to evaluate for any abnormalities or injuries.
A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?
- A. Performing the procedure independently
- B. Preparing the suction equipment but needing assistance
- C. Demonstrating knowledge of the tracheostomy care instructions
- D. Asking for assistance with the suctioning procedure
Correct Answer: A
Rationale: The correct answer is A. Performing the procedure independently indicates readiness for discharge as it shows the partner has mastered the skill and can provide proper care without supervision. Choice B indicates the partner still needs assistance, choice C shows knowledge but not necessarily competency, and choice D suggests continued reliance on the nurse.