Nokea
A nurse is caring for a client who is receiving radiation therapy. Which of the following side effects should the nurse monitor for?
- A. Fatigue
- B. Hair loss
- C. Nausea
- D. Dry mouth
Correct Answer: D
Rationale: The correct answer is D, dry mouth. Dry mouth is a common side effect of radiation therapy due to damage to the salivary glands. It is essential for the nurse to monitor for this condition as it can lead to oral health issues and discomfort. Fatigue (choice A) is a common side effect of radiation therapy, but in this case, dry mouth is a more specific side effect to monitor for. Hair loss (choice B) is more commonly associated with chemotherapy rather than radiation therapy. Nausea (choice C) is also a common side effect of radiation therapy, but dry mouth is a more direct effect of the treatment that the nurse should focus on monitoring.
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How should a healthcare professional assess for infection in a patient post-surgery?
- A. Check the surgical site
- B. Check for fever
- C. Check for abnormal breath sounds
- D. Check the patient's skin color
Correct Answer: A
Rationale: When assessing for infection in a patient post-surgery, checking the surgical site is crucial. Changes in the appearance of the surgical site, such as redness, swelling, warmth, or drainage, can indicate an infection. While checking for fever (Choice B) is also important as it can be a sign of infection, it is a more general symptom and may not always be present. Checking for abnormal breath sounds (Choice C) and skin color (Choice D) are not typically direct indicators of infection in a post-surgery patient.
A client has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan?
- A. Cleanse the wound with povidone-iodine solution daily.
- B. Irrigate the wound with hydrogen peroxide.
- C. Reposition the client every 4 hours.
- D. Apply a moisture barrier ointment.
Correct Answer: D
Rationale: The correct intervention for a client with a stage 3 pressure injury is to apply a moisture barrier ointment. This helps protect the skin, maintain moisture balance, and promote healing. Choice A is incorrect because povidone-iodine solution can be too harsh for wound care. Choice B is incorrect as hydrogen peroxide can be cytotoxic to healing tissue. Choice C is important for preventing pressure injuries but is not a direct intervention for a stage 3 wound.
How should a healthcare provider manage a patient with chronic heart failure?
- A. Monitor daily weight
- B. Provide fluid restriction
- C. Administer diuretics
- D. Monitor intake and output
Correct Answer: A
Rationale: Corrected Rationale: Daily weight monitoring is crucial in managing patients with chronic heart failure as it helps assess fluid balance. Monitoring daily weight allows healthcare providers to detect any sudden weight gain, which could indicate fluid retention and worsening heart failure. This intervention helps in adjusting treatment plans promptly. Providing fluid restriction (Choice B) can be a part of managing heart failure but is not the primary intervention mentioned in the question. Administering diuretics (Choice C) is a treatment modality for heart failure but does not encompass the comprehensive approach to patient management. Monitoring intake and output (Choice D) is important but does not specifically address the direct assessment of fluid status as daily weight monitoring does.
A client with diabetes mellitus is receiving teaching from a nurse about foot care. Which of the following instructions should the nurse include?
- A. Soak your feet in warm water daily.
- B. Wear cotton socks.
- C. Use a heating pad to warm your feet.
- D. Trim toenails straight across.
Correct Answer: D
Rationale: The correct answer is to trim toenails straight across. This instruction is crucial for clients with diabetes to prevent ingrown toenails, which can lead to infection. Soaking feet in warm water daily can increase the risk of skin breakdown. Cotton socks are recommended, but the priority in foot care for diabetes is proper nail trimming. Using a heating pad can also pose a burn risk for individuals with reduced sensation in their feet.
Which lab value should be monitored in a patient on digoxin?
- A. Monitor potassium levels
- B. Monitor calcium levels
- C. Monitor digoxin levels
- D. Monitor sodium levels
Correct Answer: C
Rationale: The correct answer is to monitor digoxin levels in a patient on digoxin. Digoxin is a medication commonly used to treat heart conditions, and monitoring its levels in the blood is crucial to ensure that the patient is within the therapeutic range and to prevent toxicity. Monitoring potassium levels (Choice A) is important due to the potential of digoxin-induced hypokalemia, but the primary focus should be on monitoring digoxin levels. Monitoring calcium levels (Choice B) and sodium levels (Choice D) are not directly related to digoxin therapy and are not the primary lab values of concern when administering digoxin.