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The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?
- A. Wears clothing to cover the radiation site.
- B. Washes the radiation site with antibacterial soap and water.
- C. Applies prescribed lotions to the radiation site.
- D. Dries the area with patting motions after taking a shower.
Correct Answer: B
Rationale: Washing with antibacterial soap can dry and irritate the sensitive skin at the radiation site, increasing the risk of damage. Mild, unscented soap is recommended, indicating a need for further teaching.
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An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?
- A. Demonstrate the use of visual scanning during meals to the client and family.
- B. Explain that weight loss will be reversed after the acute phase of the stroke has ended.
- C. Suggest that the family bring foods from home that the client enjoys eating.
- D. Encourage the family to offer to feed the client when she does not eat her entire meal.
Correct Answer: A
Rationale: Teaching visual scanning compensates for visual perception deficits post-CVA, enabling the client to see all food on the tray, addressing the root cause of poor intake and improving nutrition.
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?
- A. Has everyone at home already had varicella?
- B. Have the antifungal creams been effective?
- C. Do you have any dry patches on your feet and hands?
- D. Do your family members share combs and brushes?
Correct Answer: A
Rationale: Asking if everyone at home has had varicella helps determine the risk of transmission of the varicella-zoster virus, which causes herpes zoster, to non-immune individuals, informing isolation precautions.
A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells. When notifying the healthcare provider, which information should the nurse provide first using the SBAR (Situation, Background, Assessment, and Recommendation) communication process?
- A. Explain specific reason for urgent notification.
- B. Obtain a PRN prescription for acetaminophen for fever over 101° F (38.3° C).
- C. Preface the report by stating the client's name and admitting diagnosis.
- D. Communicate the pre-transfusion temperatures.
Correct Answer: C
Rationale: Per SBAR, starting with the client's name and diagnosis establishes identity and context, ensuring clear communication before detailing the situation, background, assessment, and recommendation.
Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?
- A. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE.
- B. Report the COVID-19 result to the local health department according to CDC guidelines.
- C. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.
- D. Explain to the client to inform others that they may have been potentially exposed in the last 14 days.
Correct Answer: A
Rationale: Isolating the client immediately prevents potential COVID-19 transmission, given the suggestive symptoms, and is the priority action before reporting, educating, or contact tracing.
The nurse is caring for a client who is still experiencing light sedation after undergoing an emergency colectomy for bowel obstruction. Which postoperative pain intervention should the nurse implement first?
- A. Provide the first medication prescribed for pain management.
- B. Review medical records to obtain pain tolerance expectations.
- C. Wait until the client is awake before providing pain management.
- D. Attempt to obtain a self-report of pain level from the client.
Correct Answer: A
Rationale: Providing the prescribed pain medication first prevents pain escalation in a sedated client, using behavioral indicators like vital signs to guide administration, as self-reporting may be unreliable.