Extract:

Question 1 of 5

A nurse discusses the self-care guidelines to minimize the side effects of radiation on the skin. Which self-care instructions can the nurse provide the client receiving radiation? [Select all that apply.]

A. Use a razor to shave the hair in the treated area.B. Wash treated area gently with lukewarm water and mild soap.C. Purchase aloe approved skin-care productsD. Wear loose-fitting, soft clothing over the treated skin.E. Sun tan the affected area for no more than 30 minutes a day

Correct Answer: B,C,D

Rationale:
B) Gentle cleansing with lukewarm water and mild soap prevents skin irritation.
C) Aloe vera products soothe and moisturize sensitive skin.
D) Loose, soft clothing avoids friction and irritation on treated skin.

Question 2 of 5

The nurse notes old and new ecchymotic areas on an older adult client's arms and buttocks upon admission. The client tells the nurse in confidence that her family members frequently hit her. Which statement should the nurse use in response?

A. I have a legal obligation to report this type of abuse.'B. Let's get these treated, and I will maintain confidence.'C. Let's talk about ways to prevent someone from hitting you'D. If this happens again, you must call the emergency department.'

Correct Answer: A

Rationale: Mandatory reporting laws require nurses to report suspected abuse to protect vulnerable clients, prioritizing safety over confidentiality.

Question 3 of 5

A home health nurse is making a home visit to a client with multiple sclerosis. The nurse reviews the home medications taken by the client. Which question should the nurse ask to determine the effectiveness of the client's medication, baclofen (Lioresal)?

A. Are you having any headaches?'B. How has your appetite been?'C. Does your urine look clear or cloudy?'D. Are you having trouble with spasms?'

Correct Answer: D

Rationale: Asking about spasms directly assesses baclofen's effectiveness, as it is prescribed to reduce muscle spasms in MS.

Question 4 of 5

A patient taking Digoxin is experiencing severe bradycardia, nausea and vomiting. A lab draw shows that their Digoxin level is 4 ng/mi (0.8-2.0 ng/ml). What management does the nurse anticipate the physician to order? Select all that apply.

A. Hydration with IV fluidsB. Nothing as the digoxin level is within normal rangesC. Hold the DigoxinD. DigibindE. Narcan

Correct Answer: A,C,D

Rationale:
A) IV fluids aid in excreting excess digoxin.
C) Holding digoxin prevents worsening toxicity.
D) Digibind neutralizes digoxin in severe toxicity.

Question 5 of 5

A client in the emergency room begins to experience an acute asthma attack. The nurse expects that which medication will be used as initial treatment?

A. A corticosteroid such as fluticasoneB. A long-acting beta 2 agonist such as salmeterolC. A short-acting, beta 2 agonist such as albuterolD. Methylxanthines such Theophylline

Correct Answer: C

Rationale: Albuterol, a short-acting beta-2 agonist, provides rapid bronchodilation, making it the first-line treatment for acute asthma attacks.