Nursing Elites

1. A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen?

• A. blood transfusion
• B. chemotherapy
• C. bone marrow transplantation
• D. immunosuppressive therapy

Correct answer: C

Rationale: In the case of acquired aplastic anemia, bone marrow transplantation offers the best chance of cure as it replaces the abnormal stem cells with healthy ones. Blood transfusion may provide temporary relief by replacing blood cells, but it does not address the root cause of the condition. Chemotherapy may be used in some cases, but it is not the preferred treatment for acquired aplastic anemia. While immunosuppressive therapy can be effective, especially in patients who are not candidates for a bone marrow transplant, it is not the first-line treatment and does not offer the same potential for a cure as bone marrow transplantation.

2. The nurse is teaching the parent of a child newly diagnosed with a latex allergy. Which information by the parents indicates a need for further teaching?

• A. Rubber-free toys, such as wooden building blocks, are good choices for the child.
• B. Only foil balloons will be used for the child's birthday party.
• C. A diet of healthy fruits, such as bananas and kiwis, is best for the child.
• D. An epinephrine auto-injector will be on hand to treat allergic reactions.

Correct answer: C

Rationale: The correct answer is C. Bananas and kiwis are foods that can cross-react with latex allergy, indicating that the parents need further teaching on managing latex allergies. Choices A, B, and D are correct as rubber-free toys, using foil balloons, and having an epinephrine auto-injector are appropriate measures to prevent and manage allergic reactions in a child with a latex allergy.

3. A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

• A. red and edematous stoma appearance
• B. liquid brown drainage from stoma
• C. stoma output of 40ml in the last hour
• D. mucous strings floating in the drainage

Correct answer: C

Rationale: Stoma output of only 40ml in the last hour may indicate a problem, such as dehydration or blockage, and should be reported immediately. A red and edematous stoma appearance could be due to inflammation, which is expected in the early postoperative period. Liquid brown drainage from the stoma is a normal finding. Mucous strings floating in the drainage are also a common occurrence postoperatively and do not typically require immediate reporting.

4. The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? (Select all that apply)

• A. apple juice
• B. black coffee
• C. orange juice
• D. hot chocolate

Correct answer: A

Rationale: The correct answer is A: apple juice. Clear liquids like apple juice and orange juice are suitable for a client following a clear liquid diet and Mormon beliefs. Options B and D, black coffee and hot chocolate, contain caffeine, which may not align with the client's religious dietary restrictions. Therefore, these options should be avoided for this client.

5. A male client with unstable angina needs a cardiac catheterization. So the healthcare provider explains the risks and benefits of the procedure and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take?

• A. Answer the client's specific questions with a short, understandable explanation
• B. Postpone the procedure until the client understands the risks and benefits
• C. Call the client's next of kin and ask them to provide verbal consent
• D. Page the healthcare provider to return and provide additional explanation

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to page the healthcare provider to return and provide additional explanation. It is crucial for the client to have a clear understanding of the procedure, including its risks and benefits, before signing the consent form. While the nurse can provide general information, the detailed explanation of how the procedure works and its effects should come from the healthcare provider who will perform the procedure. Postponing the procedure until the client understands is appropriate, but the immediate need is to clarify the client's concerns with the healthcare provider. Calling the client's next of kin for verbal consent is not the correct course of action as the client is present and able to provide consent after receiving adequate information.

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