Nursing Elites

1. A client is admitted with superior vena cava syndrome. What action by the nurse is most appropriate?

• A. Administer a dose of allopurinol.
• B. Assess the client’s serum potassium level.
• C. Gently inquire about advance directives.
• D. Prepare the client for emergency surgery.

Correct answer: C

Rationale: The correct answer is to gently inquire about advance directives. Superior vena cava syndrome is often a late-stage manifestation, indicating a serious condition. Discussing advance directives with the client is crucial to ensure their wishes are known in case of deterioration. Administering allopurinol (Choice A) is not indicated for superior vena cava syndrome. Assessing the client’s serum potassium level (Choice B) is not the priority when managing this syndrome. Emergency surgery (Choice D) is not typically the initial treatment for superior vena cava syndrome.

2. Gastric cancer is known to have numerous risk factors. Which of the following is not a risk factor?

• A. Diet high in sodium
• B. Diet with high amounts of chili garlic
• C. Smoking
• D. Diet high in fiber

Correct answer: D

Rationale: A diet high in fiber is not a risk factor for gastric cancer; in fact, it is generally considered protective against cancers. High sodium intake (Choice A) has been associated with an increased risk of gastric cancer. Diets with high amounts of chili garlic (Choice B) may irritate the stomach lining, potentially contributing to the development of gastric cancer. Smoking (Choice C) is a well-established risk factor for various types of cancers, including gastric cancer.

3. A clinic patient is being treated for polycythemia vera, and the nurse is providing health education. What practice should the nurse recommend to prevent the complications of this health problem?

• A. Avoiding natural sources of vitamin K
• B. Avoiding altitudes of 1500 feet (457 meters)
• C. Performing active range of motion exercises daily
• D. Avoiding tight and restrictive clothing on the legs

Correct answer: D

Rationale: The correct answer is D: Avoiding tight and restrictive clothing on the legs. Patients with polycythemia vera are at risk of deep vein thrombosis (DVT), so it is essential to avoid tight and restrictive clothing that can impede circulation. Choices A, B, and C are incorrect because avoiding natural sources of vitamin K, altitudes of 1500 feet, and performing active range of motion exercises are not directly related to preventing complications of polycythemia vera.

4. The nurse has taught a client with cancer ways to prevent infection. What statement by the client indicates that more teaching is needed?

• A. I should take my temperature daily and when I don’t feel well.
• B. I will discard perishable liquids after sitting out for over an hour.
• C. I won’t let anyone share any of my personal toiletries.
• D. It’s alright for me to keep my pets and change the litter box.

Correct answer: D

Rationale: Clients with cancer, especially those undergoing chemotherapy or other immunosuppressive treatments, are at increased risk for infections due to a weakened immune system. Changing a litter box exposes the client to pathogens such as Toxoplasma gondii and other harmful bacteria or parasites found in cat feces, which could lead to serious infections. It is recommended that immunocompromised individuals avoid activities like changing litter boxes to reduce their risk of exposure to infectious agents. A family member or caregiver should handle this task to protect the client.

5. A patient with a myelodysplastic syndrome is being treated on the medical unit. What assessment finding should prompt the nurse to contact the patients primary care provider?

• A. The patient is experiencing a frontal lobe headache.
• B. The patient has an episode of urinary incontinence.
• C. The patient has an oral temperature of 37.5C (99.5F).
• D. The patients SpO2 is 91% on room air.

Correct answer: C

Rationale: Patients with myelodysplastic syndrome (MDS) have a dysfunctional bone marrow that leads to ineffective blood cell production, including white blood cells, which are crucial for fighting infections. As a result, they are at high risk for infections. Even a slight elevation in temperature, such as 37.5°C (99.5°F), could be an early sign of infection in an immunocompromised patient. Early detection and treatment of infections are critical in MDS patients, as infections can quickly become severe or life-threatening due to their compromised immune system.

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