Nursing Elites

1. A client who has been receiving chemotherapy for cancer has a platelet count of 20,000/mm3. Which intervention should the nurse include in the plan of care?

• A. Apply ice packs to bruised areas.
• B. Encourage frequent oral hygiene.
• C. Avoid invasive procedures.
• D. Place the client in a private room.

Correct answer: C

Rationale: The correct intervention for a client with a platelet count of 20,000/mm3 due to chemotherapy is to avoid invasive procedures. Chemotherapy can cause a decrease in platelet count, leading to an increased risk of bleeding. By avoiding invasive procedures, the nurse helps reduce the risk of bleeding complications. Applying ice packs to bruised areas (Choice A) may further increase the risk of bleeding due to the pressure and potential trauma to the skin. Encouraging frequent oral hygiene (Choice B) is important for overall health but does not directly address the risk of bleeding associated with a low platelet count. Placing the client in a private room (Choice D) is not directly related to managing the platelet count and risk of bleeding; it is more about privacy and infection control, which are important but not the priority in this scenario.

2. A public health nurse is working with a community to improve vaccination rates. Which intervention is most likely to be effective?

• A. Setting up vaccination clinics in accessible locations
• B. Distributing flyers with information about vaccines
• C. Offering incentives for getting vaccinated
• D. Partnering with local businesses to promote vaccination

Correct answer: A

Rationale: Setting up vaccination clinics in accessible locations is the most effective intervention to improve vaccination rates. This intervention ensures easy access to vaccination services for community members, removing barriers such as transportation or time constraints. Distributing flyers (Choice B) may increase awareness but may not directly address access issues. Offering incentives (Choice C) might temporarily boost vaccination rates but may not lead to sustained behavior change. Partnering with local businesses (Choice D) could be beneficial for promotion but may not directly impact vaccination accessibility.

3. A client with chronic kidney disease is receiving erythropoietin therapy. Which finding indicates that the therapy is effective?

• A. Hemoglobin of 12 g/dL.
• B. Reticulocyte count of 1%.
• C. Blood pressure of 130/80 mm Hg.
• D. Serum ferritin level of 100 ng/mL.

Correct answer: A

Rationale: The correct answer is A: Hemoglobin of 12 g/dL. Erythropoietin therapy stimulates red blood cell production, leading to an increase in hemoglobin levels. A hemoglobin level of 12 g/dL indicates that the therapy is effective in managing anemia associated with chronic kidney disease. Choice B, a reticulocyte count of 1%, is not a direct indicator of the effectiveness of erythropoietin therapy. Choice C, a blood pressure of 130/80 mm Hg, is important to monitor in clients with chronic kidney disease but does not specifically indicate the effectiveness of erythropoietin therapy. Choice D, a serum ferritin level of 100 ng/mL, is related to iron stores in the body and may be monitored during erythropoietin therapy but does not directly reflect the therapy's effectiveness in increasing red blood cell production.

4. During a follow-up visit, a client with hypertension reports that they often forget to take their medication. What should the nurse do first?

• A. educate the client on the importance of medication adherence
• B. explore the reasons for the client's forgetfulness
• C. provide the client with a pill organizer
• D. adjust the client's medication schedule

Correct answer: B

Rationale: The correct first action for the nurse is to explore the reasons for the client's forgetfulness. By understanding the underlying causes, the nurse can provide tailored interventions to help the client improve medication adherence. Providing education on the importance of adherence (Choice A) may be necessary but should come after identifying the reasons for forgetfulness. Simply providing a pill organizer (Choice C) or adjusting the medication schedule (Choice D) does not address the root cause of the forgetfulness and may not lead to sustained improvement in adherence.

5. An elderly client with a history of falls is being discharged from the hospital. Which intervention should the home health nurse implement to reduce the client's risk of falling at home?

• A. Install grab bars in the bathroom
• B. Provide a walker for ambulation
• C. Educate the client on fall prevention strategies
• D. Refer the client to a physical therapist

Correct answer: A

Rationale: Installing grab bars in the bathroom is crucial to reducing the elderly client's risk of falling at home. Grab bars provide physical support and stability, especially in areas like the bathroom where slips and falls are common among older adults. While providing a walker for ambulation (Choice B) can assist with mobility, it may not directly address the environmental hazards at home. Educating the client on fall prevention strategies (Choice C) is important but may not be sufficient if the physical environment is not modified to reduce fall risks. Referring the client to a physical therapist (Choice D) may help improve strength and balance but does not directly address the immediate environmental risk of falling at home.

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