Nursing Elites

1. A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3. Which intervention is most important for the nurse to include in this client’s plan of care?

• A. Monitor for signs of activity intolerance
• B. Require visitors to wear respiratory masks
• C. Assess urine and stool for occult blood
• D. Obtain client’s temperature q4 hours

Correct answer: C

Rationale: The correct answer is to assess urine and stool for occult blood. With a low platelet count, there is an increased risk of bleeding. Monitoring for occult blood is essential to detect any signs of internal bleeding. Choices A, B, and D are not the priority interventions in this situation. While monitoring for signs of activity intolerance, requiring visitors to wear respiratory masks, and obtaining the client's temperature are important aspects of care, they are not as critical as assessing for occult blood in a client with a low platelet count.

2. A client with a BMI of 60.2 kg/m² is admitted to the intensive care unit 3 weeks after gastric bypass with gastric rupture and impending multiple organ dysfunction syndrome (MODS). What should the nurse prepare to implement first?

• A. Mechanical ventilation
• B. Platelet transfusion
• C. Loop diuretic therapy
• D. Cyanocobalamin administration

Correct answer: A

Rationale: In this critical situation with gastric rupture and impending MODS, the priority intervention should be mechanical ventilation. This client is at risk of respiratory compromise due to the severity of the condition. Platelet transfusion (Choice B) is not the priority as there is no indication of significant bleeding. Loop diuretic therapy (Choice C) and cyanocobalamin administration (Choice D) are not the immediate priorities in this scenario and would not address the urgent need for respiratory support.

3. When deciding whether to join a nursing strike called after collective bargaining efforts have failed, which factor is most important for the nurse to consider?

• A. Nurse Practice Act of the State
• B. The role of nurses as client advocates
• C. Standards of clinical nursing practice
• D. Personal value system

Correct answer: B

Rationale: The correct answer is B. The role of nurses as client advocates is crucial when considering the impact of a strike on patient care. Nurses have a responsibility to advocate for their patients' well-being at all times. Choices A, C, and D, although important, are not the most critical factor to consider in this situation. The Nurse Practice Act of the State is essential for guiding nursing practice, standards of clinical nursing practice ensure quality care, and personal values are important; however, the primary focus during a strike should be on the role of nurses as client advocates.

4. A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider?

• A. Pain scale rating of 9 on a 0-10 scale
• B. Last menstrual period was 7 weeks ago
• C. Reports white curdy vaginal discharge
• D. History of irritable bowel syndrome (IBS)

Correct answer: B

Rationale: The correct answer is B. A missed menstrual period could indicate a possible pregnancy-related issue, requiring urgent evaluation. Assessing the menstrual history in a female of reproductive age takes precedence in this scenario. Choice A, the pain scale rating, is important but not as urgent as evaluating the menstrual history. Choice C, reporting white curdy vaginal discharge, may suggest a vaginal infection but is not as critical as ruling out a potential pregnancy. Choice D, the history of irritable bowel syndrome, is relevant but not as crucial as determining pregnancy-related issues in this context.

5. Two hours after delivering a 9-pound infant, a client saturates a perineal pad every 15 minutes. Although an IV containing Pitocin is infusing, her uterus remains boggy, even with massage. The healthcare provider prescribes methylergometrine maleate (Methergine) 0.2 mg IM STAT. Which complication should the nurse be alert to this client developing?

• A. Decreased respiratory rate
• B. Increased temperature
• C. Tachycardia
• D. Hypertension

Correct answer: D

Rationale: The correct answer is D: Hypertension. Methylergometrine maleate (Methergine) is a medication used to prevent or control postpartum hemorrhage by causing uterine contractions. One of the potential side effects is hypertension. Therefore, the nurse should closely monitor the client's blood pressure after administering Methergine. Choices A, B, and C are incorrect because Methergine is not known to cause decreased respiratory rate, increased temperature, or tachycardia.

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