Nursing Elites

1. After completing her first chemotherapy treatment, what behavior indicates that a female client with breast cancer understands her discharge care needs?

• A. She refuses to take anti-nausea medication.
• B. She rents movies and borrows books to pass time at home.
• C. She plans to resume strenuous physical activity immediately.
• D. She reports severe fatigue and inability to perform daily activities.

Correct answer: B

Rationale: Renting movies and borrowing books for use during recovery indicates the client is planning restful activities at home, which aligns with appropriate post-chemotherapy care. Choices A, C, and D are incorrect because refusing anti-nausea medication can lead to complications, resuming strenuous physical activity immediately can be harmful, and reporting severe fatigue and inability to perform daily activities may indicate a need for medical attention rather than understanding discharge care needs.

2. A client has suspected compartment syndrome of the right lower leg. What is the nurse’s priority intervention?

• A. Elevate the right leg to reduce swelling.
• B. Loosen any restrictive dressings on the leg.
• C. Prepare the client for emergency surgery.
• D. Administer pain medication as prescribed.

Correct answer: B

Rationale: In a suspected case of compartment syndrome, the nurse's priority intervention is to loosen any restrictive dressings on the leg. This action helps to relieve pressure within the affected compartment, improve circulation, and prevent permanent damage. Elevating the leg may further increase pressure, preparing for emergency surgery is premature without proper assessment and diagnosis, and administering pain medication should come after addressing the primary issue of relieving pressure.

3. Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's care plan?

• A. Check platelet count
• B. Observe the color of urine
• C. Review liver function tests
• D. Monitor for bleeding

Correct answer: D

Rationale: Prasugrel is a platelet inhibitor, which increases the risk of bleeding. Monitoring for bleeding, particularly at the catheterization site and in other areas, is the most important assessment following administration of the drug. Checking platelet count and observing urine color are relevant but not as immediate. Reviewing liver function tests is not directly related to the adverse effects of prasugrel.

4. A client with a history of adrenal insufficiency is admitted with acute adrenal crisis. The client complains of nausea and joint pain, vital signs show a temperature of 102°F, heart rate of 138, and blood pressure of 80/60. Which intervention should the nurse implement first?

• A. Obtain an analgesic prescription.
• B. Infuse an intravenous fluid bolus.
• C. Administer PRN oral antipyretic.
• D. Cover the client with a cooling blanket.

Correct answer: B

Rationale: In acute adrenal crisis, the priority intervention is to infuse an intravenous fluid bolus to address the hypotension (blood pressure of 80/60) and help stabilize the client's condition. Adequate fluid volume is crucial in managing adrenal insufficiency crisis. Options A, C, and D do not directly address the hypotension and fluid volume depletion that are critical in this situation. Analgesics, antipyretics, and cooling blankets may be considered later, but the immediate focus should be on fluid resuscitation.

5. A client with deep vein thrombosis (DVT) is prescribed heparin therapy. What laboratory value should the nurse monitor?

• A. Monitor the client’s liver function tests.
• B. Monitor the client’s prothrombin time (PT).
• C. Monitor the client’s partial thromboplastin time (PTT).
• D. Monitor the client’s red blood cell count.

Correct answer: C

Rationale: The correct answer is C: Monitor the client’s partial thromboplastin time (PTT). During heparin therapy for DVT, it is essential to monitor the PTT to assess the effectiveness of the medication in preventing clot formation. Monitoring the PTT helps ensure that the client is within the therapeutic range for anticoagulation. Choices A, B, and D are incorrect because liver function tests, prothrombin time (PT), and red blood cell count are not specifically monitored to assess the effectiveness of heparin therapy in preventing clot formation.

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