Nursing Elites

1. A nurse is creating a plan of care for an oncology patient and one of the identified nursing diagnoses is risk for infection related to myelosuppression. What intervention addresses the leading cause of infection-related death in oncology patients?

• A. Encourage several small meals daily.
• B. Provide skin care to maintain skin integrity.
• C. Assist the patient with hygiene, as needed.
• D. Assess the integrity of the patient’s oral mucosa regularly.

Correct answer: B

Rationale: In oncology patients, particularly those undergoing chemotherapy or radiation therapy, myelosuppression (the decrease in bone marrow activity that leads to reduced white blood cells, red blood cells, and platelets) increases the risk of infection. Maintaining skin integrity is crucial because the skin acts as the body's first line of defense against infections. If the skin becomes compromised, such as through radiation burns, rashes, or breakdowns, it provides a potential entry point for pathogens, increasing the risk of infection. Since infections in oncology patients can quickly become severe due to their weakened immune systems, maintaining skin integrity is a critical intervention to reduce infection risk, especially for patients who are immunosuppressed.

2. A patient with advanced leukemia is responding poorly to treatment. The nurse finds the patient tearful and trying to express his feelings, but he is clearly having difficulty. What is the nurses most appropriate action?

• A. Tell him that you will give him privacy and leave the room.
• B. Offer to call pastoral care.
• C. Ask if he would like you to sit with him while he collects his thoughts.
• D. Tell him that you can understand how hes feeling.

Correct answer: C

Rationale: Providing emotional support and discussing the uncertain future are crucial.

3. A client is receiving rituximab. What assessment by the nurse takes priority?

• A. Blood pressure.
• B. Temperature.
• C. Oral mucous membranes.
• D. Pain.

Correct answer: A

Rationale: When a client is receiving rituximab, the nurse's priority assessment should be monitoring the blood pressure. Rituximab can lead to infusion-related reactions, such as hypotension. Therefore, assessing the client's blood pressure is crucial to detect and manage any potential adverse reactions promptly. While monitoring temperature, oral mucous membranes, and pain are essential aspects of care, they are not the priority when a client is receiving rituximab.

4. A nurse is caring for a patient who is being treated for leukemia in the hospital. The patient was able to maintain her nutritional status for the first few weeks following her diagnosis but is now exhibiting early signs and symptoms of malnutrition. In collaboration with the dietitian, what intervention should the nurse implement?

• A. Arrange for total parenteral nutrition (TPN).
• B. Facilitate placement of a percutaneous endoscopic gastrostomy (PEG) tube.
• C. Provide the patient with several small, soft-textured meals each day.
• D. Assign responsibility for the patient's nutrition to the patient's friends and family.

Correct answer: C

Rationale: For patients experiencing difficulties with oral intake, the provision of small, easily chewed meals may be beneficial. Option A (TPN) and B (PEG tube placement) are more invasive interventions and should be considered if non-oral routes are necessary. Option D is not appropriate as the primary responsibility for a patient's nutrition should lie with healthcare professionals to ensure proper management and monitoring.

5. The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment?

• A. The client's pain rating
• B. Nonverbal cues from the client
• C. The nurse's impression of the client's pain
• D. Pain relief after appropriate nursing intervention

Correct answer: A

Rationale: The correct answer is A: The client's pain rating. Pain assessment should primarily rely on the client's self-report for the most accurate determination of pain intensity. Nonverbal cues from the client (choice B) can provide additional information but should not replace the client's self-report. The nurse's impression of the client's pain (choice C) may be subjective and less reliable than the client's self-assessment. Pain relief after appropriate nursing intervention (choice D) is an important outcome but does not replace the initial assessment of the client's pain.

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