Nursing Elites

1. A nurse works on an oncology unit and delegates personal hygiene to assistive personnel (AP). What action by the AP requires intervention from the nurse?

• A. Allowing a very tired client to skip oral hygiene and sleep.
• B. Assisting clients with washing the perianal area every 12 hours.
• C. Helping the client use a soft-bristled toothbrush for oral care.
• D. Reminding the client to rinse the mouth with water or saline.

Correct answer: A

Rationale: Skipping oral hygiene is not appropriate for a client, even if they are tired, as it increases the risk of infection.

2. A client with cancer is receiving palliative care. Which statement by the client indicates an understanding of palliative care?

• A. Palliative care focuses on managing symptoms and improving quality of life.
• B. Palliative care is only provided when curative treatment is no longer an option.
• C. Palliative care includes interventions to prolong life at all costs.
• D. Palliative care provides support for both the client and their family.

Correct answer: A

Rationale: The correct answer is A. Palliative care focuses on managing symptoms and improving the quality of life for clients with serious illnesses like cancer. Choice B is incorrect as palliative care can be provided alongside curative treatments. Choice C is incorrect because palliative care does not aim to prolong life at all costs; it focuses on improving the quality of life. Choice D is partially correct but does not fully capture the essence of palliative care, which includes symptom management and holistic support for the client and their family.

3. A nurse practitioner is assessing a patient who has a fever, malaise, and a white blood cell count that is elevated. Which of the following principles should guide the nurses management of the patients care?

• A. There is a need for the patient to be assessed for lymphoma.
• B. Infection is the most likely cause of the patients change in health status.
• C. The patient is exhibiting signs and symptoms of leukemia.
• D. The patient should undergo diagnostic testing for multiple myeloma.

Correct answer: B

Rationale: An elevated white blood cell (WBC) count, also known as leukocytosis, is most commonly a response to infection. When the body detects an infection, the immune system responds by increasing the production of white blood cells to fight off the invading pathogens. The accompanying symptoms of fever and malaise are typical signs of infection, supporting the likelihood that this patient’s health status is related to an infectious process rather than a more serious hematologic condition like lymphoma or leukemia.

4. A nurse is caring for a patient diagnosed with chronic myeloid leukemia (CML) who is receiving the drug imatinib (Gleevec). What should the nurse monitor in this patient to assess for side effects of this therapy?

• A. Cardiac function
• B. Renal function
• C. Liver function
• D. Pulmonary function

Correct answer: A

Rationale: The correct answer is A: Cardiac function. Imatinib can cause fluid retention and heart failure, so cardiac function should be closely monitored. Renal function (choice B) is not typically affected by imatinib. Liver function (choice C) is not the primary concern with this medication. Pulmonary function (choice D) is not directly impacted by imatinib therapy.

5. A client in the emergency department reports difficulty breathing. The nurse assesses the client’s appearance as depicted below: What action by the nurse is most important?

• A. Assess blood pressure and pulse.
• B. Attach the client to a pulse oximeter.
• C. Have the client rate his or her pain.
• D. Facilitate urgent radiation therapy.

Correct answer: A

Rationale: The correct action by the nurse is to assess the client's blood pressure and pulse. Difficulty breathing can be a sign of various conditions, including cardiac issues. Assessing blood pressure and pulse helps in determining the client's hemodynamic status and identifying any cardiovascular compromise. Option B is less crucial as attaching the client to a pulse oximeter may provide oxygen saturation levels but does not directly assess cardiac output. Option C is not the priority in this situation as the client's difficulty breathing is a more urgent concern. Option D is incorrect as urgent radiation therapy is not indicated based on the client's presentation.

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