Nursing Elites

1. A patient from the oncology unit asks the nurse about metastasis. Which of the following statements by the nurse requires immediate intervention by the head nurse?

• A. Metastasis is the replication of cells
• B. Metastasis can happen in most parts of the body
• C. The replication of cancer cells and travel from one area to another
• D. Metastasis is the spread of cancer cells

Correct answer: A

Rationale: The correct answer is A because metastasis refers to the spread of cancer cells to distant parts of the body, not the replication of cells. Choice B is correct as metastasis can indeed occur in various body parts. Choice C is incorrect as it inaccurately combines the concepts of replication and travel of cancer cells. Choice D is also correct as it accurately defines metastasis as the spread of cancer cells.

2. The nurse is caring for a female client experiencing neutropenia as a result of chemotherapy and develops a plan of care for the client. The nurse plans to:

• A. Restrict all visitors
• B. Restrict fluid intake
• C. Teach the client and family about the need for hand hygiene
• D. Insert an indwelling urinary catheter to prevent skin breakdown

Correct answer: C

Rationale: In clients experiencing neutropenia due to chemotherapy, the immune system is significantly compromised, leaving the client highly susceptible to infections. Meticulous hand hygiene is one of the most effective ways to prevent infections in neutropenic patients. Teaching the client and their family the importance of frequent and proper handwashing helps reduce the transmission of harmful pathogens that could lead to severe infections in the neutropenic client. This simple but essential intervention is crucial in maintaining a safe environment.

3. 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.

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 clinic nurse is working with a patient who has a long-standing diagnosis of polycythemia vera. How can the nurse best gauge the course of the patient's disease?

• A. Document the color of the patient's palms and face during each visit.
• B. Follow the patient's erythrocyte sedimentation rate over time.
• C. Document the patient's response to erythropoietin injections.
• D. Follow the trends of the patient's hematocrit.

Correct answer: D

Rationale: The course of polycythemia vera can be best ascertained by monitoring the patient's hematocrit, which should remain below 45%. Hematocrit levels are a key indicator in assessing the progression of the disease. Choices A, B, and C are not the most appropriate methods for gauging the course of polycythemia vera. Monitoring the color of the patient's palms and face, or their response to erythropoietin injections, may not provide an accurate reflection of the disease's progression. Similarly, while erythrocyte sedimentation rate can be affected in polycythemia vera, it is not the primary marker for monitoring the disease's course.

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