Nursing Elites

1. A patient receiving chemotherapy has developed neutropenia. What should be included in the care plan to reduce infection risk?

• A. Monitor temperature daily
• B. Limit visitors
• C. Administer antibiotics prophylactically
• D. Use reverse isolation precautions

Correct answer: D

Rationale: When a patient receiving chemotherapy develops neutropenia, the priority is to reduce the risk of infection. Using reverse isolation precautions is crucial in this situation to protect the patient from exposure to pathogens. Monitoring temperature daily (Choice A) is important but is not as effective as isolating the patient. Limiting visitors (Choice B) can help reduce the risk of exposure, but reverse isolation is a more stringent measure. Administering antibiotics prophylactically (Choice C) is not recommended unless there is a specific indication, as it can contribute to antibiotic resistance.

2. While caring for a client receiving morphine, what assessment is the priority for a nurse to conduct?

• A. Blood pressure
• B. Heart rate
• C. Respiratory rate
• D. Temperature

Correct answer: C

Rationale: The correct answer is monitoring the respiratory rate. Morphine can depress respiratory function, leading to respiratory depression or arrest. Therefore, closely monitoring the client's respiratory rate is crucial to detect any signs of respiratory distress. While blood pressure, heart rate, and temperature are important assessments, in this scenario, respiratory rate takes precedence due to the potential respiratory complications associated with morphine administration.

3. A client is preparing for a surgical procedure but refuses to remove religious jewelry. What is the best course of action?

• A. Proceed with surgery and document the refusal.
• B. Ask the client for permission to secure the jewelry.
• C. Remove the jewelry and store it safely.
• D. Postpone the surgery until the jewelry is removed.

Correct answer: B

Rationale: The best course of action is to ask the client for permission to secure the jewelry. This respects the client's religious beliefs while also ensuring that the jewelry does not interfere during the surgical procedure. Proceeding with surgery without addressing the presence of the jewelry can lead to complications or distress for the client. Removing the jewelry without consent or postponing the surgery solely due to the presence of religious jewelry are not appropriate actions in this situation.

4. A nurse is caring for a newborn in the nursery following a circumcision. The newborn's grandparent, who does not have an identification bracelet, requests to take the newborn to his parents' room. Which of the following actions should the nurse take?

• A. Check the newborn's identification bracelet against the chart
• B. Obtain permission from the newborn's parents
• C. Respectfully deny the grandparent's request
• D. Review the newborn's footprints record

Correct answer: C

Rationale: In this scenario, where the grandparent lacks proper identification, the nurse should respectfully deny the request to take the newborn. It is crucial to prioritize the newborn's safety and security by following hospital policies and procedures. Checking the newborn's identification bracelet against the chart (Choice A) may not be sufficient to address the situation at hand, as the grandparent's lack of identification is the primary concern. While obtaining permission from the newborn's parents (Choice B) is important, the lack of proper identification from the grandparent takes precedence. Reviewing the newborn's footprints record (Choice D) is not necessary in this situation, as the immediate concern is ensuring proper identification and security before allowing the newborn to leave the nursery.

5. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

• A. Inject at a 90-degree angle
• B. Inject at a 45-degree angle
• C. Massage the injection site after administering
• D. Use a longer needle

Correct answer: B

Rationale: The correct answer is to inject enoxaparin subcutaneously at a 45-degree angle. This angle helps ensure proper delivery of the medication into the subcutaneous tissue. Option A (Inject at a 90-degree angle) is incorrect because subcutaneous injections are usually given at a shallower angle. Option C (Massage the injection site after administering) is incorrect as massaging the site can cause bruising and should generally be avoided. Option D (Use a longer needle) is incorrect as using a longer needle is unnecessary and may increase the risk of injecting the medication too deeply.

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