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. A patient with heart failure has gained 5 pounds in the last 3 days. What is the nurse's priority intervention?

• A. Restrict the patient's fluid intake.
• B. Monitor the patient's daily weight.
• C. Administer diuretics as prescribed.
• D. Increase the patient's salt intake to promote fluid balance.

Correct answer: B

Rationale: The correct answer is to monitor the patient's daily weight. In heart failure, sudden weight gain indicates fluid retention, which can worsen the condition. Monitoring daily weight helps in early detection of fluid accumulation, allowing timely intervention. Restricting fluid intake (choice A) may be necessary but is not the priority at this point. Administering diuretics (choice C) should be done based on healthcare provider orders, not the nurse's independent decision. Increasing salt intake (choice D) is contraindicated in heart failure as it can exacerbate fluid retention.

3. A healthcare provider is assessing a client who has carpal tunnel syndrome. The provider should expect which of the following findings?

• A. Positive Chvostek's sign
• B. Cool extremities
• C. Positive Phalen's sign
• D. Decreased radial pulse

Correct answer: C

Rationale: Phalen's sign is often positive in clients with carpal tunnel syndrome due to nerve compression. Chvostek's sign (Choice A) is related to hypocalcemia, cool extremities (Choice B) are not typically associated with carpal tunnel syndrome, and decreased radial pulse (Choice D) is not a common finding in carpal tunnel syndrome.

4. What is the most important nursing action when caring for a patient with a central venous catheter (CVC)?

• A. Monitor the patient's blood pressure regularly.
• B. Change the CVC dressing every 72 hours.
• C. Flush the CVC with normal saline every shift.
• D. Avoid using the CVC for blood draws.

Correct answer: B

Rationale: The most important nursing action when caring for a patient with a central venous catheter (CVC) is to change the CVC dressing every 72 hours. This practice reduces the risk of infection and ensures the catheter remains secure. Monitoring the patient's blood pressure regularly is important but not the most crucial action when managing a CVC. Flushing the CVC with normal saline is essential but not the most important action. Avoiding using the CVC for blood draws is a good practice, but it is not the most critical nursing action in this scenario.

5. A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

• A. Elevate the head of the bed no more than 45 degrees
• B. Apply cornstarch to keep sensitive skin areas dry
• C. Massage the skin over the client's bony prominences
• D. Use a transfer device to lift the client up in bed

Correct answer: D

Rationale: The correct answer is to use a transfer device to lift the client up in bed. This intervention helps reduce friction and the risk of skin breakdown, aiding in the prevention of pressure ulcers. Elevating the head of the bed no more than 45 degrees can help with respiratory issues but does not directly address skin integrity. Applying cornstarch may lead to further skin irritation. Massaging over bony prominences can increase the risk of skin damage rather than maintaining skin integrity.

Similar Questions