Nursing Elites

1. What is appropriate care for a client with neutropenia?

• A. Avoiding fresh fruits and vegetables.
• B. Having a private room.
• C. Wearing a mask when out of the room.
• D. Practicing routine hand washing.

Correct answer: C

Rationale: When a client has neutropenia, they have low white blood cell levels, which increases the risk of infections due to a weakened immune system. Wearing a mask when out of the room is crucial to reduce the risk of exposure to respiratory infections. Avoiding fresh fruits and vegetables is also necessary as they may contain harmful pathogens. Having a private room helps minimize exposure to pathogens and ensures that visitors are carefully screened for any signs of illness. Routine hand washing is essential to prevent the spread of infections in the healthcare setting, but the most direct measure to protect the client from potential infections is wearing a mask when out of the room.

2. In a client with asthma who develops respiratory acidosis, what should the nurse expect the client's serum potassium level to be?

• A. normal
• B. elevated
• C. low
• D. unrelated to the pH

Correct answer: B

Rationale: In respiratory acidosis, the serum potassium level is expected to be elevated. This occurs because potassium shifts from cells into the bloodstream as a compensatory mechanism to maintain acid-base balance. Choices A, C, and D are incorrect. A normal potassium level is not expected in respiratory acidosis. A low potassium level is more commonly associated with alkalosis, not acidosis. The potassium level is indeed related to pH changes in respiratory acidosis, leading to the expected elevation.

3. The nurse is caring for a client with full-thickness burns to the left arm and trunk. What is the priority for this client?

• A. Pain management
• B. Airway assessment
• C. Fluid volume status monitoring
• D. Risk for infection prevention

Correct answer: C

Rationale: Correct! With full-thickness burns, there is a significant risk of fluid loss through the burn wound and fluid shift, leading to hypovolemia and shock. Monitoring and maintaining the client's fluid volume status is crucial to prevent complications like hypovolemic shock. Pain management (Option A) is essential but not the priority in this situation. While airway assessment (Option B) is crucial, it is typically assessed first in clients with respiratory distress. Preventing infection (Option D) is important but managing fluid volume status takes precedence in the initial care of a client with full-thickness burns.

4. Why is it often necessary to draw a complete blood count and differential (CBC/differential) when a client is being treated with an antiepileptic drug (AED)?

• A. The hematocrit is adversely affected due to increased vascular volume.
• B. AEDs can lead to blood dyscrasia as a side effect.
• C. AEDs may cause aplastic anemia and megaloblastic anemia.
• D. Some AEDs induce white blood cell reduction.

Correct answer: B

Rationale: When a client is being treated with antiepileptic drugs (AEDs), it is essential to monitor for potential side effects on blood parameters. Some AEDs can lead to blood dyscrasia, which includes conditions like aplastic anemia and megaloblastic anemia. Therefore, drawing a complete blood count and differential helps in identifying these adverse effects early. Choices A, C, and D are incorrect because the primary concern when monitoring blood parameters in clients on AEDs is the risk of blood dyscrasia, not changes in hematocrit due to vascular volume, white blood cell reduction, or immune modulation.

5. The nurse overhears two nursing students talking about a client in the cafeteria. What should the nurse do first?

• A. Report the incident to the nursing supervisor.
• B. Write up a variance report about the incident.
• C. Instruct the students that this is a violation of HIPAA.
• D. Notify the students' faculty regarding the violation.

Correct answer: C

Rationale: The correct answer is to instruct the students that discussing a client in a public area like the cafeteria violates HIPAA regulations. This is important to educate the students about patient confidentiality and the consequences of breaching it. Reporting to the nursing supervisor or faculty should come after addressing the students directly. Writing up a variance report is not the immediate action needed in this situation, as educating the students about their mistake should be the priority. It is essential to address the issue at the source by educating the students first rather than escalating the matter to supervisors or faculty immediately.

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