Nursing Elites

1. Nurse Cecilia is caring for a client who has undergone a vaginal hysterectomy. The nurse avoids which of the following in the care of this client?

• A. Elevating the knee gatch on the bed
• B. Assisting with range-of-motion leg exercises
• C. Removal of antiembolism stockings twice daily
• D. Checking placement of pneumatic compression boots

Correct answer: A

Rationale: The correct answer is A. Elevating the knee gatch on the bed should be avoided in the care of a client who has undergone a vaginal hysterectomy. This action can inhibit venous return, increasing the risk of deep vein thrombosis or thrombophlebitis. Choices B, C, and D are appropriate nursing interventions for postoperative care to prevent complications and promote circulation.

2. A nurse is providing care to a patient who has just received a diagnosis of acute myeloid leukemia (AML). What is the priority nursing diagnosis for this patient?

• A. Risk for bleeding
• B. Risk for infection
• C. Impaired gas exchange
• D. Imbalanced nutrition

Correct answer: B

Rationale: Risk for infection is a high priority due to the patient's compromised immune system from AML.

3. An oncology nurse is caring for a patient who has developed erythema following radiation therapy. What should the nurse instruct the patient to do?

• A. Periodically apply ice to the area.
• B. Keep the area cleanly shaven.
• C. Apply petroleum jelly to the affected area.
• D. Avoid using soap on the treatment area.

Correct answer: D

Rationale: The correct answer is D. When a patient develops erythema following radiation therapy, it is essential to avoid further irritation and potential infection. Using soap on the affected area can exacerbate the condition. Applying ice (choice A) may provide temporary relief for discomfort but does not address the underlying issue. Keeping the area cleanly shaven (choice B) is not necessary and may increase the risk of skin irritation. Applying petroleum jelly (choice C) can trap heat and worsen the erythema, so it is not recommended.

4. A patient has been found to have an indolent neoplasm. The nurse should recognize what implication of this condition?

• A. The patient faces a significant risk of malignancy.
• B. The patient has a myeloid form of leukemia.
• C. The patient has a lymphocytic form of leukemia.
• D. The patient has a major risk factor for hemophilia.

Correct answer: A

Rationale: The correct answer is A: 'The patient faces a significant risk of malignancy.' Indolent neoplasms are characterized by their slow growth and relatively low malignancy potential; however, they do have the capability to progress to malignancy over time. Choices B, C, and D are incorrect because they make assumptions about specific types of leukemia and hemophilia, which are not necessarily related to the presence of an indolent neoplasm.

5. Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients would the nurse assess first?

• A. Dry, itchy, peeling skin.
• B. Serum calcium of 9.2 mg/dL (2.3 mmol/L).
• C. Serum potassium of 2.8 mEq/L (2.8 mmol/L).
• D. Weight gain of 0.5 lb (1.1 kg) in 1 day.

Correct answer: C

Rationale: A potassium level of 2.8 mEq/L is critically low and requires immediate intervention.

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