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 client who is at risk for disseminated intravascular coagulation (DIC) has a serum fibrinogen level of 110 mg/dL. The nurse should take which of the following actions first?

• A. Recheck the fibrinogen level in 4 hours
• B. Notify the health care provider
• C. Continue to monitor the client
• D. Administer cryoprecipitate as prescribed

Correct answer: B

Rationale: A serum fibrinogen level of 110 mg/dL indicates a low level, which puts the client at risk for bleeding in DIC. The priority action for the nurse is to notify the health care provider. Rechecking the fibrinogen level may delay necessary interventions, administering cryoprecipitate should be done based on the provider's prescription, and while monitoring is important, immediate notification of the provider is crucial to address the low fibrinogen level promptly.

3. In an adult patient, which assessment finding is considered diagnostic of Hodgkin lymphoma?

• A. Schwann cells
• B. Reed-Sternberg cells
• C. Lewy bodies
• D. Loops of Henle

Correct answer: B

Rationale: The correct answer is B: Reed-Sternberg cells. In Hodgkin lymphoma, the presence of Reed-Sternberg cells in lymph node biopsy is diagnostic. These cells are large, atypical cells originating from B-lymphocytes. They are distinctive in appearance and are key to diagnosing Hodgkin lymphoma. Choices A, C, and D are incorrect because Schwann cells are related to nerve function, Lewy bodies are associated with Parkinson's disease, and Loops of Henle are structures in the kidney, none of which are specific to Hodgkin lymphoma.

4. A nurse at a long-term care facility is amending the care plan of a resident who has just been diagnosed with essential thrombocythemia (ET). The nurse should anticipate the administration of what medication?

• A. Dalteparin
• B. Allopurinol
• C. Hydroxyurea
• D. Hydrochlorothiazide

Correct answer: C

Rationale: Hydroxyurea is effective in lowering the platelet count for patients with ET.

5. Nurse Maria is preparing a care plan for a client receiving external radiation therapy. Which of the following interventions should be included?

• A. Use heating pads on the treated area
• B. Wear loose, soft clothing over the treated area
• C. Expose the treated area to sunlight
• D. Apply ice packs to the treated area

Correct answer: B

Rationale: Radiation therapy can cause skin irritation, dryness, and sensitivity in the treated area. Wearing loose, soft clothing helps minimize friction and pressure on the skin, reducing irritation and promoting comfort. The skin in the treated area is often more sensitive and vulnerable to damage, so this intervention helps protect the skin while maintaining the client’s comfort during the course of treatment.

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