Nursing Elites

1. Nurse Farah is caring for a client following a mastectomy. Which assessment finding indicates that the client is experiencing a complication related to the surgery?

• A. Pain at the incision site
• B. Arm edema on the operative side
• C. Sanguineous drainage in the Jackson-Pratt drain
• D. Complaints of decreased sensation near the operative site

Correct answer: B

Rationale: Arm edema on the operative side (lymphedema) is a known complication after a mastectomy. This can indicate impaired lymphatic drainage, leading to fluid accumulation in the arm. Pain at the incision site is expected postoperatively and may not necessarily indicate a complication. Sanguineous drainage in the Jackson-Pratt drain is a common finding in the immediate postoperative period. Complaints of decreased sensation near the operative site could be related to nerve damage or surgical manipulation, but it is not a typical complication after a mastectomy.

2. When reviewing the safe administration of antineoplastic agents, what action should the nurse emphasize?

• A. Adjust the dose based on the patient's present symptoms.
• B. Wash hands with an alcohol-based cleanser before and after administration.
• C. Use gloves and a lab coat when preparing and administering the medication.
• D. Dispose of the antineoplastic wastes in the hazardous waste receptacle.

Correct answer: D

Rationale: The correct answer is to dispose of the antineoplastic wastes in the hazardous waste receptacle. Antineoplastic agents are hazardous materials, and proper disposal is crucial to prevent harm to individuals and the environment. Option A is incorrect because adjusting the dose based on the patient's present symptoms may not be safe without proper authorization. Option B is incorrect as hand hygiene should be performed both before and after administering medications. Option C is incorrect as gloves and a lab coat should be worn primarily during handling and administration, not just during preparation.

3. An oncology nurse is caring for a patient with multiple myeloma who is experiencing bone destruction. When reviewing the patient's most recent blood tests, the nurse should anticipate what imbalance?

• A. Hypercalcemia
• B. Hyperproteinemia
• C. Elevated serum viscosity
• D. Elevated RBC count

Correct answer: A

Rationale: The correct answer is A, Hypercalcemia. In multiple myeloma, bone destruction can lead to the release of calcium from the bones into the bloodstream, causing hypercalcemia. This imbalance is commonly seen in patients with multiple myeloma. Choice B, Hyperproteinemia, is not typically associated with bone destruction in multiple myeloma. Choice C, Elevated serum viscosity, and Choice D, Elevated RBC count, are not directly related to the bone destruction seen in multiple myeloma.

4. A patient with Hodgkin lymphoma is receiving radiation therapy. What side effect should the nurse monitor for that is most common with this type of treatment?

• A. Alopecia
• B. Fatigue
• C. Nausea
• D. Mucositis

Correct answer: D

Rationale: Mucositis is a common side effect of radiation therapy that should be closely monitored.

5. The nurse is caring for a client who is postoperative following a pelvic exenteration, and the health care provider changes the client's diet from NPO status to clear liquids. The nurse should check which priority item before administering the diet?

• A. Bowel sounds
• B. Ability to ambulate
• C. Incision appearance
• D. Urine specific gravity

Correct answer: A

Rationale: The correct answer is A: Bowel sounds. Checking for bowel sounds is crucial before administering any diet to ensure the gastrointestinal tract is functioning properly following surgery. This assessment helps prevent complications such as paralytic ileus. Choices B, C, and D are not the priority in this situation. While the ability to ambulate, incision appearance, and urine specific gravity are important assessments, ensuring bowel function takes precedence in this postoperative scenario.

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