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. 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.

3. A nurse is providing education to a patient with polycythemia vera about self-care strategies. What advice should the nurse include?

• A. Avoid hot showers
• B. Drink plenty of fluids
• C. Avoid tight and restrictive clothing
• D. Avoid prolonged sitting

Correct answer: B

Rationale: The correct advice for a patient with polycythemia vera is to drink plenty of fluids. This helps in reducing the risk of thrombosis by keeping the blood less viscous. Avoiding hot showers (Choice A) is not directly related to managing polycythemia vera. While avoiding tight and restrictive clothing (Choice C) can help improve circulation, it is not the most crucial advice for these patients. Avoiding prolonged sitting (Choice D) is important to prevent blood clots but is not as critical as staying well-hydrated.

4. Nurse Rose is caring for a client with cancer who has developed spinal cord compression. Which of the following symptoms would the nurse expect to find?

• A. Decreased deep tendon reflexes
• B. Severe headache
• C. Back pain
• D. Loss of bladder control

Correct answer: C

Rationale: The correct answer is C: 'Back pain.' Back pain is a common symptom of spinal cord compression in cancer patients. This condition can cause localized or radiating back pain due to the compression of the spinal cord or nerves. While symptoms such as decreased deep tendon reflexes, severe headache, and loss of bladder control can occur in other conditions, back pain is specifically associated with spinal cord compression in cancer patients.

5. The healthcare professional working with oncology clients understands that which age-related change increases the older client’s susceptibility to infection during chemotherapy?

• A. Decreased immune function.
• B. Diminished nutritional stores.
• C. Existing cognitive deficits.
• D. Poor physical reserves.

Correct answer: A

Rationale: The correct answer is A: Decreased immune function. Aging leads to a decline in immune function, which increases susceptibility to infections during chemotherapy. This decline is due to changes in the immune system that occur with age. Choices B, C, and D are incorrect because while they may impact overall health in older clients, they do not directly increase susceptibility to infections during chemotherapy like decreased immune function does.

Similar Questions