Nursing Elites

1. Nurse Jane is providing care for a client with superior vena cava syndrome. Which of the following interventions would be the priority?

• A. Elevate the head of the bed
• B. Administer steroids as prescribed
• C. Provide supplemental oxygen
• D. Administer diuretics as prescribed

Correct answer: A

Rationale: The correct answer is to elevate the head of the bed. Elevating the head of the bed can help reduce the pressure on the superior vena cava, improve venous return, and facilitate breathing in clients with superior vena cava syndrome. Administering steroids (Choice B) may be necessary in some cases, but it is not the priority in the immediate care of a client with superior vena cava syndrome. Providing supplemental oxygen (Choice C) may help improve oxygenation but does not directly address the underlying issue of venous congestion. Administering diuretics (Choice D) may be contraindicated as it can further decrease preload and worsen the condition in superior vena cava syndrome.

2. The nurse is caring for a client with multiple myeloma and is monitoring the client for signs of hypercalcemia. Which symptom would be an early indication?

• A. Polyuria
• B. Polyphagia
• C. Polydipsia
• D. Weight loss

Correct answer: A

Rationale: In patients with multiple myeloma, hypercalcemia is a common complication due to the release of calcium from the bones as a result of osteolytic lesions. One of the early symptoms of hypercalcemia is polyuria, or increased urine output. This occurs because elevated calcium levels can lead to impaired renal function and increased renal excretion of calcium, which results in increased urine production. Early recognition of polyuria can help prompt further evaluation and management of hypercalcemia, as untreated hypercalcemia can lead to more severe complications.

3. A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate?

• A. Are you getting adequate rest and sleep each day?
• B. It is normal to be fatigued even for months afterward.
• C. This is not normal and I’ll let the primary health care provider know.
• D. Try adding more vitamins B and C to your diet.

Correct answer: B

Rationale: Radiation-induced fatigue can last for months; it’s important to normalize this for the client.

4. A nurse is planning the care of a patient who has been diagnosed with essential thrombocythemia (ET). What nursing diagnosis should the nurse prioritize when choosing interventions?

• A. Risk for Ineffective Tissue Perfusion
• B. Risk for Imbalanced Fluid Volume
• C. Risk for Ineffective Breathing Pattern
• D. Risk for Ineffective Thermoregulation

Correct answer: A

Rationale: Essential thrombocythemia (ET) is a myeloproliferative disorder characterized by an abnormally high platelet count, which increases the risk of hypercoagulation and thrombosis (blood clot formation). These clots can impair blood flow to tissues, leading to ineffective tissue perfusion. Thrombotic events, such as strokes, deep vein thrombosis, or myocardial infarctions, are common complications of ET, making Risk for Ineffective Tissue Perfusion the most critical nursing diagnosis to prioritize. The goal of nursing interventions will be to prevent clot formation and ensure adequate blood flow to tissues.

5. During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which symptom as typical of the disease?

• A. Diarrhea
• B. Hypermenorrhea
• C. Abnormal bleeding
• D. Abdominal distention

Correct answer: D

Rationale: Abdominal distention is a common symptom in advanced ovarian cancer due to several factors, including the accumulation of ascites (fluid in the abdominal cavity) and the presence of tumors that can increase abdominal girth. As the disease progresses, the pressure from growing masses or fluid buildup can lead to noticeable swelling and discomfort in the abdomen. This symptom often prompts further evaluation and can significantly impact the patient’s quality of life.

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