Nursing Elites

1. The nurse is admitting an oncology patient to the unit prior to surgery. The nurse reads in the electronic health record that the patient has just finished radiation therapy. With knowledge of the consequent health risks, the nurse should prioritize assessments related to what health problem?

• A. Cognitive deficits
• B. Impaired wound healing
• C. Cardiac tamponade
• D. Tumor lysis syndrome

Correct answer: B

Rationale: The correct answer is B: Impaired wound healing. Patients who have undergone radiation therapy are at risk for impaired wound healing due to tissue damage. While cognitive deficits, cardiac tamponade, and tumor lysis syndrome can be concerns for oncology patients, the immediate priority following radiation therapy is assessing for impaired wound healing to prevent complications post-surgery.

2. A patient with chronic lymphocytic leukemia (CLL) is at risk for tumor lysis syndrome. What laboratory values should the nurse monitor to detect this complication?

• A. Creatinine and blood urea nitrogen (BUN)
• B. Electrolytes and uric acid levels
• C. Serum glucose and calcium levels
• D. Liver enzymes and bilirubin levels

Correct answer: B

Rationale: Electrolytes and uric acid levels are important to monitor for the development of tumor lysis syndrome.

3. The client is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care?

• A. I change my pouch every week.
• B. I change the appliance in the morning.
• C. I empty the urinary collection bag when it is two-thirds full.
• D. When I'm in the shower, I direct the flow of water away from my stoma.

Correct answer: D

Rationale: The correct answer is D because directing water away from the stoma while showering is incorrect. The stoma can and should be cleaned with water. Choices A, B, and C demonstrate proper stoma care practices, such as changing the pouch regularly, changing the appliance in the morning, and emptying the collection bag when it is two-thirds full, which are all appropriate actions for caring for a urinary stoma.

4. The cells of a normal individual can replicate in a specified rate. If the rate of replication becomes uncontrollable, which of the following is lacking from the patient?

• A. Apoptosis
• B. Contact inhibition
• C. Stable cells
• D. Labile cells

Correct answer: B

Rationale: Contact inhibition is a regulatory mechanism that prevents cells from proliferating once they reach a certain density. Normally, when cells grow and touch each other (such as in a monolayer), they stop dividing, maintaining tissue integrity and structure. When contact inhibition is lacking, as in many cancerous cells, cells continue to grow and divide uncontrollably, leading to tumor formation. This loss of regulation is a hallmark of cancerous growth.

5. A patient with non-Hodgkin lymphoma (NHL) is receiving monoclonal antibody therapy. What is the priority assessment during the infusion of this medication?

• A. Vital signs
• B. Skin reactions
• C. Respiratory status
• D. Renal function

Correct answer: A

Rationale: The correct answer is A: Vital signs. Monitoring vital signs is crucial during the infusion of monoclonal antibody therapy as there is a risk of infusion reactions such as fevers, chills, hypotension, and tachycardia. Assessing vital signs allows for early detection of any adverse reactions, enabling prompt intervention. Skin reactions (choice B), respiratory status (choice C), and renal function (choice D) are important assessments in general patient care but are not the priority during the infusion of monoclonal antibody therapy.

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