Nursing Elites

1. The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate?

• A. Clamp the Penrose drain.
• B. Change the dressing as prescribed.
• C. Notify the healthcare provider (HCP).
• D. Remove and replace the perineal packing.

Correct answer: B

Rationale: In this scenario, the appropriate nursing intervention for serosanguineous drainage from the wound is to change the dressing as prescribed. This helps in maintaining wound cleanliness, preventing infection, and promoting proper wound healing. Clamping the Penrose drain (Choice A) is not indicated as the drainage is from the wound itself, not the drain. Notifying the healthcare provider (Choice C) may be necessary if there are signs of infection or other concerning issues, but changing the dressing should be done first. Removing and replacing the perineal packing (Choice D) is not the priority in this situation unless specifically prescribed by the healthcare provider after assessing the wound.

2. What advice should the oncology nurse give to a client planning a beach vacation after completing radiation treatments for cancer?

• A. Avoid getting salt water on the radiation site.
• B. Do not expose the radiation area to direct sunlight.
• C. Have a wonderful time and enjoy your vacation!
• D. Remember you should not drink alcohol for a year.

Correct answer: B

Rationale: The correct answer is B because the skin at the radiation site is sensitive to sunlight, and exposure can cause further damage. It is crucial to protect the area from direct sunlight to prevent skin irritation or burns. Choice A is incorrect as salt water typically does not pose a significant risk to the radiation site. Choice C is a positive and encouraging response but does not provide necessary advice for post-radiation care. Choice D, while important in some cases, is not directly related to the client's beach vacation after completing radiation treatments.

3. A client with long-standing heart failure being treated for cancer has received a dose of ondansetron for nausea. What action by the nurse is most important?

• A. Assess the client for a headache or dizziness.
• B. Request a prescription for cardiac monitoring.
• C. Instruct the client to change positions slowly.
• D. Weigh the client daily before eating.

Correct answer: B

Rationale: Ondansetron can prolong the QT interval, making cardiac monitoring essential in this scenario.

4. A nurse knows that all of the following are managements of breast cancer except:

• A. Administer chemotherapy as ordered
• B. Let the patient lie down with 1-2 pillows
• C. Give patient Tamoxifen as ordered
• D. Let the patient elevate affected arm post op

Correct answer: B

Rationale: In the management of breast cancer, particularly after procedures such as a mastectomy, it is important to position the patient in a way that promotes healing and comfort. However, lying down with 1-2 pillows is not a standard practice for postoperative care. Instead, patients are often advised to elevate the affected arm to reduce swelling and promote drainage, and they may benefit from sleeping in a more upright position if they are experiencing discomfort. The focus should be on facilitating recovery rather than simply lying down.

5. A young adult patient has received the news that her treatment for Hodgkin lymphoma has been deemed successful and that no further treatment is necessary at this time. The care team should ensure that the patient receives regular health assessments in the future due to the risk of what complication?

• A. Iron-deficiency anemia
• B. Hemophilia
• C. Hematologic cancers
• D. Genitourinary cancers

Correct answer: C

Rationale: The correct answer is C: Hematologic cancers. Survivors of Hodgkin lymphoma are at a high risk of developing second cancers, with hematologic cancers being the most common complication. Regular health assessments are crucial for early detection and management. Iron-deficiency anemia (A) is not a typical long-term complication of Hodgkin lymphoma treatment. Hemophilia (B) is a genetic bleeding disorder unrelated to Hodgkin lymphoma. Genitourinary cancers (D) are not the most common complication seen in survivors of Hodgkin lymphoma.

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