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. A client is receiving rituximab and asks how it works. What response by the nurse is best?

• A. It causes rapid lysis of the cancer cell membranes.
• B. It destroys the enzymes needed to create cancer cells.
• C. It prevents the start of cell division in the cancer cells.
• D. It sensitizes certain cancer cells to chemotherapy.

Correct answer: C

Rationale: Rituximab is a monoclonal antibody that targets CD20, a protein found on the surface of certain B-cells, including some cancerous B-cells, such as in non-Hodgkin's lymphoma and chronic lymphocytic leukemia (CLL). Rituximab works by binding to the CD20 protein, which leads to the destruction of the cancerous B-cells through various mechanisms, including preventing the initiation of cell division. By blocking the division process, rituximab helps slow the growth and proliferation of cancer cells, allowing the immune system and additional treatments to clear them more effectively.

3. A nurse is planning the care of a patient who has been admitted to the medical unit with a diagnosis of multiple myeloma. In the patients care plan, the nurse has identified a diagnosis of Risk for Injury. What pathophysiologic effect of multiple myeloma most contributes to this risk?

• A. Labyrinthitis
• B. Left ventricular hypertrophy
• C. Decreased bone density
• D. Hypercoagulation

Correct answer: C

Rationale: In multiple myeloma, the malignant proliferation of plasma cells within the bone marrow leads to the secretion of osteoclast-activating factors, which increase the breakdown of bone tissue (osteolysis). This results in decreased bone density, osteoporosis, and osteolytic lesions, making bones fragile and more prone to pathologic fractures. Patients with multiple myeloma are at high risk for fractures even with minimal trauma due to the weakened bone structure, which is why Risk for Injury is a key diagnosis.

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. A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action?

• A. Measure abdominal girth.
• B. Irrigate the nasogastric tube.
• C. Continue to monitor the drainage.
• D. Notify the health care provider (HCP).

Correct answer: D

Rationale: In the immediate postoperative period following a gastrectomy, any bloody drainage from the nasogastric (NG) tube is concerning and requires prompt evaluation. This could indicate potential complications such as bleeding from the surgical site, erosion, or other postoperative issues. Notifying the healthcare provider immediately is crucial to ensure that the patient receives timely assessment and intervention. The presence of blood may necessitate further diagnostic procedures, interventions, or changes in management to prevent serious complications.

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