Nursing Elites

1. The nurse is caring for a client following radical neck dissection and creation of a tracheostomy. Which assessment finding would indicate an immediate need for intervention?

• A. Frequent swallowing
• B. Presence of mucous membranes
• C. Bubbling in the water-seal chamber
• D. Inspiratory stridor

Correct answer: D

Rationale: Inspiratory stridor is the correct answer as it suggests airway obstruction, a critical issue requiring immediate intervention. Frequent swallowing (choice A) is a common postoperative finding and does not indicate an immediate need for intervention. The presence of mucous membranes (choice B) is a normal finding and does not require immediate intervention. Bubbling in the water-seal chamber (choice C) of a chest tube drainage system is an expected finding and indicates proper functioning of the system, not an immediate need for intervention.

2. When preparing for the patient's subsequent care after completing the full course of treatment for acute lymphocytic leukemia without a significant response, what action should the nurse take?

• A. Arrange a meeting between the patient's family and the hospital chaplain.
• B. Assess the factors underlying the patient's failure to adhere to the treatment regimen.
• C. Encourage the patient to vigorously pursue complementary and alternative medicine (CAM).
• D. Identify the patient's specific wishes around end-of-life care.

Correct answer: D

Rationale: In cases where a patient does not respond appreciably to therapy, it is crucial to identify and respect the patient's choices regarding treatment, including preferences for end-of-life care. Option A is incorrect because it focuses on spiritual support rather than the patient's care preferences. Option B is incorrect as it assumes non-adherence to treatment without evidence. Option C is incorrect as it suggests an alternative treatment approach without considering the patient's wishes for end-of-life care.

3. Which of the following is not a manifestation of breast cancer?

• A. Peau d'orange
• B. Painless breast mass
• C. Alopecia
• D. Breast enlargement

Correct answer: C

Rationale: Alopecia (hair loss) is not a direct manifestation of breast cancer but rather a common side effect of chemotherapy used in breast cancer treatment. Peau d'orange refers to the dimpling or pitting of the skin resembling an orange peel, which can be a sign of breast cancer due to blockage of lymphatic vessels. A painless breast mass and breast enlargement can both be manifestations of breast cancer, with a painless mass being a common symptom and breast enlargement sometimes occurring due to tumor growth.

4. A patient with acute lymphocytic leukemia (ALL) is undergoing chemotherapy and develops neutropenia. What is the most important nursing intervention for this patient?

• A. Administering antipyretics
• B. Restricting visitors
• C. Maintaining a sterile environment
• D. Administering prophylactic antibiotics

Correct answer: C

Rationale: Maintaining a sterile environment is crucial to prevent infection in neutropenic patients.

5. A client has a platelet count of 9800/mm3. What action by the nurse is most appropriate?

• A. Assess the client for calf pain, warmth, and redness.
• B. Instruct the client to call for help to get out of bed.
• C. Obtain cultures as per the facility’s standing policy.
• D. Place the client on protective Isolation Precautions.

Correct answer: B

Rationale: A platelet count of 9800/mm³ indicates severe thrombocytopenia, placing the client at high risk for bleeding, even with minor trauma or injury. Instructing the client to call for help before getting out of bed ensures they receive assistance with mobility, which reduces the risk of falls or injuries that could lead to serious bleeding. Preventing any activity that could result in trauma is crucial when managing clients with very low platelet counts.

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