Nursing Elites

1. What are the nursing interventions for a patient with neutropenia?

• A. Monitor for signs of infection and administer antibiotics
• B. Isolate the patient and provide a low-microbial diet
• C. Monitor vital signs and avoid unnecessary invasive procedures
• D. Encourage the patient to engage in social activities

Correct answer: A

Rationale: The correct nursing interventions for a patient with neutropenia include monitoring for signs of infection and administering antibiotics. Neutropenia is characterized by a low neutrophil count, which increases the risk of infections. Monitoring for signs of infection allows for early detection and prompt treatment, while administering antibiotics helps prevent or treat any infections that may occur. Isolating the patient and providing a low-microbial diet (Choice B) are not necessary unless the patient develops an active infection. Monitoring vital signs and avoiding unnecessary invasive procedures (Choice C) are important but do not specifically address the increased infection risk in neutropenic patients. Encouraging the patient to engage in social activities (Choice D) is not appropriate for a neutropenic patient due to the risk of exposure to infectious agents.

2. A nurse is caring for a client with a pressure ulcer. Which of the following interventions is most appropriate?

• A. Administer a protein supplement
• B. Increase protein intake in the client's diet
• C. Increase IV fluid intake to improve hydration
• D. Cleanse the wound from the center outwards

Correct answer: D

Rationale: The correct answer is to cleanse the wound from the center outwards. This technique helps prevent infection and promotes healing by ensuring that any contaminants are moved away from the center of the wound. Administering a protein supplement (choice A) or increasing protein intake in the client's diet (choice B) may be beneficial for overall healing but are not the most appropriate interventions specifically for wound care. Increasing IV fluid intake (choice C) is important for hydration but is not the most appropriate intervention for managing a pressure ulcer.

3. A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?

• A. Offer small amounts of clear liquids 6 hr following surgery.
• B. Give cromolyn nebulizer solution every 6 hr.
• C. Apply a warm compress to the operative site every 4 hr.
• D. Administer analgesics on a scheduled basis for the first 24 hr.

Correct answer: D

Rationale: Administering analgesics on a scheduled basis for the first 24 hours is crucial to ensure adequate pain control in the immediate postoperative period. Choice A is incorrect because clear liquids are typically initiated gradually and advanced as tolerated but not specifically at 6 hours post-surgery. Choice B is incorrect as cromolyn nebulizer solution is not indicated for postoperative pain management in this scenario. Choice C is incorrect as applying a warm compress may not be appropriate for the operative site after appendicitis surgery and can potentially increase the risk of infection.

4. Which nursing intervention is best for a client with constipation?

• A. Encourage the client to remain in bed to avoid straining
• B. Administer a stool softener as prescribed
• C. Increase fiber intake through dietary changes
• D. Encourage regular exercise to promote bowel movement

Correct answer: C

Rationale: Increasing fiber intake is the most appropriate nursing intervention for a client experiencing constipation. Fiber helps add bulk to the stool, making it easier to pass and promoting regular bowel movements. Encouraging the client to remain in bed may exacerbate constipation by reducing movement and promoting inactivity. While stool softeners can be beneficial, they are typically used as a short-term solution and may not address the underlying issue of low fiber intake. Regular exercise is important for overall bowel health; however, in the immediate management of constipation, increasing fiber intake is the most effective intervention.

5. When assessing a client with signs of delirium, which factor should be the nurse's priority in determining the cause?

• A. Medication history
• B. Fluid and electrolyte imbalances
• C. Psychosocial stressors
• D. Environmental factors

Correct answer: B

Rationale: When a nurse assesses a client with signs of delirium, the priority in determining the cause should be focusing on fluid and electrolyte imbalances. Delirium can often be linked to imbalances in these essential elements, making it crucial to address them promptly. While medication history, psychosocial stressors, and environmental factors can also contribute to delirium, they should be assessed after addressing fluid and electrolyte imbalances due to their immediate impact on cognitive function.

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