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. After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate?

• A. Irrigate the nasogastric tube with distilled water
• B. Aspirate the gastric contents with a syringe
• C. Administer an antiemetic medication
• D. Insert a new nasogastric tube

Correct answer: B

Rationale: The most appropriate nursing intervention when a client with a nasogastric tube experiences nausea and a decrease in gastric secretions is to aspirate the gastric contents with a syringe. This action helps relieve nausea by removing excess fluid and gas. Option A, irrigating the nasogastric tube with distilled water, is not indicated as it does not address the underlying issue of decreased gastric secretions. Option C, administering an antiemetic medication, may provide symptomatic relief but does not address the mechanical issue of decreased flow in the nasogastric tube. Option D, inserting a new nasogastric tube, is not necessary unless there are specific complications or obstructions in the current tube.

3. Which of the following interventions is most appropriate for a client with left-leg weakness who is learning to use a cane?

• A. Maintain two points of support on the floor at all times
• B. Use the cane on the weak side of the body
• C. Advance the cane and the strong leg simultaneously
• D. Advance the cane 30 to 45 cm (12-18 in) with each step

Correct answer: A

Rationale: The most appropriate intervention for a client with left-leg weakness learning to use a cane is to maintain two points of support on the floor at all times. This ensures stability and helps distribute weight evenly between the legs, reducing the risk of falls. Using the cane on the weak side of the body (Choice B) may not provide adequate support. Advancing the cane and the strong leg simultaneously (Choice C) can lead to imbalance and increases the risk of falls. Advancing the cane too far with each step (Choice D) can also compromise balance and stability.

4. What is the main symptom of left-sided heart failure?

• A. Shortness of breath
• B. Edema
• C. Increased heart rate
• D. Decreased urine output

Correct answer: A

Rationale: Shortness of breath is the main symptom of left-sided heart failure because it results from pulmonary congestion due to fluid buildup in the lungs. Edema, increased heart rate, and decreased urine output are associated with right-sided heart failure rather than left-sided heart failure.

5. A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication?

• A. The client's urine test is positive for glucose and acetone
• B. The client has 1+ pedal edema in both feet at the end of the day
• C. The client complains of an increase in vaginal discharge
• D. The client says she feels pressure against her diaphragm when the baby moves

Correct answer: A

Rationale: The correct answer is A. Positive urine glucose and acetone could indicate gestational diabetes or preeclampsia, both of which are complications. Choice B, pedal edema, is common in pregnancy but may also be a sign of preeclampsia if severe. Choice C, an increase in vaginal discharge, is a normal finding in pregnancy due to hormonal changes. Choice D, pressure against the diaphragm when the baby moves, is a normal sensation due to the growing uterus displacing abdominal contents.

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