Nursing Elites

1. Which of the following management strategies is not included for a patient taking chemotherapeutic drugs?

• A. Limit exposure of pregnant visitors
• B. Protect client from infection
• C. Allow client to use makeup and wig
• D. Administer IV fluids as ordered

Correct answer: C

Rationale: The correct answer is C. Chemotherapy can lead to hair loss, and while using wigs is common, it is not a primary management strategy. The focus should be on limiting exposure to pregnant visitors to prevent harm to the fetus, protecting the client from infections due to a compromised immune system, and administering IV fluids as ordered to maintain hydration levels. Allowing the client to use makeup and wigs is not a primary concern when managing a patient taking chemotherapeutic drugs.

2. The nurse has educated a client on precautions to take with thrombocytopenia. What statement by the client indicates a need to review the information?

• A. I will be careful if I need enemas for constipation.
• B. I will use an electric shaver instead of a razor.
• C. I should only eat soft food that is either cool or warm.
• D. I won’t be able to play sports with my grandkids.

Correct answer: A

Rationale: The correct answer is A because enemas can cause injury to a thrombocytopenic client due to the risk of bleeding. Choices B, C, and D are correct precautions for a client with thrombocytopenia. Using an electric shaver reduces the risk of cuts that could lead to bleeding. Eating soft, cool, or warm food helps prevent injuries to the oral mucosa. Avoiding activities like sports that carry a risk of injury is also advisable.

3. A patient on the oncology unit is receiving carmustine, a chemotherapy agent, and the nurse is aware that a significant side effect of this medication is thrombocytopenia. Which symptom should the nurse assess for in patients at risk for thrombocytopenia?

• A. Interrupted sleep pattern
• B. Hot flashes
• C. Epistaxis (nose bleed)
• D. Increased weight

Correct answer: C

Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which increases the risk of bleeding and hemorrhage. Patients receiving chemotherapy agents like carmustine may experience thrombocytopenia as a significant side effect. Epistaxis (nosebleeds) is a common symptom associated with thrombocytopenia, as the blood vessels can become more fragile, and even minor trauma or spontaneous bleeding can occur. Therefore, assessing for signs of bleeding, including epistaxis, is crucial in patients at risk for thrombocytopenia.

4. Nurse Kate is reviewing the complications of conization with a client who has microinvasive cervical cancer. Which complication, if identified by the client, indicates a need for further teaching?

• A. Infection
• B. Hemorrhage
• C. Cervical stenosis
• D. Ovarian perforation

Correct answer: D

Rationale: The correct answer is D, 'Ovarian perforation.' Ovarian perforation is not a complication associated with conization; therefore, if the client identifies this as a potential complication, it indicates a need for further teaching. Choices A, B, and C are incorrect: Infection, hemorrhage, and cervical stenosis are potential complications of conization, so identifying them would not necessarily indicate a need for further teaching.

5. A nurse is planning the care of a patient who has been diagnosed with essential thrombocythemia (ET). What nursing diagnosis should the nurse prioritize when choosing interventions?

• A. Risk for Ineffective Tissue Perfusion
• B. Risk for Imbalanced Fluid Volume
• C. Risk for Ineffective Breathing Pattern
• D. Risk for Ineffective Thermoregulation

Correct answer: A

Rationale: Essential thrombocythemia (ET) is a myeloproliferative disorder characterized by an abnormally high platelet count, which increases the risk of hypercoagulation and thrombosis (blood clot formation). These clots can impair blood flow to tissues, leading to ineffective tissue perfusion. Thrombotic events, such as strokes, deep vein thrombosis, or myocardial infarctions, are common complications of ET, making Risk for Ineffective Tissue Perfusion the most critical nursing diagnosis to prioritize. The goal of nursing interventions will be to prevent clot formation and ensure adequate blood flow to tissues.

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