Nursing Elites

1. While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action?

• A. Call the health care provider (HCP).
• B. Reinsert the implant into the vagina.
• C. Pick up the implant with gloved hands and flush it down the toilet.
• D. Pick up the implant with long-handled forceps and place it in a lead container.

Correct answer: D

Rationale: When caring for a client with an internal cervical radiation implant, safety measures must be followed to protect both the client and healthcare personnel from radiation exposure. If the implant becomes dislodged and is found in the bed, the nurse’s priority is to handle it safely using long-handled forceps, as direct contact with the implant could result in radiation exposure. The implant should be placed in a lead-lined container, which is specifically designed to shield against radiation, to prevent further contamination or exposure. After securing the implant, the nurse should notify the radiation safety officer or healthcare provider for further guidance.

2. All of the following are warning signs of cancer except:

• A. Patient palpates a bump on the side of the breast
• B. Bruises are found on the body that the client cannot explain
• C. Patient often complains of impaired digestion
• D. Patient has blood-tinged sputum

Correct answer: D

Rationale: The correct answer is D. Blood-tinged sputum is not a typical warning sign of cancer but rather a symptom that can indicate other serious conditions like respiratory issues or infections. Choices A, B, and C are common warning signs of cancer: palpable lumps or bumps, unexplained bruises, and persistent digestive issues are often associated with cancer and should be evaluated by a healthcare professional for further assessment and diagnosis.

3. A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the client’s oral chemotherapy medications. What action by the nurse is most appropriate?

• A. Crush the medications if the client cannot swallow them.
• B. Give one medication at a time with a full glass of water.
• C. No special precautions are needed for these medications.
• D. Wear personal protective equipment when handling the medications.

Correct answer: D

Rationale: Oral chemotherapy requires the same precautions as IV chemotherapy; personal protective equipment is necessary.

4. A patient diagnosed with polycythemia vera presents to the clinic for routine bloodwork. What should the nurse monitor for in this patient as a priority?

• A. Hemoglobin and hematocrit levels
• B. Platelet count
• C. White blood cell count
• D. Blood pressure

Correct answer: B

Rationale: In polycythemia vera, there is an overproduction of red blood cells, white blood cells, and platelets, which leads to increased blood viscosity and a high risk for thrombosis (blood clot formation). Monitoring the platelet count is a priority because elevated platelet levels contribute significantly to the risk of developing blood clots, which can result in life-threatening complications such as strokes, heart attacks, or deep vein thrombosis (DVT). Therefore, regular monitoring of the platelet count is essential to assess the patient’s risk for thrombosis and to guide treatment decisions, such as phlebotomy or medication adjustments to lower platelet levels.

5. The nurse is instructing a client on ways to reduce the risk of lymphedema after a mastectomy. Which of the following should be emphasized?

• A. Elevate the affected arm
• B. Avoid lifting heavy objects
• C. Use compression garments as prescribed
• D. Avoid wearing tight clothing

Correct answer: D

Rationale: After a mastectomy, particularly when lymph nodes are removed, patients are at increased risk for developing lymphedema, which is a buildup of lymph fluid that can cause swelling in the affected arm. Wearing tight clothing can constrict lymphatic flow and increase the risk of developing lymphedema by impeding normal lymphatic drainage. Therefore, it is crucial to advise patients to avoid tight-fitting clothing, especially around the chest and arm areas.

Similar Questions