Nursing Elites

1. What action should the nurse implement when the infusion of chemotherapy via an implanted medication port is complete for a 16-year-old with acute myelocytic leukemia at the outpatient oncology clinic?

• A. Administer Zofran
• B. Obtain blood samples for RBCs, WBCs, and platelets
• C. Flush mediport with saline and heparin solution
• D. Initiate an infusion of normal saline

Correct answer: C

Rationale: The correct action for the nurse to implement when the chemotherapy infusion is complete is to flush the mediport with saline and heparin solution. This process helps prevent clotting and ensures the patency of the port, which is essential for future medication administrations and blood draws. Administering Zofran (Choice A) is not necessary after completing the chemotherapy infusion. Obtaining blood samples (Choice B) for RBCs, WBCs, and platelets is important but not the immediate action after completing the infusion. Initiating an infusion of normal saline (Choice D) is not required unless there is a specific indication for it.

2. A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?

• A. The mother is a single parent and lives with her parents
• B. The mother states the baby is irritable during feedings
• C. The infant’s formula has been changed twice
• D. The diaper area shows severe skin breakdown

Correct answer: D

Rationale: Severe skin breakdown in the diaper area is a significant finding indicating a potential health issue that needs immediate attention. It may be a sign of a skin condition, such as a diaper rash, which can cause discomfort and pain for the infant. Addressing this concern promptly is crucial to prevent further complications and ensure the baby's well-being. The other choices may also be important in assessing the overall situation of the family, but in terms of immediate care for the infant, the severe skin breakdown takes priority.

3. The healthcare provider is providing postoperative care to a 7-year-old child who had surgery for appendicitis. The child is experiencing pain at the surgical site. What is the healthcare provider's priority action?

• A. Administer the prescribed pain medication
• B. Encourage the child to take deep breaths
• C. Apply a warm compress to the surgical site
• D. Reposition the child to a more comfortable position

Correct answer: A

Rationale: Administering the prescribed pain medication is crucial to effectively manage the child's postoperative pain. Pain management is a priority to ensure the child's comfort and promote healing following surgery. Encouraging deep breaths, applying warm compresses, or repositioning the child may help, but addressing the pain with medication is the initial and most vital intervention.

4. An adolescent female who comes to the school clinic is reluctant to confide her concerns to the practical nurse (PN). The PN tells the teen that confidentiality and privacy are maintained unless a life-threatening situation arises. Which principle supports the PN's response?

• A. The adolescent should be encouraged to seek help outside of the school clinic.
• B. Disclosures from the adolescent should be kept confidential.
• C. Honest information ensures establishing a trusting relationship.
• D. Minor adolescents should not be encouraged to disclose private concerns.

Correct answer: C

Rationale: The correct principle supporting the practical nurse's response is that honest information ensures establishing a trusting relationship. By assuring confidentiality and privacy to the adolescent unless there is a life-threatening situation, the practical nurse fosters an environment where the teen feels safe to share their concerns openly. This approach helps build trust, encouraging effective communication and support for the adolescent's well-being. Choices A, B, and D are incorrect because encouraging seeking help outside the school clinic, keeping disclosures confidential, and discouraging minor adolescents from sharing private concerns do not address the immediate need to build trust and ensure the well-being of the adolescent in a school setting.

5. A 12-year-old child with type 1 diabetes is under the nurse's care. The child’s parent asks how to prevent hypoglycemia during physical activity. What is the nurse’s best response?

• A. Give your child extra insulin before exercise
• B. Make sure your child eats a snack before exercise
• C. Limit your child’s physical activity to avoid hypoglycemia
• D. Monitor your child’s blood glucose levels after exercise

Correct answer: B

Rationale: The most effective way to prevent hypoglycemia during physical activity in a child with type 1 diabetes is to ensure they eat a snack before exercising. Eating a snack before exercise helps maintain blood glucose levels by providing additional glucose for energy during physical activity, reducing the risk of hypoglycemia. Giving extra insulin before exercise (Choice A) can increase the risk of hypoglycemia as it lowers blood glucose levels further. Limiting physical activity (Choice C) is not recommended as exercise is important for overall health. Monitoring blood glucose levels after exercise (Choice D) is essential but does not directly prevent hypoglycemia during physical activity.

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