Nursing Elites

1. A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3. Which intervention is most important for the nurse to include in this client’s plan of care?

• A. Monitor for signs of activity intolerance
• B. Require visitors to wear respiratory masks
• C. Assess urine and stool for occult blood
• D. Obtain client’s temperature q4 hours

Correct answer: C

Rationale: The correct answer is to assess urine and stool for occult blood. With a low platelet count, there is an increased risk of bleeding. Monitoring for occult blood is essential to detect any signs of internal bleeding. Choices A, B, and D are not the priority interventions in this situation. While monitoring for signs of activity intolerance, requiring visitors to wear respiratory masks, and obtaining the client's temperature are important aspects of care, they are not as critical as assessing for occult blood in a client with a low platelet count.

2. A client who is bleeding after a vaginal delivery receives a prescription for methylergonovine (Methergine) 0.4 mg IM every 2 hours, not to exceed 5 doses. The medication is available in ampules containing 0.2 mg/ml. What is the maximum dosage in mg that the nurse should administer to this client? (Enter numeric value only)

• A. 2
• B. 3
• C. 4
• D. 5

Correct answer: A

Rationale: To calculate the maximum dosage in mg that the nurse should administer, multiply the dose per administration (0.4 mg) by the maximum number of doses allowed (5 doses): 0.4 mg/dose * 5 doses = 2 mg. Therefore, the nurse should administer a maximum dosage of 2 mg to the client. Choices B, C, and D are incorrect as they do not reflect the correct calculation based on the provided information.

3. While changing a client’s chest tube dressing, the nurse notes a crackling sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take?

• A. Apply a pressure dressing around the chest tube insertion site
• B. Assess the client for allergies to topical cleaning agents
• C. Measure the area of swelling and crackling
• D. Administer an oral antihistamine per PRN protocol

Correct answer: A

Rationale: A crackling sensation indicates subcutaneous emphysema, caused by air trapped under the skin. Applying a pressure dressing around the chest tube insertion site can help manage the issue by preventing further air leakage into the tissues. Choice B is incorrect because the crackling sensation is not related to allergies. Choice C is incorrect as measuring the area does not address the underlying cause. Choice D is incorrect as administering an oral antihistamine is not indicated for subcutaneous emphysema.

4. The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

• A. An older client receiving packed RBCs on the third day postoperatively for colon resection
• B. An older client with continuous bladder irrigation who is 2 days postoperatively for bladder surgery
• C. An adult one day postoperatively from laparoscopic cholecystectomy requesting pain medication
• D. An adult in Buck’s traction, scheduled for hip arthroplasty within the next 12 hours

Correct answer: B

Rationale: The correct answer is B because the client with continuous bladder irrigation post-bladder surgery is at risk for complications like infection or bleeding. This client requires immediate attention to assess for any signs of complications such as urinary retention, hemorrhage, or infection. Choices A, C, and D have less urgent needs compared to a client with continuous bladder irrigation, which requires priority assessment.

5. A 10-year-old who has terminal brain cancer asks the nurse, 'What will happen to my body when I die?' How should the nurse respond?

• A. The heart will stop beating, and you will stop breathing.
• B. You will go to sleep and not wake up.
• C. Your body will stop functioning, and you will no longer feel pain.
• D. You will feel very tired, and your body will shut down slowly.

Correct answer: C

Rationale: The correct answer is C because it provides a truthful yet sensitive response to the child's question. Saying that the body will stop functioning and that there will be no more pain helps the child understand what to expect without unnecessary details or causing distress. Choice A is too technical and may not be suitable for a child. Choice B might give the impression of a peaceful passing, which may not always be the case. Choice D introduces the concept of feeling tired, which might not be accurate or helpful in this context.

Similar Questions