Nursing Elites

1. A nurse is caring for a patient diagnosed with chronic myeloid leukemia (CML) who is receiving the drug imatinib (Gleevec). What should the nurse monitor in this patient to assess for side effects of this therapy?

• A. Cardiac function
• B. Renal function
• C. Liver function
• D. Pulmonary function

Correct answer: A

Rationale: The correct answer is A: Cardiac function. Imatinib can cause fluid retention and heart failure, so cardiac function should be closely monitored. Renal function (choice B) is not typically affected by imatinib. Liver function (choice C) is not the primary concern with this medication. Pulmonary function (choice D) is not directly impacted by imatinib therapy.

2. The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy?

• A. Restrict all visitors.
• B. Restrict fluid intake.
• C. Teach the client and family about the need for hand hygiene.
• D. Insert an indwelling urinary catheter to prevent skin breakdown.

Correct answer: C

Rationale: In clients experiencing neutropenia, particularly due to chemotherapy, the immune system is significantly compromised, increasing the risk of infections. Hand hygiene is one of the most effective methods for preventing the spread of pathogens that can lead to infections. Teaching both the client and their family about the importance of frequent and proper handwashing helps create a safer environment and reduces the risk of infections, which can be critical in neutropenic patients.

3. A patient from the oncology unit asks the nurse about metastasis. Which of the following statements by the nurse requires immediate intervention by the head nurse?

• A. Metastasis is the replication of cells
• B. Metastasis can happen in most parts of the body
• C. The replication of cancer cells and travel from one area to another
• D. Metastasis is the spread of cancer cells

Correct answer: A

Rationale: The correct answer is A because metastasis refers to the spread of cancer cells to distant parts of the body, not the replication of cells. Choice B is correct as metastasis can indeed occur in various body parts. Choice C is incorrect as it inaccurately combines the concepts of replication and travel of cancer cells. Choice D is also correct as it accurately defines metastasis as the spread of cancer cells.

4. The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time?

• A. At the onset of menstruation
• B. Every month during ovulation
• C. Weekly at the same time of day
• D. 1 week after menstruation begins

Correct answer: D

Rationale: The optimal time for performing a breast self-examination (BSE) is about one week after menstruation begins, as this is when the breasts are least likely to be swollen, tender, or affected by hormonal changes. Hormonal fluctuations during the menstrual cycle can cause temporary changes in breast tissue, such as swelling, lumpiness, or tenderness, which may make it more difficult to detect any unusual lumps or changes. Conducting the examination during this period ensures that the breasts are in their natural state, making it easier to notice any abnormalities.

5. A nurse is creating a plan of care for an oncology patient and one of the identified nursing diagnoses is risk for infection related to myelosuppression. What intervention addresses the leading cause of infection-related death in oncology patients?

• A. Encourage several small meals daily.
• B. Provide skin care to maintain skin integrity.
• C. Assist the patient with hygiene, as needed.
• D. Assess the integrity of the patient’s oral mucosa regularly.

Correct answer: B

Rationale: In oncology patients, particularly those undergoing chemotherapy or radiation therapy, myelosuppression (the decrease in bone marrow activity that leads to reduced white blood cells, red blood cells, and platelets) increases the risk of infection. Maintaining skin integrity is crucial because the skin acts as the body's first line of defense against infections. If the skin becomes compromised, such as through radiation burns, rashes, or breakdowns, it provides a potential entry point for pathogens, increasing the risk of infection. Since infections in oncology patients can quickly become severe due to their weakened immune systems, maintaining skin integrity is a critical intervention to reduce infection risk, especially for patients who are immunosuppressed.

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