Nursing Elites

1. 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.

2. A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action?

• A. Measure abdominal girth.
• B. Irrigate the nasogastric tube.
• C. Continue to monitor the drainage.
• D. Notify the health care provider (HCP).

Correct answer: D

Rationale: In the immediate postoperative period following a gastrectomy, any bloody drainage from the nasogastric (NG) tube is concerning and requires prompt evaluation. This could indicate potential complications such as bleeding from the surgical site, erosion, or other postoperative issues. Notifying the healthcare provider immediately is crucial to ensure that the patient receives timely assessment and intervention. The presence of blood may necessitate further diagnostic procedures, interventions, or changes in management to prevent serious complications.

3. Nurse Maria is preparing a care plan for a client receiving external radiation therapy. Which of the following interventions should be included?

• A. Use heating pads on the treated area
• B. Wear loose, soft clothing over the treated area
• C. Expose the treated area to sunlight
• D. Apply ice packs to the treated area

Correct answer: B

Rationale: Radiation therapy can cause skin irritation, dryness, and sensitivity in the treated area. Wearing loose, soft clothing helps minimize friction and pressure on the skin, reducing irritation and promoting comfort. The skin in the treated area is often more sensitive and vulnerable to damage, so this intervention helps protect the skin while maintaining the client’s comfort during the course of treatment.

4. A new nurse has been assigned a client who is in the hospital to receive iodine-131 treatment. Which action by the nurse is best?

• A. Ensure the client is placed in protective isolation.
• B. Have pregnant visitors stay 6 feet from the client.
• C. No special action is necessary to care for this client.
• D. Read the policy on handling radioactive excreta.

Correct answer: D

Rationale: Handling radioactive excreta requires special precautions; the nurse must be familiar with the facility's policies.

5. A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority?

• A. Helping clients adjust to their appearance.
• B. Reassuring clients that this change is temporary.
• C. Referring clients to a reputable wig shop.
• D. Teaching measures to prevent scalp injury.

Correct answer: D

Rationale: The correct answer is D: Teaching measures to prevent scalp injury. Alopecia makes the scalp more vulnerable to injury, so educating clients on protective measures is crucial. Choices A and B focus on emotional support and reassurance, which are important but secondary to physical safety. Referring clients to a wig shop (choice C) addresses appearance but does not directly address the physical risk associated with scalp vulnerability.

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