Nursing Elites

1. A nurse is providing care to a patient who has just received a diagnosis of acute myeloid leukemia (AML). What is the priority nursing diagnosis for this patient?

• A. Risk for bleeding
• B. Risk for infection
• C. Impaired gas exchange
• D. Imbalanced nutrition

Correct answer: B

Rationale: Risk for infection is a high priority due to the patient's compromised immune system from AML.

2. 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.

3. The nurse is caring for a 39-year-old woman with a family history of breast cancer. She requested a breast tumor marking test and the results have come back positive. As a result, the patient is requesting a bilateral mastectomy. This surgery is an example of what type of oncologic surgery?

• A. Salvage surgery
• B. Palliative surgery
• C. Prophylactic surgery
• D. Reconstructive surgery

Correct answer: C

Rationale: Prophylactic surgery refers to the preventive removal of tissues or organs at high risk for developing cancer, even when no cancer is currently present. In this case, the patient has a positive breast tumor marking test and a significant family history of breast cancer, which places her at increased risk for developing the disease. A bilateral mastectomy is performed to significantly reduce this risk by removing both breasts, thereby preventing the potential future occurrence of breast cancer.

4. A patient with multiple myeloma is receiving chemotherapy and is at risk for bone fractures. What intervention should the nurse prioritize to reduce this risk?

• A. Encouraging bed rest
• B. Promoting bed rest to avoid injury
• C. Encouraging weight-bearing exercises
• D. Ensuring adequate hydration

Correct answer: B

Rationale: The correct answer is B: 'Promoting bed rest to avoid injury.' In patients with multiple myeloma undergoing chemotherapy, encouraging bed rest can lead to muscle weakness and bone loss, increasing the risk of fractures. Promoting bed rest to avoid injury means advising the patient on safe movement and activities to prevent fractures. Encouraging weight-bearing exercises (choice C) would be more beneficial than bed rest as it helps in maintaining bone density and strength. Ensuring adequate hydration (choice D) is essential for overall health but does not directly address the risk of bone fractures associated with multiple myeloma and chemotherapy. Choice A, 'Encouraging bed rest,' is incorrect as it may worsen the risk of fractures rather than reduce it.

5. A client has a platelet count of 9800/mm3. What action by the nurse is most appropriate?

• A. Assess the client for calf pain, warmth, and redness.
• B. Instruct the client to call for help to get out of bed.
• C. Obtain cultures as per the facility’s standing policy.
• D. Place the client on protective Isolation Precautions.

Correct answer: B

Rationale: A platelet count of 9800/mm³ indicates severe thrombocytopenia, placing the client at high risk for bleeding, even with minor trauma or injury. Instructing the client to call for help before getting out of bed ensures they receive assistance with mobility, which reduces the risk of falls or injuries that could lead to serious bleeding. Preventing any activity that could result in trauma is crucial when managing clients with very low platelet counts.

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