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. A client who is at risk for disseminated intravascular coagulation (DIC) has a serum fibrinogen level of 110 mg/dL. The nurse should take which of the following actions first?

• A. Recheck the fibrinogen level in 4 hours
• B. Notify the health care provider
• C. Continue to monitor the client
• D. Administer cryoprecipitate as prescribed

Correct answer: B

Rationale: A serum fibrinogen level of 110 mg/dL indicates a low level, which puts the client at risk for bleeding in DIC. The priority action for the nurse is to notify the health care provider. Rechecking the fibrinogen level may delay necessary interventions, administering cryoprecipitate should be done based on the provider's prescription, and while monitoring is important, immediate notification of the provider is crucial to address the low fibrinogen level promptly.

3. The nurse on a bone marrow transplant unit is caring for a patient with cancer who is preparing for HSCT. What is a priority nursing diagnosis for this patient?

• A. Fatigue related to altered metabolic processes
• B. Altered nutrition: less than body requirements related to anorexia
• C. Risk for infection related to altered immunologic response
• D. Body image disturbance related to weight loss and anorexia

Correct answer: C

Rationale: Patients preparing for hematopoietic stem cell transplantation (HSCT) undergo intensive chemotherapy and/or radiation, which significantly suppresses their immune system. This immunosuppression leads to a heightened risk for infection, making it the most critical nursing diagnosis for these patients. As the body’s ability to fight off pathogens is compromised, close monitoring and interventions aimed at preventing infections are essential for their safety and recovery.

4. A clinic patient is being treated for polycythemia vera, and the nurse is providing health education. What practice should the nurse recommend to prevent the complications of this health problem?

• A. Avoiding natural sources of vitamin K
• B. Avoiding altitudes of 1500 feet (457 meters)
• C. Performing active range of motion exercises daily
• D. Avoiding tight and restrictive clothing on the legs

Correct answer: D

Rationale: The correct answer is D: Avoiding tight and restrictive clothing on the legs. Patients with polycythemia vera are at risk of deep vein thrombosis (DVT), so it is essential to avoid tight and restrictive clothing that can impede circulation. Choices A, B, and C are incorrect because avoiding natural sources of vitamin K, altitudes of 1500 feet, and performing active range of motion exercises are not directly related to preventing complications of polycythemia vera.

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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