Nursing Elites

1. A nurse provides care on a bone marrow transplant unit and is preparing a female patient for a hematopoietic stem cell transplantation (HSCT) the following day. What information should the nurse emphasize to the patient’s family and friends?

• A. Your family should gather at the bedside in case there is a negative outcome.
• B. Ensure she abstains from eating any food 24 hours before the procedure.
• C. Wear a hospital gown when entering the patient's room.
• D. Avoid visiting if you've had a recent infection.

Correct answer: D

Rationale: The correct answer is D: 'Avoid visiting if you've had a recent infection.' Before a hematopoietic stem cell transplantation, it is essential for visitors to refrain from visiting if they have had a recent illness or vaccination to minimize the risk of infection to the patient. Choice A is incorrect because emphasizing a negative outcome is not beneficial to the patient or their family. Choice B is incorrect as it is not necessary to abstain from food for a hematopoietic stem cell transplantation. Choice C is irrelevant to the situation as wearing a hospital gown is not the key information for family and friends to be aware of.

2. Mina, who is suspected of an ovarian tumor is scheduled for a pelvic ultrasound. The nurse provides which preprocedure instruction to the client?

• A. Eat a light breakfast only
• B. Maintain an NPO status before the procedure
• C. Wear comfortable clothing and shoes for the procedure
• D. Drink six to eight glasses of water without voiding before the test

Correct answer: D

Rationale: A pelvic ultrasound requires the client to have a full bladder because the bladder acts as a window through which pelvic organs, such as the uterus and ovaries, can be visualized more clearly. The full bladder pushes the intestines out of the way and provides a better acoustic pathway for the ultrasound waves. Without this, the pelvic organs might be obscured, and the images would be less accurate.

3. While a patient is receiving IV doxorubicin hydrochloride for the treatment of cancer, the nurse observes swelling and pain at the IV site. The nurse should prioritize what action?

• A. Stopping the administration of the drug immediately
• B. Notifying the patient's physician
• C. Continuing the infusion but decreasing the rate
• D. Applying a warm compress to the infusion site

Correct answer: A

Rationale: The correct action for the nurse to take when observing swelling and pain at the IV site during the administration of doxorubicin hydrochloride is to stop the administration of the drug immediately. Doxorubicin hydrochloride can cause severe tissue damage, so discontinuing the infusion is crucial to prevent further harm to the patient. Notifying the physician is important, but it should not take precedence over stopping the drug. Continuing the infusion, even at a decreased rate, can exacerbate tissue damage. Applying a warm compress is not appropriate in this situation and may worsen the tissue injury caused by the drug.

4. A nurse is teaching a patient with chronic lymphocytic leukemia (CLL) about potential complications. Which complication should the nurse emphasize?

• A. Infection
• B. Hemorrhage
• C. Fatigue
• D. Splenomegaly

Correct answer: A

Rationale: The correct answer is A: Infection. Patients with chronic lymphocytic leukemia (CLL) are at a significant risk of infection due to their compromised immune system. Emphasizing the importance of infection prevention and prompt treatment is crucial in the care of these patients. Choice B, Hemorrhage, is less common in CLL compared to other types of leukemia. Choice C, Fatigue, is a common symptom but not a complication that poses immediate risks. Choice D, Splenomegaly, is a common finding in CLL but not the most critical complication to emphasize regarding patient education.

5. A 16-year-old female patient experiences alopecia resulting from chemotherapy, prompting the nursing diagnoses of disturbed body image and situational low self-esteem. What action by the patient would best indicate that she is meeting the goal of improved body image and self-esteem?

• A. The patient requests that her family bring her makeup and wig.
• B. The patient begins to discuss the future with her family.
• C. The patient reports less disruption from pain and discomfort.
• D. The patient cries openly when discussing her disease.

Correct answer: A

Rationale: When a patient experiences alopecia due to chemotherapy, it can significantly impact their self-esteem and body image, particularly in adolescents who are especially sensitive to physical changes. A request for makeup and a wig indicates that the patient is actively taking steps to enhance her appearance and cope with the changes brought on by her treatment. This action reflects a positive engagement with her body image and suggests a desire to feel more comfortable and confident in her appearance, signaling an improvement in her self-esteem.

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