Nursing Elites

1. A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client?

• A. Ineffective airway clearance
• B. Altered nutrition less than body requirements
• C. Fluid volume excess
• D. Activity intolerance

Correct answer: A

Rationale: In this scenario, the highest priority nursing problem for the postoperative client following a ureterolithotomy via a flank incision is ineffective airway clearance. After surgery, there is a risk of airway obstruction due to factors like anesthesia, positioning during surgery, or the presence of secretions. Maintaining a clear airway is crucial to prevent respiratory complications, such as atelectasis or pneumonia. Altered nutrition, fluid volume excess, and activity intolerance are important considerations but are secondary to the immediate threat of compromised airway clearance in the postoperative period.

2. A 20-year-old male client is diagnosed with Ewing’s sarcoma following an examination for a knee injury. Which instruction is most important for the nurse to provide the client?

• A. Take analgesics regularly to manage pain
• B. Notify the healthcare provider if the swelling worsens
• C. Avoid weight-bearing on the affected knee until the injury heals
• D. Seek treatment for the sarcoma immediately

Correct answer: D

Rationale: The most crucial instruction for the nurse to provide the client is to seek treatment for the sarcoma immediately. Ewing's sarcoma is a type of cancer that necessitates prompt and aggressive treatment for the best possible outcome. While managing pain (Choice A) and monitoring swelling (Choice B) are important, addressing the underlying sarcoma is the priority. Instructing the client to avoid weight-bearing (Choice C) is not directly related to the treatment of Ewing's sarcoma and may not be the most critical instruction at this point.

3. An adult client presents to the clinic with large draining ulcers on both lower legs that are characteristic of Kaposi’s Sarcoma lesions. The client is accompanied by two family members. What action should the nurse take?

• A. Obtain a blood sample to determine if the client is HIV positive
• B. Send the family to the waiting area while conducting a head-to-toe assessment
• C. Complete a head-to-toe assessment to identify other signs of HIV
• D. Ask the family members to wear gloves when touching the client

Correct answer: C

Rationale: In this scenario, the most appropriate action for the nurse to take is to complete a head-to-toe assessment to identify other signs of HIV. Kaposi’s Sarcoma is commonly associated with HIV infection, and conducting a comprehensive assessment can provide crucial information on potential signs and symptoms related to HIV. This information is essential for providing appropriate care and treatment. Option A is not the priority at this moment, as the focus should be on assessing the client comprehensively first. Sending the family members away (Option B) may not be necessary if they are not interfering with the assessment process. While infection control is important, asking the family members to wear gloves (Option D) is not the most critical action to take in this situation.

4. Parents who have one male child with sickle cell anemia are concerned about having more children with the disease. What client teaching should the nurse provide?

• A. All future children will be carriers, but will not necessarily have the disease
• B. There is a chance that each future child will have the disease
• C. Only male children cannot inherit the sickle cell disease trait
• D. Only one out of four of their children will definitely manifest the disease

Correct answer: B

Rationale: The correct answer is B. Each child has a 25% chance of having sickle cell anemia if both parents are carriers of the trait. Choice A is incorrect because not all future children will be carriers; some may have the disease. Choice C is incorrect as both male and female children can inherit the sickle cell disease trait. Choice D is incorrect as the chance is not fixed at one out of four; each child has an independent 25% chance of having the disease.

5. While changing the pressure ulcer dressing of a client who is immobile, the nurse notes that the boundary edges of the wound have increased. Before reporting this finding to the healthcare provider, the nurse should review which of the client’s serum laboratory values?

• A. Potassium
• B. Platelets
• C. Creatinine
• D. Albumin

Correct answer: D

Rationale: The correct answer is D: Albumin. Reviewing albumin levels is crucial in this situation because low albumin levels can impact wound healing and contribute to increased wound edges. Potassium (choice A) is not directly related to wound healing or wound edges. Platelets (choice B) are more related to blood clotting than wound healing. Creatinine (choice C) is related to kidney function, not specifically to wound healing or wound edges.

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