Nursing Elites

1. What is appropriate care for a client with neutropenia?

• A. Avoiding fresh fruits and vegetables.
• B. Having a private room.
• C. Wearing a mask when out of the room.
• D. Practicing routine hand washing.

Correct answer: C

Rationale: When a client has neutropenia, they have low white blood cell levels, which increases the risk of infections due to a weakened immune system. Wearing a mask when out of the room is crucial to reduce the risk of exposure to respiratory infections. Avoiding fresh fruits and vegetables is also necessary as they may contain harmful pathogens. Having a private room helps minimize exposure to pathogens and ensures that visitors are carefully screened for any signs of illness. Routine hand washing is essential to prevent the spread of infections in the healthcare setting, but the most direct measure to protect the client from potential infections is wearing a mask when out of the room.

2. Paula is a 32-year-old woman seeking evaluation and treatment for major depressive symptoms. A major nursing priority during the assessment process includes which of the following?

• A. meaning of current stressors
• B. possibility of self-harm
• C. motivation to participate in treatment
• D. presence of alcohol or other drug use

Correct answer: B

Rationale: The correct answer is to consider the possibility of self-harm during the assessment process. This is crucial because unless the client is first assessed for self-harm or suicide potential, the necessary degree of vigilance in the client's environment may not be observed. While understanding the meaning of current stressors is important for treatment planning, ensuring the client's safety takes precedence. Motivation to participate in treatment and the presence of alcohol or other drug use are also important aspects to assess but ensuring the client's safety is the top priority in this scenario.

3. Which of the following should be included in a diet rich in iron?

• A. peaches, eggs, beef
• B. cereals, kale, cheese
• C. red beans, enriched breads, squash
• D. legumes, green beans, eggs

Correct answer: A

Rationale: The correct answer is peaches, eggs, beef. These are good sources of heme iron, which is more easily absorbed by the body compared to nonheme iron. Heme iron is mainly found in animal-based foods like meat, poultry, and fish. Peaches, eggs, and beef are rich in iron and can help prevent iron deficiency anemia. Choices B, C, and D are incorrect because they do not include significant sources of heme iron. Cereals, kale, cheese, red beans, enriched breads, squash, legumes, and green beans are sources of nonheme iron, which is not as efficiently absorbed by the body as heme iron. It is important to include heme iron sources in the diet for optimal iron absorption.

4. The schizophrenic client who is admitted to the hospital for possible bowel obstruction has an NG tube and complains of pain. What should the nurse do at this time?

• A. Decrease the stimuli and observe frequently
• B. Administer the PRN sedative
• C. Call the physician immediately
• D. Administer the PRN pain medication

Correct answer: D

Rationale: In this scenario, the nurse should administer the PRN (as needed) pain medication to address the schizophrenic client's complaint of pain. It is essential to provide relief and comfort to the client experiencing pain. Option A, decreasing stimuli and observing frequently, may not address the underlying cause of pain and delay relief. Option B, administering a sedative, does not target the pain but may mask symptoms. Option C, calling the physician immediately, while important in some situations, is not the most immediate action needed to alleviate the client's pain. Therefore, the most appropriate action at this time is to administer the PRN pain medication to help alleviate the client's discomfort.

5. A client is 36 hours post-op a TKR surgery. 270 cc of sero-sanguinous fluid accumulates in the surgical drains. What action should the nurse take?

• A. Notify the doctor
• B. Empty the drain
• C. Do nothing
• D. Remove the drain

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to notify the doctor. Significant sero-sanguinous drainage after TKR surgery could indicate a potential issue such as infection or bleeding. The physician needs to be informed promptly to assess the situation and determine the appropriate course of action. Emptying the drain, doing nothing, or removing the drain without consulting the physician could lead to complications going unnoticed or untreated. It is crucial to involve the physician in decision-making to ensure the best outcomes for the client.

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