Nursing Elites

1. Nurse Jane is providing care for a client with superior vena cava syndrome. Which of the following interventions would be the priority?

• A. Elevate the head of the bed
• B. Administer steroids as prescribed
• C. Provide supplemental oxygen
• D. Administer diuretics as prescribed

Correct answer: A

Rationale: The correct answer is to elevate the head of the bed. Elevating the head of the bed can help reduce the pressure on the superior vena cava, improve venous return, and facilitate breathing in clients with superior vena cava syndrome. Administering steroids (Choice B) may be necessary in some cases, but it is not the priority in the immediate care of a client with superior vena cava syndrome. Providing supplemental oxygen (Choice C) may help improve oxygenation but does not directly address the underlying issue of venous congestion. Administering diuretics (Choice D) may be contraindicated as it can further decrease preload and worsen the condition in superior vena cava syndrome.

2. A patient with myelofibrosis is being treated with ruxolitinib. What should the nurse monitor to assess the effectiveness of this treatment?

• A. Blood pressure
• B. White blood cell count
• C. Hemoglobin and hematocrit
• D. Spleen size

Correct answer: C

Rationale: Monitoring hemoglobin and hematocrit is essential to assess the effectiveness of ruxolitinib in treating myelofibrosis. Ruxolitinib works by inhibiting JAK1 and JAK2, which are involved in the signaling pathways that regulate blood cell production. Therefore, monitoring hemoglobin and hematocrit levels can provide valuable information on how well the drug is managing the disease. Blood pressure, white blood cell count, and spleen size are not direct indicators of the treatment's effectiveness in myelofibrosis.

3. The nurse is admitting an oncology patient to the unit prior to surgery. The nurse reads in the electronic health record that the patient has just finished radiation therapy. With knowledge of the consequent health risks, the nurse should prioritize assessments related to what health problem?

• A. Cognitive deficits
• B. Impaired wound healing
• C. Cardiac tamponade
• D. Tumor lysis syndrome

Correct answer: B

Rationale: The correct answer is B: Impaired wound healing. Patients who have undergone radiation therapy are at risk for impaired wound healing due to tissue damage. While cognitive deficits, cardiac tamponade, and tumor lysis syndrome can be concerns for oncology patients, the immediate priority following radiation therapy is assessing for impaired wound healing to prevent complications post-surgery.

4. The hospice nurse is caring for a patient with cancer in her home. The nurse has explained to the patient and the family that the patient is at risk for hypercalcemia and has educated them on the signs and symptoms of this health problem. What else should the nurse teach this patient and family to do to reduce the patient’s risk of hypercalcemia?

• A. Stool softeners are contraindicated.
• B. Laxatives should be taken daily.
• C. Consume 2 to 4 L of fluid daily.
• D. Restrict calcium intake.

Correct answer: C

Rationale: The nurse should encourage the patient to consume 2 to 4 liters of fluid daily to reduce the risk of hypercalcemia.

5. A nurse is planning the care of a patient who has been diagnosed with essential thrombocythemia (ET). What nursing diagnosis should the nurse prioritize when choosing interventions?

• A. Risk for Ineffective Tissue Perfusion
• B. Risk for Imbalanced Fluid Volume
• C. Risk for Ineffective Breathing Pattern
• D. Risk for Ineffective Thermoregulation

Correct answer: A

Rationale: Essential thrombocythemia (ET) is a myeloproliferative disorder characterized by an abnormally high platelet count, which increases the risk of hypercoagulation and thrombosis (blood clot formation). These clots can impair blood flow to tissues, leading to ineffective tissue perfusion. Thrombotic events, such as strokes, deep vein thrombosis, or myocardial infarctions, are common complications of ET, making Risk for Ineffective Tissue Perfusion the most critical nursing diagnosis to prioritize. The goal of nursing interventions will be to prevent clot formation and ensure adequate blood flow to tissues.

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