Nursing Elites

1. The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take before this procedure?

• A. Check for any iodine allergy.
• B. Insert a large-bore IV catheter.
• C. Administer prescribed sedatives.
• D. Assist the patient to a flat position.

Correct answer: D

Rationale: Before a liver and spleen scan, it is essential to assist the patient to a flat position. This position helps obtain clear images of the liver and spleen. Checking for iodine allergy (Choice A) is more relevant for procedures involving contrast dye, not a liver and spleen scan. Inserting a large-bore IV catheter (Choice B) may not be necessary for this specific procedure. Administering sedatives (Choice C) is not typically required for a liver and spleen scan, as the patient needs to remain still during the procedure.

2. Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate?

• A. I will call my health care provider if my stools turn black.
• B. I will take a stool softener if I feel constipated occasionally.
• C. I should take the iron with orange juice about an hour before eating.
• D. I should increase my fluid and fiber intake while I am taking iron tablets.

Correct answer: A

Rationale: It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the health care provider about this.

3. Which menu choice indicates that the patient understands the nurse's teaching about recommended dietary choices for iron-deficiency anemia?

• A. Omelet and whole wheat toast
• B. Cantaloupe and cottage cheese
• C. Strawberry and banana fruit plate
• D. Cornmeal muffin and orange juice

Correct answer: D

Rationale: The correct answer is D: "Cornmeal muffin and orange juice." Cornmeal muffin is a good source of iron, which is beneficial for individuals with iron-deficiency anemia. Orange juice is high in vitamin C, which aids in iron absorption. Choices A, B, and C do not specifically address the need for iron-rich foods, making them less suitable for someone with iron-deficiency anemia. Omelet and whole wheat toast (Choice A) may provide some iron but are not as focused on addressing the specific deficiency. Cantaloupe and cottage cheese (Choice B) and strawberry and banana fruit plate (Choice C) are more general fruit choices and do not emphasize iron-rich options.

4. The health care provider's progress note for a patient states that the complete blood count (CBC) shows a 'shift to the left.' Which assessment finding will the nurse expect?

• A. Cool extremities
• B. Pallor and weakness
• C. Elevated temperature
• D. Low oxygen saturation

Correct answer: C

Rationale: The correct answer is C: Elevated temperature. When a CBC shows a 'shift to the left,' it indicates elevated levels of immature polymorphonuclear neutrophils (bands), which is a sign of infection. In response to the infection, the body increases its temperature as part of the immune response. Choices A, B, and D are incorrect because cool extremities, pallor and weakness, and low oxygen saturation are not typically associated with a 'shift to the left' in a CBC; they are more indicative of other conditions or issues.

5. An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/µL during chemotherapy is to

• A. check all stools for occult blood
• B. encourage fluids to 3000 mL/day
• C. provide oral hygiene every 2 hours
• D. check the temperature every 4 hours

Correct answer: A

Rationale: The correct answer is to check all stools for occult blood. With a platelet count of 18,000/µL, the patient is at a high risk of spontaneous bleeding. Checking stools for occult blood can help detect any internal bleeding early. Encouraging fluids and providing oral hygiene are important interventions in general, but in this case, monitoring for bleeding takes precedence. Checking the temperature every 4 hours is not directly related to the patient's current condition and platelet count.

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