Nursing Elites

1. The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?

• A. The passage of flatus
• B. Absent bowel sounds
• C. The client’s ability to tolerate food
• D. Bloody drainage from the colostomy

Correct answer: A

Rationale: The passage of flatus (gas) from the colostomy is an early sign that the bowel is beginning to function after surgery. This indicates that peristalsis, or the movement of the intestines, has resumed and that the digestive system is actively moving gas and eventually stool through the bowel and out of the colostomy. It’s a positive sign that the bowel is recovering from the surgery and starting to work as intended.

2. 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.

3. Which of the following is not a manifestation of breast cancer?

• A. Peau d'orange
• B. Painless breast mass
• C. Alopecia
• D. Breast enlargement

Correct answer: C

Rationale: Alopecia (hair loss) is not a direct manifestation of breast cancer but rather a common side effect of chemotherapy used in breast cancer treatment. Peau d'orange refers to the dimpling or pitting of the skin resembling an orange peel, which can be a sign of breast cancer due to blockage of lymphatic vessels. A painless breast mass and breast enlargement can both be manifestations of breast cancer, with a painless mass being a common symptom and breast enlargement sometimes occurring due to tumor growth.

4. A nurse is caring for a patient who has been diagnosed with leukemia. The nurse's most recent assessment reveals the presence of ecchymoses on the patient's sacral area and petechiae on her forearms. In addition to informing the patient's primary care provider, what action should the nurse take?

• A. Initiate measures to prevent venous thromboembolism (VTE).
• B. Check the patient's most recent platelet level.
• C. Place the patient on protective isolation.
• D. Ambulate the patient to promote circulatory function.

Correct answer: B

Rationale: The patient's signs of ecchymoses and petechiae are suggestive of thrombocytopenia, which is a common complication of leukemia. Thrombocytopenia is a condition characterized by a low platelet count, leading to abnormal bleeding. Checking the patient's most recent platelet level is crucial to assess the severity of thrombocytopenia and guide further interventions. Initiating measures to prevent venous thromboembolism (VTE) (Choice A) is not directly related to the patient's current signs. Placing the patient on protective isolation (Choice C) is not necessary for ecchymoses and petechiae. Ambulating the patient (Choice D) is not appropriate without addressing the underlying cause of abnormal bleeding.

5. A nurse is providing care to a patient who has just received a diagnosis of acute myeloid leukemia (AML). What is the priority nursing diagnosis for this patient?

• A. Risk for bleeding
• B. Risk for infection
• C. Impaired gas exchange
• D. Imbalanced nutrition

Correct answer: B

Rationale: Risk for infection is a high priority due to the patient's compromised immune system from AML.

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