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. An older adult patient is undergoing diagnostic testing for chronic lymphocytic leukemia (CLL). What assessment finding is certain to be present if the patient has CLL?

• A. Increased numbers of blast cells
• B. Increased lymphocyte levels
• C. Intractable bone pain
• D. Thrombocytopenia with no evidence of bleeding

Correct answer: B

Rationale: An increased lymphocyte count (lymphocytosis) is always present in patients with CLL.

3. A patient with acute myeloid leukemia (AML) is receiving induction therapy. What is the priority nursing intervention during this phase of treatment?

• A. Administering pain management
• B. Monitoring for signs of infection
• C. Providing emotional support
• D. Monitoring fluid balance

Correct answer: B

Rationale: Induction therapy for acute myeloid leukemia (AML) involves intensive chemotherapy aimed at achieving remission by eliminating a large number of cancerous cells. However, this aggressive treatment also severely reduces the production of healthy blood cells, including neutrophils, which leads to neutropenia (a dangerously low number of neutrophils). This makes the patient highly susceptible to infections, which can be life-threatening. Monitoring for signs of infection is critical during this phase, as infections may occur quickly and progress rapidly due to the compromised immune system. Early detection and prompt treatment of infections are vital to improving patient outcomes during induction therapy.

4. A nurse works on an oncology unit and delegates personal hygiene to assistive personnel (AP). What action by the AP requires intervention from the nurse?

• A. Allowing a very tired client to skip oral hygiene and sleep.
• B. Assisting clients with washing the perianal area every 12 hours.
• C. Helping the client use a soft-bristled toothbrush for oral care.
• D. Reminding the client to rinse the mouth with water or saline.

Correct answer: A

Rationale: Skipping oral hygiene is not appropriate for a client, even if they are tired, as it increases the risk of infection.

5. A nurse is caring for a patient diagnosed with essential thrombocythemia (ET) who is at risk for thromboembolic events. What nursing intervention is most appropriate for this patient?

• A. Encouraging regular physical activity
• B. Administering anticoagulant therapy
• C. Monitoring for signs of bleeding
• D. Monitoring for signs of infection

Correct answer: B

Rationale: Administering anticoagulant therapy is crucial to prevent thromboembolic events in patients with ET.

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