Nursing Elites

1. The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate?

• A. Clamp the Penrose drain.
• B. Change the dressing as prescribed.
• C. Notify the healthcare provider (HCP).
• D. Remove and replace the perineal packing.

Correct answer: B

Rationale: In this scenario, the appropriate nursing intervention for serosanguineous drainage from the wound is to change the dressing as prescribed. This helps in maintaining wound cleanliness, preventing infection, and promoting proper wound healing. Clamping the Penrose drain (Choice A) is not indicated as the drainage is from the wound itself, not the drain. Notifying the healthcare provider (Choice C) may be necessary if there are signs of infection or other concerning issues, but changing the dressing should be done first. Removing and replacing the perineal packing (Choice D) is not the priority in this situation unless specifically prescribed by the healthcare provider after assessing the wound.

2. A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important?

• A. Assessing the IV site and blood return every hour.
• B. Educating the client on side effects.
• C. Monitoring the client for nausea.
• D. Providing warm packs for comfort.

Correct answer: A

Rationale: Chemotherapy drugs are often vesicants, meaning they can cause severe tissue damage if they leak (extravasate) outside of the vein. When chemotherapy is administered through a peripheral IV line, it is crucial for the nurse to frequently assess the IV site for signs of complications such as redness, swelling, or pain, which could indicate extravasation. Checking for blood return ensures the IV catheter is still in the vein and functioning properly. Preventing tissue damage from chemotherapy extravasation is a top priority, and frequent monitoring helps ensure the infusion is proceeding safely.

3. The nurse is teaching a client about the signs of infection after chemotherapy. Which of the following should the nurse emphasize?

• A. Frequent urination
• B. Increased thirst
• C. Chills and shaking
• D. Fever over 100.4°F (38°C)

Correct answer: D

Rationale: In clients undergoing chemotherapy, the immune system is often compromised due to the effects of treatment, making them more susceptible to infections. A fever over 100.4°F (38°C) is considered a critical sign of infection in these patients and requires immediate medical evaluation. Fever may indicate the presence of an infection that could escalate quickly in immunocompromised individuals, so it is vital for patients to recognize this symptom and seek prompt medical attention.

4. A clinic nurse is working with a patient who has a long-standing diagnosis of polycythemia vera. How can the nurse best gauge the course of the patient's disease?

• A. Document the color of the patient's palms and face during each visit.
• B. Follow the patient's erythrocyte sedimentation rate over time.
• C. Document the patient's response to erythropoietin injections.
• D. Follow the trends of the patient's hematocrit.

Correct answer: D

Rationale: The course of polycythemia vera can be best ascertained by monitoring the patient's hematocrit, which should remain below 45%. Hematocrit levels are a key indicator in assessing the progression of the disease. Choices A, B, and C are not the most appropriate methods for gauging the course of polycythemia vera. Monitoring the color of the patient's palms and face, or their response to erythropoietin injections, may not provide an accurate reflection of the disease's progression. Similarly, while erythrocyte sedimentation rate can be affected in polycythemia vera, it is not the primary marker for monitoring the disease's course.

5. Nurse Farah is caring for a client following a mastectomy. Which assessment finding indicates that the client is experiencing a complication related to the surgery?

• A. Pain at the incision site
• B. Arm edema on the operative side
• C. Sanguineous drainage in the Jackson-Pratt drain
• D. Complaints of decreased sensation near the operative site

Correct answer: B

Rationale: Arm edema on the operative side (lymphedema) is a known complication after a mastectomy. This can indicate impaired lymphatic drainage, leading to fluid accumulation in the arm. Pain at the incision site is expected postoperatively and may not necessarily indicate a complication. Sanguineous drainage in the Jackson-Pratt drain is a common finding in the immediate postoperative period. Complaints of decreased sensation near the operative site could be related to nerve damage or surgical manipulation, but it is not a typical complication after a mastectomy.

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