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 nurse at a long-term care facility is amending the care plan of a resident who has just been diagnosed with essential thrombocythemia (ET). The nurse should anticipate the administration of what medication?

• A. Dalteparin
• B. Allopurinol
• C. Hydroxyurea
• D. Hydrochlorothiazide

Correct answer: C

Rationale: Hydroxyurea is effective in lowering the platelet count for patients with ET.

3. 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.

4. A patient diagnosed with polycythemia vera presents to the clinic for routine bloodwork. What should the nurse monitor for in this patient as a priority?

• A. Hemoglobin and hematocrit levels
• B. Platelet count
• C. White blood cell count
• D. Blood pressure

Correct answer: B

Rationale: In polycythemia vera, there is an overproduction of red blood cells, white blood cells, and platelets, which leads to increased blood viscosity and a high risk for thrombosis (blood clot formation). Monitoring the platelet count is a priority because elevated platelet levels contribute significantly to the risk of developing blood clots, which can result in life-threatening complications such as strokes, heart attacks, or deep vein thrombosis (DVT). Therefore, regular monitoring of the platelet count is essential to assess the patient’s risk for thrombosis and to guide treatment decisions, such as phlebotomy or medication adjustments to lower platelet levels.

5. The clinical nurse educator is presenting health promotion education to a patient who will be treated for non-Hodgkin lymphoma on an outpatient basis. The nurse should recommend which of the following actions?

• A. Avoiding direct sun exposure in excess of 15 minutes daily
• B. Avoiding grapefruit juice and fresh grapefruit
• C. Avoiding highly crowded public places
• D. Using an electric shaver rather than a razor

Correct answer: C

Rationale: Patients with non-Hodgkin lymphoma (NHL) often experience a compromised immune system due to both the disease itself and the effects of treatments like chemotherapy and radiation, which cause myelosuppression (decreased production of blood cells, including white blood cells). This puts them at significant risk for infections. Avoiding crowded places is a crucial preventive measure, as it reduces the patient's exposure to pathogens that could lead to infections, which can be particularly severe due to their weakened immune system.

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