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. Which of the following descriptions of chemotherapy is correct?

• A. Chemotherapy is externally given through high energy waves
• B. Chemotherapy is known to have fatigue as a common side effect
• C. Chemotherapy spreads throughout the body
• D. Chemotherapy attacks cancer cells only

Correct answer: C

Rationale: Chemotherapy drugs are typically administered systemically, meaning they circulate throughout the body via the bloodstream. This allows them to target cancer cells that may have spread beyond the original tumor site, making chemotherapy an effective treatment for cancers that are metastatic (have spread to other parts of the body). However, because chemotherapy is not selective, it can also affect healthy cells that divide rapidly, leading to a range of side effects.

3. A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL (61 mmol/L). The client is symptomatic but refuses blood transfusions. What medication does the nurse prepare to administer?

• A. Epoetin alfa.
• B. Filgrastim.
• C. Mesna.
• D. Dexrazoxane.

Correct answer: A

Rationale: Epoetin alfa stimulates the production of red blood cells, which is important for a client who refuses blood transfusions.

4. A nurse is caring for a patient who has a diagnosis of acute leukemia. What assessment most directly addresses the most common cause of death among patients with leukemia?

• A. Monitoring for infection
• B. Monitoring nutritional status
• C. Monitoring electrolyte levels
• D. Monitoring liver function

Correct answer: A

Rationale: The correct answer is monitoring for infection. In patients with acute leukemia, the most common cause of death is usually infection or bleeding. By closely monitoring for signs of infection, such as fever, altered mental status, or elevated white blood cell count, healthcare providers can intervene promptly. Monitoring nutritional status (choice B) is important but does not directly address the most common cause of death among leukemia patients. Monitoring electrolyte levels (choice C) and liver function (choice D) are also important assessments in cancer patients; however, they are not the most direct assessment to address the leading cause of death in patients with leukemia.

5. Which of the following is a correct statement by the nurse to a patient under radiation therapy?

• A. Brachytherapy can be performed by a pregnant nurse.
• B. Teletherapy makes the patient radioactive.
• C. Brachytherapy is an internal radiation therapy.
• D. Teletherapy requires proper disposal of feces since it can be a source of radiation.

Correct answer: C

Rationale: The correct answer is C: 'Brachytherapy is an internal radiation therapy.' Brachytherapy involves the placement of radioactive sources inside or next to the area requiring treatment. This differs from teletherapy, which is external radiation therapy. Choice A is incorrect as pregnant individuals should avoid exposure to radiation. Choice B is incorrect because teletherapy does not make the patient radioactive; the radiation source is external. Choice D is incorrect as feces is not a significant source of radiation during teletherapy.

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