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 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.

3. Nurse Meredith is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination:

• A. at the end of her menstrual cycle.
• B. on the same day each month.
• C. on the 1st day of the menstrual cycle.
• D. immediately after her menstrual period.

Correct answer: D

Rationale: For premenopausal women, the best time to perform a breast self-examination (BSE) is immediately after their menstrual period ends. This timing is ideal because hormonal fluctuations during the menstrual cycle can cause breast tissue to become swollen and tender, making it more difficult to detect any lumps or changes. After the menstrual period, breast tissue is usually softer and less lumpy, allowing for a more accurate assessment of any abnormalities.

4. In caring for a patient with a diagnosis of acute myeloid leukemia (AML) receiving induction therapy on the oncology unit, what nursing action should be prioritized in the patient's care plan?

• A. Protective isolation and vigilant use of standard precautions
• B. Provision of a high-calorie, low-texture diet and appropriate oral hygiene
• C. Including the family in planning the patient's activities of daily living
• D. Monitoring and treating the patient's pain

Correct answer: A

Rationale: The correct answer is A: Protective isolation and vigilant use of standard precautions. Induction therapy for acute myeloid leukemia (AML) can lead to neutropenia, significantly increasing the risk of infections. Therefore, the priority is to protect the patient from potential pathogens by implementing protective isolation measures and adhering to strict standard precautions. This action is crucial for the patient's survival. Choice B is incorrect as nutritional support and oral hygiene are important but not the priority in this situation. Choice C, involving the family in planning activities, is a valuable aspect of care but not the priority during induction therapy. Choice D, monitoring and treating pain, is essential but ensuring protection against infection takes precedence due to the high risk of neutropenia.

5. An emergency department nurse is triaging a 77-year-old man who presents with uncharacteristic fatigue as well as back and rib pain. The patient denies any recent injuries. The nurse should recognize the need for this patient to be assessed for what health problem?

• A. Hodgkin disease
• B. Non-Hodgkin lymphoma
• C. Multiple myeloma
• D. Acute thrombocythemia

Correct answer: C

Rationale: The correct answer is multiple myeloma (choice C). Back pain is a common presenting symptom in multiple myeloma, especially in older patients. This malignancy can lead to bone pain due to bone destruction and fractures. Hodgkin disease (choice A) and Non-Hodgkin lymphoma (choice B) typically present with symptoms like painless lymph node enlargement, fever, and weight loss. Acute thrombocythemia (choice D) is characterized by an increase in platelet count but is not typically associated with the symptoms described by the patient.

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