Nursing Elites

1. The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm?

• A. Placing cool compresses on the affected arm
• B. Elevating the affected arm on a pillow above heart level
• C. Avoiding arm exercises in the immediate postoperative period
• D. Maintaining an intravenous site below the antecubital area on the affected side

Correct answer: B

Rationale: After a mastectomy, particularly when lymph nodes are removed, there is an increased risk of lymphedema in the affected arm due to impaired lymphatic drainage. Elevating the affected arm above heart level helps promote lymphatic drainage and reduces the risk of swelling. This intervention facilitates the return of lymph fluid and helps prevent fluid accumulation in the arm.

2. A nurse is caring for a patient who is being treated for leukemia in the hospital. The patient was able to maintain her nutritional status for the first few weeks following her diagnosis but is now exhibiting early signs and symptoms of malnutrition. In collaboration with the dietitian, what intervention should the nurse implement?

• A. Arrange for total parenteral nutrition (TPN).
• B. Facilitate placement of a percutaneous endoscopic gastrostomy (PEG) tube.
• C. Provide the patient with several small, soft-textured meals each day.
• D. Assign responsibility for the patient's nutrition to the patient's friends and family.

Correct answer: C

Rationale: For patients experiencing difficulties with oral intake, the provision of small, easily chewed meals may be beneficial. Option A (TPN) and B (PEG tube placement) are more invasive interventions and should be considered if non-oral routes are necessary. Option D is not appropriate as the primary responsibility for a patient's nutrition should lie with healthcare professionals to ensure proper management and monitoring.

3. The nurse is caring for a patient who is to begin receiving external radiation for a malignant tumor of the neck. While providing patient education, what potential adverse effects should the nurse discuss with the patient?

• A. Impaired nutritional status
• B. Cognitive changes
• C. Diarrhea
• D. Alopecia

Correct answer: A

Rationale: Corrected Rationale: Impaired nutritional status is a potential adverse effect of radiotherapy to the head and neck due to alterations in oral mucosa and taste. While cognitive changes, diarrhea, and alopecia can be side effects of other treatments or conditions, they are not typically associated with external radiation for a malignant tumor of the neck. Therefore, the nurse should primarily focus on discussing the risk of impaired nutritional status with the patient.

4. The nurse has educated a client on precautions to take with thrombocytopenia. What statement by the client indicates a need to review the information?

• A. I will be careful if I need enemas for constipation.
• B. I will use an electric shaver instead of a razor.
• C. I should only eat soft food that is either cool or warm.
• D. I won’t be able to play sports with my grandkids.

Correct answer: A

Rationale: The correct answer is A because enemas can cause injury to a thrombocytopenic client due to the risk of bleeding. Choices B, C, and D are correct precautions for a client with thrombocytopenia. Using an electric shaver reduces the risk of cuts that could lead to bleeding. Eating soft, cool, or warm food helps prevent injuries to the oral mucosa. Avoiding activities like sports that carry a risk of injury is also advisable.

5. A patient has been found to have an indolent neoplasm. The nurse should recognize what implication of this condition?

• A. The patient faces a significant risk of malignancy.
• B. The patient has a myeloid form of leukemia.
• C. The patient has a lymphocytic form of leukemia.
• D. The patient has a major risk factor for hemophilia.

Correct answer: A

Rationale: The correct answer is A: 'The patient faces a significant risk of malignancy.' Indolent neoplasms are characterized by their slow growth and relatively low malignancy potential; however, they do have the capability to progress to malignancy over time. Choices B, C, and D are incorrect because they make assumptions about specific types of leukemia and hemophilia, which are not necessarily related to the presence of an indolent neoplasm.

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