Nursing Elites

1. The nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. The nurse should be particularly alert for:

• A. Nasal congestion
• B. Abdominal tenderness
• C. Muscle tetany
• D. Oliguria

Correct answer: A

Rationale: During the removal of a pituitary tumor using the transsphenoidal approach, nasal congestion is a significant concern as it can further obstruct the airway. This can be due to mucosal swelling, bleeding, or edema resulting from the surgery. Nasal congestion requires immediate attention to prevent airway compromise. Abdominal tenderness, muscle tetany, and oliguria are not directly associated with the pituitary gland or the transsphenoidal approach, making them incorrect choices. Abdominal tenderness is more common in abdominal or pelvic surgeries due to intra-abdominal issues. Muscle tetany is related to electrolyte imbalances or neuromuscular disorders, not specific to pituitary surgery. Oliguria is a concern in renal-related conditions, not typically in pituitary tumor surgeries.

2. The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis?

• A. Foul breath
• B. Dysphagia
• C. Diarrhea
• D. Chronic hiccups

Correct answer: C

Rationale: Diarrhea is not a common finding in clients with laryngeal cancer. Foul breath (A), dysphagia (B), and chronic hiccups (D) are expected findings associated with laryngeal cancer. Foul breath can result from tissue breakdown in the mouth and throat. Dysphagia, or difficulty swallowing, can occur due to the tumor's location affecting the swallowing mechanism. Chronic hiccups can be a symptom of irritation to the phrenic nerves from the cancer.

3. A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period?

• A. Teaching perineal wound care techniques
• B. Monitoring electrolyte levels
• C. Encouraging early ambulation
• D. Facilitating perineal wound drainage

Correct answer: D

Rationale: The priority nursing care during the post-op period for a client who underwent an abdominal perineal resection is to facilitate perineal wound drainage. This is crucial for preventing infection of the surgical site and promoting healing. Teaching perineal wound care techniques, as in choice A, is more appropriate than ileostomy care in this scenario. While monitoring electrolyte levels is important, it is not the priority compared to ensuring proper wound drainage, making choice B less crucial. Encouraging early ambulation, as in choice C, is beneficial but not as critical as facilitating wound drainage immediately post-op.

4. Why might the physician order antibiotics to be given through the central venous access device (CVAD) rather than through a peripheral IV line if the CVAD becomes infected?

• A. To prevent infiltration of the peripheral line
• B. To reduce the pain and discomfort associated with antibiotic administration in a small vein
• C. To lessen the chance of an allergic reaction to the antibiotic
• D. To attempt to eliminate microorganisms in the catheter and prevent having to remove it

Correct answer: D

Rationale: When a patient's central venous access device (CVAD) becomes infected, administering antibiotics through the line is essential to attempt to eliminate microorganisms within the catheter. The goal is to prevent the necessity of removing the catheter, which might be required if the infection persists. Choice A, 'To prevent infiltration of the peripheral line,' is incorrect as the priority is addressing the catheter infection, not preventing issues with a peripheral line. Choice B, 'To reduce the pain and discomfort associated with antibiotic administration in a small vein,' is not relevant to the rationale for choosing the CVAD for antibiotic administration. Choice C, 'To lessen the chance of an allergic reaction to the antibiotic,' is also incorrect as the main focus is managing the catheter-associated infection rather than allergy prevention.

5. The difference between spirituality and religion is that spirituality is:

• A. a belief about a higher power.
• B. an individual's relationship with a higher power.
• C. organized worship.
• D. a belief in an invisible energy or ideal.

Correct answer: B

Rationale: The correct answer is 'an individual's relationship with a higher power.' Spirituality is more about personal connection, beliefs, and experiences related to a higher power or force, whereas religion is often associated with organized practices, rituals, and doctrines within a specific faith community. Choice A is incorrect as spirituality goes beyond just believing in a higher power; it encompasses a personal connection. Choice C, 'organized worship,' is incorrect because spirituality can exist outside formal religious settings. Choice D is incorrect as it oversimplifies spirituality as merely a belief in an invisible energy or ideal, missing the relational aspect with a higher power.

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