Nursing Elites

1. When planning care for a client taking Heparin, which nursing diagnosis should the nurse address first?

• A. Ineffective tissue perfusion related to the presence of a thrombus obstructing blood flow
• B. Risk for injury related to active loss of blood from the vascular space
• C. Deficient knowledge related to the client's lack of understanding of the disease process
• D. Impaired skin integrity related to the development of bruises and/or hematoma

Correct answer: B

Rationale: The correct answer is 'Risk for injury related to active loss of blood from the vascular space.' When a client is taking Heparin, the primary concern is the risk of bleeding due to its anticoagulant properties. Monitoring for signs of active blood loss is crucial to prevent complications like hemorrhage. While ineffective tissue perfusion, deficient knowledge, and impaired skin integrity are important, they are secondary to the immediate risk of bleeding in clients taking anticoagulants like Heparin.

2. A healthcare professional is screening patients for immunizations. Which of the following is not a contraindication for immunization?

• A. Seizures
• B. Fever lasting more than 3 days
• C. Malignancy within the past 3 months
• D. Illness lasting more than 6 months

Correct answer: D

Rationale: The correct answer is D, 'Illness lasting more than 6 months.' Chronic conditions lasting more than 6 months are not considered a contraindication for immunization. Choice A, 'Seizures,' can be a contraindication in certain situations, especially if linked to a specific vaccine component. Choice B, 'Fever lasting more than 3 days,' can be a temporary precaution but not a general contraindication. Choice C, 'Malignancy within the past 3 months,' is a contraindication due to the compromised immune system in cancer patients.

3. Chemotherapeutic agents often produce a degree of myelosuppression including leukopenia. Leukopenia does not present immediately but is delayed several days or weeks because:

• A. the client's hemoglobin and hematocrit are normal.
• B. red blood cells are affected first.
• C. folic acid levels are normal.
• D. the current white cell count is not affected by chemotherapy.

Correct answer: D

Rationale: Leukopenia does not present immediately after chemotherapy because time is required to clear circulating cells before the effect on precursor cell maturation in the bone marrow becomes evident. Leukopenia is characterized by an abnormally low white blood cell count. The correct answer is D because the white cell count is not immediately affected by chemotherapy. Choices A, B, and C are incorrect as they pertain to red blood cells (hemoglobin and hematocrit), which are not directly related to the delayed onset of leukopenia.

4. On morning rounds, the nurse finds a somnolent client with a Blood glucose of 89 mg/dL. A sulfonurea and a proton pump inhibitor are scheduled to be administered. What is the nurse's best action?

• A. Give the proton pump inhibitor and hold the sulfonurea until the client eats
• B. Hold medications and notify the physician
• C. Arouse the client and give some orange juice with sugar packets added
• D. Give the medications as ordered and re-check blood sugar in one hour

Correct answer: A

Rationale: The correct action is to give the proton pump inhibitor and hold the sulfonurea until the client eats. Sulfonureas should be held for blood glucose levels below 100 mg/dL until the client has food to prevent hypoglycemia. Giving the proton pump inhibitor is appropriate and does not need to be delayed. Option B is incorrect because holding both medications without taking appropriate action may lead to further complications. Option C is not the best choice as it does not address the need to hold the sulfonurea until the client eats. Option D is incorrect because administering the medications without ensuring the client eats may lead to hypoglycemia.

5. Which of the following is an inappropriate item to include in planning care for a severely neutropenic client?

• A. Transfuse neutrophils (granulocytes) to prevent infection.
• B. Exclude raw vegetables from the diet.
• C. Avoid administering rectal suppositories.
• D. Prohibit vases of fresh flowers and plants in the client's room.

Correct answer: A

Rationale: Transfusing neutrophils (granulocytes) to prevent infection is inappropriate in the care of a severely neutropenic client. Neutrophils normally comprise 70% of all white blood cells and can be beneficial in a selected population of infected, severely granulocytopenic clients (less than 500/mm3) who do not respond to antibiotic therapy and who are expected to experience prolonged suppression of granulocyte production. Therefore, transfusing neutrophils is not a standard practice in caring for neutropenic clients. The other choices are appropriate in caring for a severely neutropenic client: excluding raw vegetables from the diet to reduce the risk of infections from potential pathogens, avoiding administering rectal suppositories to prevent any injury or infection due to mucosal damage, and prohibiting vases of fresh flowers and plants in the client's room to minimize the risk of exposure to environmental pathogens.

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