Nursing Elites

1. Which patient requires the most rapid assessment and care by the emergency department nurse?

• A. The patient with hemochromatosis who reports abdominal pain
• B. The patient with neutropenia who has a temperature of 101.8°F
• C. The patient with thrombocytopenia who has oozing gums after a tooth extraction
• D. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours

Correct answer: B

Rationale: The correct answer is B because a neutropenic patient with a fever is at high risk for developing sepsis. Sepsis can progress rapidly and lead to life-threatening complications. Immediate assessment, obtaining cultures, and initiating antibiotic therapy are essential in this situation. Choices A, C, and D do not present with the same level of urgency as a neutropenic patient with a fever. Abdominal pain in a hemochromatosis patient, oozing gums after a tooth extraction in a thrombocytopenic patient, and nausea and diarrhea in a patient with sickle cell anemia, while concerning, do not indicate the same immediate risk of sepsis as a neutropenic patient with a fever.

2. Which action will the admitting nurse include in the care plan for a patient who has neutropenia?

• A. Avoid intramuscular injections
• B. Check temperature every 4 hours
• C. Omit fruits or vegetables from the diet
• D. Place a 'No Visitors' sign on the door

Correct answer: B

Rationale: The correct answer is B: 'Check temperature every 4 hours.' Neutropenic patients have a weakened immune system due to low levels of neutrophils, which are a type of white blood cell that helps fight infections. Monitoring the patient's temperature every 4 hours is crucial because the earliest sign of infection in a neutropenic patient is often a fever. This allows for early detection of any potential infections. Choices A, C, and D are incorrect because avoiding intramuscular injections, omitting fruits or vegetables from the diet, and placing a 'No Visitors' sign on the door are not specific actions directly related to managing neutropenia or monitoring for signs of infection.

3. The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the

• A. Schilling test
• B. bilirubin level
• C. gastric analysis
• D. stool occult blood

Correct answer: B

Rationale: The correct answer is B: bilirubin level. Jaundice, characterized by scleral jaundice, is caused by the elevation of bilirubin levels associated with red blood cell hemolysis. Checking the bilirubin level in the laboratory results will help assess the severity of jaundice in the patient. Choices A, C, and D are incorrect because the Schilling test is used to assess vitamin B12 absorption, gastric analysis is used to evaluate gastric function, and stool occult blood is used to detect hidden blood in the stool, which are not directly related to evaluating jaundice in a patient with hemolytic anemia.

4. A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to

• A. administer oxygen therapy at a high flow rate
• B. obtain a urine specimen to send to the laboratory
• C. notify the healthcare provider about the symptoms
• D. disconnect the transfusion and infuse normal saline

Correct answer: D

Rationale: The patient's symptoms, back pain, and difficulty breathing after the transfusion indicate a possible acute hemolytic reaction, a severe transfusion reaction. The priority action in this situation is to discontinue the transfusion immediately to prevent further complications. Infusing normal saline helps maintain the patient's intravascular volume and prevent renal damage. Administering oxygen or obtaining a urine specimen is not the most urgent action and could delay essential treatment. Notifying the healthcare provider is important but should come after ensuring the patient's safety by stopping the blood transfusion.

5. Which instruction will the nurse plan to include in discharge teaching for a patient admitted with a sickle cell crisis?

• A. Take a daily multivitamin with iron
• B. Limit fluids to 2 to 3 quarts per day
• C. Avoid exposure to crowds when possible
• D. Drink only two caffeinated beverages daily

Correct answer: C

Rationale: The correct answer is C: 'Avoid exposure to crowds when possible.' This instruction is crucial in discharge teaching for a patient admitted with a sickle cell crisis because exposure to crowds increases the risk of infection, which is the most common cause of sickle cell crisis. Choices A, B, and D are incorrect. Taking a daily multivitamin with iron (Choice A) may be beneficial for some individuals but is not specifically related to managing sickle cell crisis. Limiting fluids to 2 to 3 quarts per day (Choice B) is not typically recommended for patients with sickle cell crisis, as adequate hydration is important. Drinking only two caffeinated beverages daily (Choice D) is not a priority instruction in managing sickle cell crisis.

Similar Questions