Nursing Elites

1. While a patient is receiving IV doxorubicin hydrochloride for the treatment of cancer, the nurse observes swelling and pain at the IV site. The nurse should prioritize what action?

• A. Stopping the administration of the drug immediately
• B. Notifying the patient's physician
• C. Continuing the infusion but decreasing the rate
• D. Applying a warm compress to the infusion site

Correct answer: A

Rationale: The correct action for the nurse to take when observing swelling and pain at the IV site during the administration of doxorubicin hydrochloride is to stop the administration of the drug immediately. Doxorubicin hydrochloride can cause severe tissue damage, so discontinuing the infusion is crucial to prevent further harm to the patient. Notifying the physician is important, but it should not take precedence over stopping the drug. Continuing the infusion, even at a decreased rate, can exacerbate tissue damage. Applying a warm compress is not appropriate in this situation and may worsen the tissue injury caused by the drug.

2. An oncology nurse is caring for a patient with multiple myeloma who is experiencing bone destruction. When reviewing the patient's most recent blood tests, the nurse should anticipate what imbalance?

• A. Hypercalcemia
• B. Hyperproteinemia
• C. Elevated serum viscosity
• D. Elevated RBC count

Correct answer: A

Rationale: The correct answer is A, Hypercalcemia. In multiple myeloma, bone destruction can lead to the release of calcium from the bones into the bloodstream, causing hypercalcemia. This imbalance is commonly seen in patients with multiple myeloma. Choice B, Hyperproteinemia, is not typically associated with bone destruction in multiple myeloma. Choice C, Elevated serum viscosity, and Choice D, Elevated RBC count, are not directly related to the bone destruction seen in multiple myeloma.

3. A patient with non-Hodgkin lymphoma (NHL) is receiving treatment. What is the most important assessment for the nurse to make in this patient?

• A. Skin integrity
• B. Nutritional status
• C. Respiratory function
• D. Cognitive function

Correct answer: C

Rationale: The correct answer is C: Respiratory function. In a patient with non-Hodgkin lymphoma (NHL), monitoring respiratory function is crucial due to the potential for complications such as pleural effusion or pneumonia. Assessing skin integrity (choice A) is important but not as critical as monitoring respiratory function in this case. Nutritional status (choice B) and cognitive function (choice D) are also important aspects of care but do not take precedence over assessing respiratory function in a patient with NHL undergoing treatment.

4. A healthcare professional is assessing a female client who is taking hormone therapy for breast cancer. What assessment finding requires the healthcare professional to notify the primary health care provider immediately?

• A. Irregular menses.
• B. Edema in the lower extremities.
• C. Ongoing breast tenderness.
• D. Red, warm, swollen calf.

Correct answer: D

Rationale: The correct answer is D. A red, warm, swollen calf may indicate a deep vein thrombosis, which is a medical emergency. This finding requires immediate notification of the primary health care provider to prevent potential complications such as pulmonary embolism. Choices A, B, and C are not indicative of life-threatening conditions and should be monitored but do not require immediate notification like a suspected deep vein thrombosis.

5. A client has a platelet count of 9800/mm3. What action by the nurse is most appropriate?

• A. Assess the client for calf pain, warmth, and redness.
• B. Instruct the client to call for help to get out of bed.
• C. Obtain cultures as per the facility’s standing policy.
• D. Place the client on protective Isolation Precautions.

Correct answer: B

Rationale: A platelet count of 9800/mm³ indicates severe thrombocytopenia, placing the client at high risk for bleeding, even with minor trauma or injury. Instructing the client to call for help before getting out of bed ensures they receive assistance with mobility, which reduces the risk of falls or injuries that could lead to serious bleeding. Preventing any activity that could result in trauma is crucial when managing clients with very low platelet counts.

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