Which unit does the nurse receive the change of shift report?
The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first? ANS: C Because neck bleeding may indicate possible carotid artery rupture in a patient who is receiving radiation to the neck, this patient should be seen first.
Where does the nurse receive change of shift report for lung cancer?
The other findings also require intervention, but are common in patients with lung cancer and not immediately life threatening. The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first?
When does the nurse need to notify the health care provider?
When monitoring the patient, the nurse will need to notify the health care provider immediately if the patient develops a. oxygen saturation of 93%. b. respirations of 20 breaths/minute.
Are the diagnoses and clinical manifestations of other patients immediately life threatening?
The diagnoses and clinical manifestations for the other patients are not immediately life threatening. A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first?
After change-of-shift report on the oncology unit, which patient should the nurse assess first? a. Patient who has a platelet count of 82,000/μL after chemotherapy b. Patient who has xerostomia after receiving head and neck radiation c. Patient who is neutropenic and has a temperature of 100.5° F (38.1° C) d. Patient who is worried about getting the prescribed long-acting opioid on time
ANS: C Temperature elevation is an emergency in neutropenic patients because of the risk for rapid progression to severe infections and sepsis. The...
A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to maintain the patient's self-esteem? a. Tell the patient to limit social contacts until regrowth of the hair occurs. b. Encourage the patient to purchase a wig or hat and wear it once hair loss begins. c. Teach the patient to gently wash hair with a mild shampoo to minimize hair loss. d. Inform the patient that hair usually grows back once the chemotherapy is complete.
ANS: B The patient is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats. Limiting social contacts is not appropriate at...
During a routine health examination, a 40-year-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next? a. Teach the patient about the need for a colonoscopy at age 50. b. Teach the patient how to do home testing for fecal occult blood. c. Obtain more information from the patient about the family history. d. Schedule a sigmoidoscopy to provide baseline data about the patient.
ANS: C The patient may be at increased risk for colon cancer, but the nurse's first action should be further assessment. The other actions may be a...
During the teaching session for a patient who has a new diagnosis of acute leukemia the patient is restless and is looking away, never making eye contact. After teaching about the complications associated with chemotherapy, the patient asks the nurse to repeat all of the information. Based on this assessment, which nursing diagnosis is most appropriate for the patient? a. Risk for ineffective adherence to treatment related to denial of need for chemotherapy b. Acute confusion related to infiltration of leukemia cells into the central nervous system c. Risk for ineffective health maintenance related to anxiety about new leukemia diagnosis d. Deficient knowledge: chemotherapy related to a lack of interest in learning about treatment
ANS: C The patient who has a new cancer diagnosis is likely to have high anxiety, which may impact learning and require that the nurse repeat and r...
External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation? a. Test all stools for the presence of blood. b. Maintain a high-residue, high-fiber diet. c. Clean the perianal area carefully after every bowel movement. d. Inspect the mouth and throat daily for the appearance of thrush.
ANS: C Radiation to the abdomen will affect organs in the radiation path, such as the bowel, and cause frequent diarrhea. Careful cleaning of this...
The home health nurse cares for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment? a. "I have frequent muscle aches and pains." b. "I rarely have the energy to get out of bed." c. "I experience chills after I inject the interferon." d. "I take acetaminophen (Tylenol) every 4 hours."
ANS: B Fatigue can be a dose-limiting toxicity for use of biologic therapies. Flulike symptoms, such as muscle aches and chills, are common side ef...
A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching? a. The patient ambulates several times a day in the room. b. The patient's visitors bring in some fresh peaches from home. c. The patient cleans with a warm washcloth after having a stool. d. The patient uses soap and shampoo to shower every other day.
ANS: B Fresh, thinned-skin fruits are not permitted in a neutropenic diet because of the risk of bacteria being present. The patient should ambulat...
Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient? a. IL-2 enhances the immunologic response to tumor cells. b. IL-2 stimulates malignant cells in the resting phase to enter mitosis. c. IL-2 prevents the bone marrow depression caused by chemotherapy. d. IL-2 protects normal cells from the harmful effects of chemotherapy.
ANS: A IL-2 enhances the ability of the patient's own immune response to suppress tumor cells. IL-2 does not protect normal cells from damage cause...
The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? a. Infuse the medication over a short period of time. b. Stop the infusion if swelling is observed at the site. c. Administer the chemotherapy through a small-bore catheter. d. Hold the medication unless a central venous line is available.
ANS: B Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication generally should be given slowly t...
What does a graduate nurse need to discuss with the UAP?
The graduate nurse must discuss the insubordination directly with the UAP first. The nurse must give objective data as to when and where the UAP did not follow through with the completion of assigned tasks. A male HCP frequently tells jokes with sexual undertones at the nursing station.
What should the nurse do if the infant has no pulse?
1. If the infant has no pulse, the nurse should begin chest compressions using two fingers at a rate of 30:2. The nurse on a pediatric unit has received the AM.shift report and tells the UAP to keep the 2-year-old child NPO for a procedure. At 0830, the nurse observes the mother feeding the child.
Why is a client at risk for dying?
Because the client is having an evolving stroke, the client is experiencing a worsening of signs and symptoms over several minutes to hours; thus, the client is at risk for dying and should be cared for by the most experienced nurse. Unlock all answers Please join to get access.