1.
A nurse is caring for a client who has developed mucositis of the oral membrane. The client is being discharged. The nurse should teach the client to:
Correct Answer
C. The client should rinse his/her mouth with a solution of saline and water after each meal.
Explanation
The correct answer is to rinse the mouth with a solution of saline and water after each meal. This is because mucositis of the oral membrane can cause inflammation and irritation, making it important to maintain oral hygiene. Rinsing with a saline and water solution can help remove debris and bacteria, soothe the mouth, and promote healing. Drinking iced liquids before each meal may provide temporary relief, but it does not address the need for oral hygiene. Using a commercial mouthwash may contain alcohol or other irritants that can worsen mucositis. Firmly brushing the teeth can further irritate the oral membrane.
2.
2. The nurse is about to access a client's implanted vascular port to administer medication. What nursing action should be implemented first?
Correct Answer
D. .Inspect the port site for redness or swelling
Explanation
The first nursing action that should be implemented before accessing a client's implanted vascular port to administer medication is to inspect the port site for redness or swelling. This is important to assess for any signs of infection or inflammation, which could indicate a potential complication or contraindication for accessing the port. By inspecting the port site first, the nurse can ensure the safety and well-being of the client before proceeding with the medication administration.
3.
After a liver biopsy which position is the client assisted to assume?
Correct Answer
A. Right lying with a folded towel under the puncture site.
Explanation
After a liver biopsy, the client is assisted to assume the right lying position with a folded towel under the puncture site. This position helps to minimize the risk of bleeding or hematoma formation at the puncture site. By lying on the right side, pressure is applied to the area, which can help to control bleeding. The folded towel provides additional support and compression to the puncture site, further reducing the risk of complications.
4.
The nurse is teaching a client proper skin care for external radiation treatments. The nurse knows the client understands when the client states:
Correct Answer
C. I will wear clothing that does not place pressure on the area.
Explanation
The correct answer is "I will wear clothing that does not place pressure on the area." This statement indicates that the client understands the importance of avoiding pressure on the area being treated with external radiation. Pressure can cause irritation and damage to the skin, which can further worsen the side effects of radiation therapy. By wearing loose-fitting clothing, the client can minimize friction and pressure on the treated area, promoting healing and reducing discomfort.
5.
A nurse is discharging a client to home after the client received a round of chemotherapy. The client states "I am glad to be going home so that I can continue my herbal remedy for nausea." The best response by the nurse is:
Correct Answer
A. Tell me what herbal remedies you are planning on taking. Then we can discuss their safety with your pHysician.
Explanation
The best response by the nurse is to ask the client about the specific herbal remedies they plan on taking and then discuss their safety with the physician. This response shows the nurse's willingness to listen to the client's preferences and ensures that the client's safety is prioritized by involving the physician in the discussion. It promotes open communication and collaboration between the nurse, client, and physician to make informed decisions about the client's care.
6.
A nurse is caring for a client who states they have sudden pain at the IV site when receiving Vincristine. The nurse's first action should be to:
Correct Answer
D. Stop the infusion immediately.
Explanation
The correct answer is to stop the infusion immediately. Vincristine is a chemotherapy medication that can cause severe tissue damage if it infiltrates into the surrounding tissues. Therefore, it is crucial to stop the infusion as soon as the client reports sudden pain at the IV site. This action will help prevent further damage and potential complications. Calling the physician can be done after stopping the infusion to report the situation and seek further instructions. Applying cool or warm compresses may not address the underlying issue and should not be the nurse's first action in this situation.
7.
A client is to start chemotherapy next week for ovarian cancer. The nurse knows the client understands teaching concerning alopecia when the client states:
Correct Answer
D. I have decided to have my hair cut short tomorrow. I already bought my wig.
Explanation
The client's statement of having their hair cut short and buying a wig indicates that they understand the potential side effect of alopecia (hair loss) from chemotherapy. Cutting their hair short and purchasing a wig shows that they are prepared for the hair loss and have taken proactive steps to manage it. This demonstrates their understanding of the teaching regarding alopecia.
8.
A client receiving chemotherapy states that everything she tries to eat does not taste good. The nurse explains that this is a side effect of chemotherapy and the client can perform which of the following to decrease this symptom.
Correct Answer
B. Frequently perform mouth care.
Explanation
Chemotherapy often causes changes in taste and appetite, resulting in a metallic or unpleasant taste in the mouth. Performing mouth care frequently can help alleviate this symptom by removing any residual tastes and improving the overall cleanliness of the mouth. This can be done by brushing the teeth and tongue regularly, using mouthwash, and rinsing the mouth with water. These actions help to refresh the taste buds and improve the sensation of taste, making food more enjoyable for the client.
9.
A client with a diagnosis of terminal cancer is being cared for at home. The nurse is teaching the client how to control pain. The nurse teaches the client to:
Correct Answer
A. Start with the lower dosage of a medication then gradually increase the dose until pain relief is obtained.
Explanation
The nurse teaches the client to start with a lower dosage of medication and gradually increase the dose until pain relief is obtained. This approach is commonly used in pain management to find the lowest effective dose of medication while minimizing the risk of side effects. It allows the client to have better control over their pain by finding the optimal dosage that provides relief without causing excessive sedation or other adverse effects. By gradually increasing the dose, the client can also monitor their response to the medication and make adjustments as needed.
10.
A client is being admitted to the hospital for a radiation implant for cervical cancer. The nurse teaches the client that:
Correct Answer
C. Visitors should be limited. Small children and pregnant women should not visit.
Explanation
During radiation therapy, the client will be radioactive, and this radiation can be harmful to small children and pregnant women. Therefore, it is important to limit visitors and restrict the presence of small children and pregnant women in order to ensure their safety. The other options mentioned in the question, such as the client's school age children visiting for a limited time and the radioactivity of the client's urine and stool, are not relevant to the safety precautions regarding visitors.
11.
The goal of each chemotherapy treatment is to:
Correct Answer
D. Eradicate a percentage of the cancer cells
Explanation
The goal of each chemotherapy treatment is to eradicate a percentage of the cancer cells. Chemotherapy drugs are designed to target and kill rapidly dividing cells, which includes cancer cells. However, it is not always possible to completely eradicate all cancer cells with chemotherapy alone. The effectiveness of chemotherapy varies depending on the type and stage of cancer, as well as individual patient factors. Therefore, the goal is to reduce the number of cancer cells as much as possible to slow down or stop the growth of the tumor and improve the patient's overall prognosis.
12.
A client with cancer under going surgery to relieve symptoms. Which type of surgery is the client undergoing ?
Correct Answer
A. Palliative
Explanation
The client is undergoing palliative surgery. Palliative surgery aims to relieve symptoms and improve the quality of life for patients with cancer. It is not curative or meant to remove the cancer completely, but rather to alleviate pain, discomfort, or other symptoms caused by the cancer.
13.
The nurse is caring for a client who received an allogenic bone marrow transplant. This type of transplant involves receiving cells from which type of donor?
Correct Answer
C. A donor other than the client
Explanation
An allogenic bone marrow transplant involves receiving cells from a donor other than the client. In this type of transplant, the donor can be a family member, a friend, or an unrelated individual whose tissue type matches the recipient's. The purpose of the transplant is to replace the recipient's damaged or diseased bone marrow with healthy donor cells. This allows for the production of new, healthy blood cells in the recipient's body.
14.
A client who is receiving chemotherapy for lung cancer has a neutrophil count of 600/mm. Which of the following statements should be included in teaching for this client:
Correct Answer
B. Avoid eating raw fruits and vegetables
Explanation
Clients receiving chemotherapy often have a weakened immune system, which can lead to a decreased neutrophil count. Neutrophils are a type of white blood cell that helps fight off infections. Raw fruits and vegetables may carry bacteria or other pathogens that can cause infections, so it is important for the client to avoid consuming them. This precaution helps reduce the risk of developing foodborne illnesses, which can be more severe in individuals with compromised immune systems.
15.
A nurse is caring for a client with thrombocytopenia. Which of the following should be included in the client's plan of care? Check all that apply.
Correct Answer(s)
A. Monitor platelet counts
B. Assess the patient for melena
D. Monitor the patient for hematemesis
Explanation
The client with thrombocytopenia has a decreased number of platelets, which are responsible for blood clotting. Therefore, it is important to monitor platelet counts to assess the client's clotting ability. Thrombocytopenia can cause bleeding in the digestive tract, which can result in melena (dark, tarry stools), so assessing the patient for melena is necessary. Additionally, thrombocytopenia can also cause bleeding in the upper gastrointestinal tract, which can lead to hematemesis (vomiting blood). Therefore, monitoring the patient for hematemesis is important to detect any signs of bleeding. Monitoring WBC counts is not directly related to thrombocytopenia and is not necessary in this case.