Nokea
A client has thrombocytopenia. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Apply the client's shoes before getting the client out of bed.
- B. Assist with ambulation.
- C. Shave the client with a safety razor only.
- D. Use a lift sheet to move the client up in bed.
- E. Use the Waterpik on a low setting for oral care.
Correct Answer: A,B,D
Rationale: Clients with thrombocytopenia are at risk of significant bleeding even with minor injuries. The nurse instructs the UAP to put the client's shoes on before getting the client out of bed, assist with ambulation, and use a lift sheet when needed to reposition the client. An electric razor should be used instead of a safety razor, and a soft-bristled toothbrush is preferred over a Waterpik for oral care.
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A client has a low hemoglobin level. Which medication does the nurse prepare to administer?
- A. Epoetin alfa (Epogen)
- B. Filgrastim (Neupogen)
- C. Mesna (Mesnex)
- D. Oprelvekin (Neumega)
Correct Answer: A
Rationale: The client's hemoglobin is low, so the nurse should prepare to administer epoetin alfa, a colony-stimulating factor that increases production of red blood cells. Filgrastim is for neutropenia. Mesna is used to decrease bladder toxicity from some chemotherapeutic agents. Oprelvekin is used to increase platelet count.
A client has mucositis. What actions by the nurse will improve the client's nutrition? (Select all that apply.)
- A. Assist with rinsing the mouth with saline frequently.
- B. Encourage the client to eat room-temperature foods.
- C. Give the client hot liquids to hold in the mouth.
- D. Provide local anesthetic medications to swish and spit.
- E. Remind the client to brush gently after each meal.
Correct Answer: A,B,D,E
Rationale: Mucositis can interfere with nutrition. The nurse can help by assisting with rinsing the mouth frequently with saline, encouraging the client to eat cool or room-temperature foods, providing swish-and-spit anesthetics, and reminding the client to keep the mouth clean by brushing gently after each meal. Hot liquids should be avoided as they can be painful for the client.
A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority?
- A. Reassuring clients that this change is temporary
- B. Referring clients to a reputable wig shop
- C. Teaching measures to prevent scalp injury
- D. Providing emotional support for body image changes
Correct Answer: D
Rationale: All actions are appropriate for clients with alopecia. However, the priority is client safety, so the nurse should first teach ways to prevent scalp injury.
A client tells the oncology nurse about an upcoming vacation to be back to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate?
- A. Are you ensuring the radiation site is protected?
- B. Do not expose the radiation area to direct sunlight.
- C. Have a wonderful time and enjoy your vacation!
- D. Remember you should not drink alcohol for a year.
Correct Answer: B
Rationale: The radiation site is extremely sensitive to sunlight after radiation therapy has been completed. The nurse should inform the client to avoid sun exposure to this area. This advice continues for 1 year after treatment has been completed. The other statements are not appropriate.
A nurse in the oncology clinic is providing preoperative education to a client just diagnosed with cancer. The client has been scheduled for many days. What action by the nurse is best?
- A. Call the client at home the next day to review teaching.
- B. Give the client information about a cancer support group.
- C. Provide all the preoperative instructions in writing.
- D. Reassure the client that surgery will be over soon.
Correct Answer: A
Rationale: Clients are often overwhelmed at a sudden diagnosis of cancer and may be more overwhelmed at the idea of a major operation so soon. This stress significantly impacts the client's ability to understand, retain, and recall information. The nurse should call the client at home the next day to review the teaching and to answer questions. The client may or may not be ready to investigate a support group, but this does not help with teaching. Giving information in writing is important (if the client can read it), but in itself will not be enough. Telling the client about surgery will be over soon is giving false reassurance and does nothing for teaching.