Nokea
A client is having a catheter placed in the femoral artery to deliver yttrium-90 beads into a liver tumor. What action by the nurse is most important?
- A. Assessing the client's allergies
- B. Ensuring that informed consent is on the chart
- C. Marking the client's bilateral pedal pulses
- D. Reviewing client teaching done previously
Correct Answer: B
Rationale: This is an invasive procedure requiring informed consent. The nurse should ensure that consent is on the chart. The other actions are also appropriate but not the priority.
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A client is receiving interleukins along with chemotherapy. What assessment by the nurse takes priority?
- A. Blood pressure
- B. Lung assessment
- C. Oral mucous membranes
- D. Skin integrity
Correct Answer: A
Rationale: Interleukins can cause capillary leak syndrome and fluid shifting, leading to intravascular volume depletion. Although all assessments are important in caring for clients with cancer, blood pressure and other assessments of fluid status take priority.
Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients should the nurse assess first?
- A. Client with dry, itchy, peeling skin
- B. Client with a serum calcium of 9.2 mg/dL
- C. Client with a serum potassium of 2.8 mg/dL
- D. Client with a weight gain of 6.6 pounds (1.1 kg) in 1 day
Correct Answer: C
Rationale: TKIs can cause electrolyte imbalances. A potassium level of 2.8 mg/dL is very low, so the nurse should assess this client first. Dry, itchy, peeling skin can be a problem in clients receiving biologic response modifiers, and the nurse should assess that client next because of the potential for discomfort and infection. The calcium level is normal, and the weight gain, while concerning, is less critical than the low potassium level.
A nurse working with clients who experience alopecia knows that which is the best method of helping clients manage the psychosocial impacts of this problem?
- A. Assisting the client to plan for this event
- B. Reassuring the client that alopecia is temporary
- C. Referring the client to a support group
- D. Telling the client that there are worse side effects
Correct Answer: A
Rationale: Alopecia does not occur in all clients with cancer, but when it does, it can be devastating. The best action by the nurse is to teach the client about the possibility and to give the client multiple choices for preparing for it.
A client with cancer has anorexia and mucositis, and is losing weight. The client's family members continually bring favorite foods to the client and are distressed when the client won't eat them. What action by the nurse is best?
- A. Assessing the client's oral cavity every 12 hours
- B. Ensuring that informed consent is on the chart
- C. Marking the client's bilateral pedal pulses
- D. Reviewing client teaching done previously
Correct Answer: A
Rationale: Mucositis can cause significant pain and discomfort, contributing to anorexia and weight loss. Assessing the client's oral cavity every 12 hours allows the nurse to monitor the severity of mucositis and implement interventions to improve nutrition and comfort.
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.