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A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important?
- A. Assessing the IV site and blood return every hour.
- B. Educating the client on side effects.
- C. Monitoring the client for nausea.
- D. Providing warm packs for comfort.
Correct Answer: A
Rationale: Chemotherapy drugs are often vesicants, meaning they can cause severe tissue damage if they leak (extravasate) outside of the vein. When chemotherapy is administered through a peripheral IV line, it is crucial for the nurse to frequently assess the IV site for signs of complications such as redness, swelling, or pain, which could indicate extravasation. Checking for blood return ensures the IV catheter is still in the vein and functioning properly. Preventing tissue damage from chemotherapy extravasation is a top priority, and frequent monitoring helps ensure the infusion is proceeding safely.
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A patient with acute myeloid leukemia (AML) is receiving induction therapy. What is the priority nursing intervention during this phase of treatment?
- A. Administering pain management
- B. Monitoring for signs of infection
- C. Providing emotional support
- D. Monitoring fluid balance
Correct Answer: B
Rationale: Induction therapy for acute myeloid leukemia (AML) involves intensive chemotherapy aimed at achieving remission by eliminating a large number of cancerous cells. However, this aggressive treatment also severely reduces the production of healthy blood cells, including neutrophils, which leads to neutropenia (a dangerously low number of neutrophils). This makes the patient highly susceptible to infections, which can be life-threatening. Monitoring for signs of infection is critical during this phase, as infections may occur quickly and progress rapidly due to the compromised immune system. Early detection and prompt treatment of infections are vital to improving patient outcomes during induction therapy.
A patient admitted with cancer asks the nurse about the difference between chemotherapy and radiation therapy. Which of the following responses by the nurse indicates a need for further teaching?
- A. Chemotherapy kills cancer cells
- B. Radiation therapy can be internal or external
- C. Radiation therapy is often external
- D. Chemotherapy is more likely to kill normal cells
Correct Answer: D
Rationale: While chemotherapy does affect normal, healthy cells-particularly those that divide rapidly-it is not "more likely" to kill normal cells compared to cancer cells. Chemotherapy targets rapidly dividing cells, which includes both cancer cells and some normal cells (like those in hair follicles, the gastrointestinal tract, and bone marrow). However, its primary goal is to kill cancer cells, and its effects on normal cells are a side effect, not the main function. Therefore, the statement that chemotherapy is "more likely" to kill normal cells is inaccurate and indicates a need for further teaching.
Nurse Maria is preparing a care plan for a client receiving external radiation therapy. Which of the following interventions should be included?
- A. Use heating pads on the treated area
- B. Wear loose, soft clothing over the treated area
- C. Expose the treated area to sunlight
- D. Apply ice packs to the treated area
Correct Answer: B
Rationale: Radiation therapy can cause skin irritation, dryness, and sensitivity in the treated area. Wearing loose, soft clothing helps minimize friction and pressure on the skin, reducing irritation and promoting comfort. The skin in the treated area is often more sensitive and vulnerable to damage, so this intervention helps protect the skin while maintaining the client's comfort during the course of treatment.
The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?
- A. The passage of flatus
- B. Absent bowel sounds
- C. The client¢â‚¬â„¢s ability to tolerate food
- D. Bloody drainage from the colostomy
Correct Answer: A
Rationale: The passage of flatus (gas) from the colostomy is an early sign that the bowel is beginning to function after surgery. This indicates that peristalsis, or the movement of the intestines, has resumed and that the digestive system is actively moving gas and eventually stool through the bowel and out of the colostomy. It's a positive sign that the bowel is recovering from the surgery and starting to work as intended.
The nurse has taught a client with cancer ways to prevent infection. What statement by the client indicates that more teaching is needed?
- A. I should take my temperature daily and when I don't feel well.
- B. I will discard perishable liquids after sitting out for over an hour.
- C. I won't let anyone share any of my personal toiletries.
- D. It's alright for me to keep my pets and change the litter box.
Correct Answer: D
Rationale: Clients with cancer, especially those undergoing chemotherapy or other immunosuppressive treatments, are at increased risk for infections due to a weakened immune system. Changing a litter box exposes the client to pathogens such as Toxoplasma gondii and other harmful bacteria or parasites found in cat feces, which could lead to serious infections. It is recommended that immunocompromised individuals avoid activities like changing litter boxes to reduce their risk of exposure to infectious agents. A family member or caregiver should handle this task to protect the client.