Nokea
A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important?
- A. Assessing the IV site 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: Intravenous chemotherapy can cause local tissue destruction if it extravasates into the surrounding tissues. Peripheral IV lines are more prone to this than centrally placed lines. The most important intervention is prevention, so the nurse should check hourly to ensure the IV site is patent, or more frequently depending on facility policy. Education and monitoring for side effects such as nausea are important for all clients receiving chemotherapy. Warm packs may be helpful for comfort, but if the client reports the IV site is painful, this is not the most appropriate action.
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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.
A client's family members are concerned that telling the client about a new finding of cancer will cause extreme emotional distress. They approach the nurse and ask if this can be kept from the client. What actions by the nurse are most appropriate? (Select all that apply.)
- A. Ask the family to describe their concerns more fully.
- B. Consult with a social worker, chaplain, or ethics committee.
- C. Explain the client's right to know and ask for their assistance.
- D. Have the unit manager take over the care of this client and family.
- E. Tell the family that this secret will not be kept from the client.
Correct Answer: A,B,C
Rationale: The client's right of autonomy means that the client must be fully informed as to their diagnosis and treatment options. The nurse cannot ethically keep this information from the client. The nurse can ask the family to explain their concerns more fully so everyone understands the concerns. A social worker, chaplain, or ethics committee can become involved to assist the nurse, client, and family. Explaining the client's right to know while seeking family assistance fosters collaboration.
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 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.
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.