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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.
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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.
A client has received a dose of ondansetron (Zofran) for nausea. What action by the nurse is most important?
- A. Assess the client for a headache.
- B. Assist the client by getting out of bed.
- C. Initiate the client to reduce salt intake.
- D. Weigh the client daily before the client eats.
Correct Answer: B
Rationale: Ondansetron side effects include postural hypotension, vertigo, and bradycardia, all of which increase the client's risk for injury. The nurse should assist the client when getting out of bed. Headache and fluid retention are not side effects of this drug.
A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the client's chemotherapy medications. What action by the nurse is most appropriate?
- A. Crush the medications if the client reports difficulty swallowing them.
- B. Give one medication at a time with a full glass of water.
- C. No special precautions are needed for these medications.
- D. Wear personal protective equipment when handling the medications.
Correct Answer: D
Rationale: During the administration of oral chemotherapy agents, nurses must take the same precautions that are used when administering IV chemotherapy. This includes using personal protective equipment. These medications cannot be crushed, split, or chewed. Giving one at a time is not needed.
A client receiving chemotherapy has a white blood cell count of 1000/mm³. What actions by the nurse are most appropriate? (Select all that apply.)
- A. Assess all mucous membranes every 4 to 8 hours.
- B. Do not allow the client to eat meat or poultry.
- C. Listen to lung sounds and monitor for cough.
- D. Monitor the venous access device appearance with vital signs.
- E. Take and record vital signs every 4 to 8 hours.
Correct Answer: A,C,D,E
Rationale: Per facility protocol, the nurse should assess this client for infection every 4 to 8 hours by assessing all mucous membranes, listening to lung sounds, monitoring for cough, monitoring the appearance of the venous access device, and recording vital signs. Eating meat and poultry is allowed.
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.