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A nurse is caring for a 65-year-old male who recently underwent an aortic valve replacement. Which of the following is a post-operative nursing care priority?
- A. Temperature monitoring
- B. Assess for bleeding
- C. Advance diet as tolerated
- D. Dressing change
Correct Answer: B
Rationale: Valve replacement bleeds assessing for hemorrhage at surgical sites or anticoagulation tops post-op care, a life-or-death watch per ABCs. Fever, diet, dressings matter, but bleeding's immediate. Nurses hunt oozing or shock, ensuring stability, a priority in this fresh-cut cardiac zone.
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The nurse is reviewing laboratory values for a client. Which of the following lab values should the nurse address immediately?
- A. Potassium 5.9 mmol/L
- B. Phosphorus 5.1 mg/dL
- C. Creatinine 6.2 mg/dL
- D. Sodium 147 mEq/L
Correct Answer: A
Rationale: Potassium 5.9 mmol/L above 5.5 sparks hyperkalemia, risking arrhythmias, a now-or-never fix over phosphorus's mild bump (3.0-4.5 normal). Creatinine's renal cry waits; sodium's high but tolerable. Nurses jump on potassium, anticipating ECG or kayexalate, a heart-stopping lab in this urgent sweep.
The physician tells the patient that there will be an initial course of treatment with continued maintenance treatments and ongoing observation for signs and symptoms over a prolonged period of time. You can help the patient by reinforcing that the primary goal for this type of treatment is:
- A. Cure
- B. Control
- C. Palliation
- D. Permanent remission
Correct Answer: B
Rationale: The physician's plan initial treatment, maintenance, and long-term monitoring suggests a chronic cancer unamenable to cure, aiming instead to control growth and spread. Control stabilizes disease, extending life and quality, unlike cure, which eradicates cancer, or permanent remission, implying no recurrence both unfeasible here. Palliation focuses on symptom relief, not longevity, misaligning with ongoing treatments. Reinforcing control clarifies expectations, reducing anxiety by framing therapy as proactive management, not defeat. Nurses bolster this by explaining observation's role in adjusting care, aligning patient understanding with realistic goals, vital for adherence and emotional resilience in prolonged cancer battles.
As per Johnson and Chang (2014) which of the following is not a component of the Chronic Care Model?
- A. Person centred care
- B. Population health approach
- C. Community setting, collaborative across both primary and secondary care
- D. Reactive, symptom driven
Correct Answer: D
Rationale: The Chronic Care Model thrives on proactive pillars person-centered focus, population health, and community-primary-secondary teamwork aiming to preempt, not just patch, chronic woes. Reactive, symptom-driven care's old-school, clashing with this forward lean. Nurses ditch that lag, embracing prevention, a model shift for chronic mastery.
Which condition assessed by the nurse would be an early warning sign of childhood cancer?
- A. Difficulty swallowing
- B. Frequent cough or hoarseness
- C. Change in bowel and bladder habits
- D. Swellings, lumps or masses anywhere on the body
Correct Answer: D
Rationale: Childhood cancers often present with subtle, non-specific signs, but swellings, lumps, or masses anywhere on the body are a key early warning, indicating possible tumors like leukemia (lymphadenopathy), Wilms tumor, or sarcomas. Nurses must assess these palpable abnormalities, as they prompt urgent diagnostic workup imaging or biopsy to catch cancer early when treatment is most effective. Difficulty swallowing might suggest esophageal or brain tumors but isn't a common early childhood cancer sign. Frequent cough or hoarseness could indicate adult cancers (e.g., lung) or late-stage disease, not typical pediatric onset. Bowel and bladder changes are more adult-specific (e.g., colorectal cancer) or late effects in children. Lumps' prominence in pediatric guidelines underscores their priority, aligning with nursing's role in early detection to improve survival rates in young patients.
The nurse is caring for a patient with an advanced stage of breast cancer and the patient has recently learned that her cancer has metastasized. The nurse enters the room and finds the patient struggling to breathe and the nurse's rapid assessment reveals that the patient's jugular veins are distended. The nurse should suspect the development of what oncologic emergency?
- A. Increased intracranial pressure
- B. Superior vena cava syndrome (SVCS)
- C. Spinal cord compression
- D. Metastatic tumor of the neck
Correct Answer: B
Rationale: Dyspnea plus distended jugulars scream SVCS breast cancer's mets can squeeze the vena cava, blocking venous return from the head and chest. It's an oncology emergency, fast-tracking to edema and airway issues if unchecked. Intracranial pressure needs brain involvement less likely here. Spinal compression hits legs and bladder, not breathing. Neck tumors might press locally, but SVCS fits this picture. Nurses jump on this, pushing for steroids or stenting, knowing seconds count.