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A nurse provides care on a bone marrow transplant unit and is preparing a female patient for a hematopoietic stem cell transplantation (HSCT) the following day. What information should the nurse emphasize to the patients family and friends?
- A. Your family should likely gather at the bedside in case theres a negative outcome
- B. Make sure she doesnt eat any food in the 24 hours before the procedure
- C. Wear a hospital gown when you go into the patients room
- D. Do not visit if youve had a recent infection
Correct Answer: D
Rationale: Before HSCT, patients are at a high risk for infection, sepsis, and bleeding. Visitors should not visit if they have had a recent illness or vaccination. Gowns should indeed be worn, but this is secondary in importance to avoiding the patients contact with ill visitors. Prolonged fasting is unnecessary. Negative outcomes are possible, but the procedure would not normally be so risky as to require the family to gather at the bedside.
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An oncology patient has just returned from the postanesthesia care unit after an open hemicolectomy. This patients plan of nursing care should prioritize which of the following?
- A. Assess the patient hourly for signs of compartment syndrome
- B. Assess the patients fine motor skills once per shift
- C. Assess the patients wound for dehiscence every 4 hours
- D. Maintain the patients head of bed at 45 degrees or more at all times
Correct Answer: C
Rationale: Postoperatively, the nurse assesses the patients responses to the surgery and monitors the patient for possible complications, such as infection, bleeding, thrombophlebitis, wound dehiscence, fluid and electrolyte imbalance, and organ dysfunction. Fine motor skills are unlikely to be affected by surgery and compartment syndrome is a complication of fracture casting, not abdominal surgery. There is no need to maintain a high head of bed.
An oncology patient has begun to experience skin reactions to radiation therapy, prompting the nurse to make the diagnosis Impaired Skin Integrity: erythematous reaction to radiation therapy. What intervention best addresses this nursing diagnosis?
- A. Apply an ice pack or heating pad PRN to relieve pain and symptoms
- B. Avoid skin contact with water whenever possible
- C. Apply phototherapy PRN
- D. Avoid rubbing or scratching the affected area
Correct Answer: D
Rationale: Rubbing and or scratching will lead to additional skin irritation, damage, and increased risk of infection. Extremes of hot, cold, and light should be avoided. No need to avoid contact with water.
A patients most recent diagnostic imaging has revealed that his lung cancer has metastasized to his bones and liver. What is the most likely mechanism by which the patients cancer cells spread?
- A. Hematologic spread
- B. Lymphatic circulation
- C. Invasion
- D. Angiogenesis
Correct Answer: B
Rationale: Lymph and blood are key mechanisms by which cancer cells spread. Lymphatic spread (the transport of tumor cells through the lymphatic circulation) is the most common mechanism of metastasis.
The home health nurse is performing a home visit for an oncology patient discharged 3 days ago after completing treatment for non-Hodgkin lymphoma. The nurses assessment should include examination for the signs and symptoms of what complication?
- A. Tumor lysis syndrome (TLS)
- B. Syndrome of inappropriate antidiuretic hormone (SIADH)
- C. Disseminated intravascular coagulation (DIC)
- D. Hypercalcemia
Correct Answer: A
Rationale: TLS is a potentially fatal complication that occurs spontaneously or more commonly following radiation, biotherapy, or chemotherapy-induced cell destruction of large or rapidly growing cancers such as leukemia, lymphoma, and small cell lung cancer. DIC, SIADH and hypercalcemia are less likely complications following this treatment and diagnosis.
The hospice nurse has just admitted a new patient to the program. What principle guides hospice care?
- A. Care addresses the needs of the patient as well as the needs of the family
- B. Care is focused on the patient centrally and the rest of the family is secondary
- C. The focus of all aspects of care is solely on the patient
- D. The care team prioritizes the patients physical needs and the family is responsible for the patients emotional needs
Correct Answer: A
Rationale: The focus of hospice care is on the family as well as the patient. The family is not solely responsible for the patients emotional well-being.