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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.
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A client is receiving rituximab (Rituxan) and asks how it works. What response by the nurse is best?
- A. It causes rapid lysis of the cancer cell membranes.
- B. It destroys the enzymes needed to create cancer cells.
- C. It prevents the initiation of cancer cell division.
- D. It sensitizes certain cancer cells to chemotherapy.
Correct Answer: C
Rationale: Rituximab prevents the initiation of cancer cell division. The other statements are not accurate.
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.
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.
Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients should the nurse assess first?
- A. Client with dry, itchy, peeling skin
- B. Client with a serum calcium of 9.2 mg/dL
- C. Client with a serum potassium of 2.8 mg/dL
- D. Client with a weight gain of 6.6 pounds (1.1 kg) in 1 day
Correct Answer: C
Rationale: TKIs can cause electrolyte imbalances. A potassium level of 2.8 mg/dL is very low, so the nurse should assess this client first. Dry, itchy, peeling skin can be a problem in clients receiving biologic response modifiers, and the nurse should assess that client next because of the potential for discomfort and infection. The calcium level is normal, and the weight gain, while concerning, is less critical than the low potassium level.