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A patient with advanced leukemia is responding poorly to treatment. The nurse finds the patient tearful and trying to express his feelings, but he is clearly having difficulty. What is the nurses most appropriate action?
- A. Tell him that you will give him privacy and leave the room.
- B. Offer to call pastoral care.
- C. Ask if he would like you to sit with him while he collects his thoughts.
- D. Tell him that you can understand how hes feeling.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy?
- A. Restrict all visitors.
- B. Restrict fluid intake.
- C. Teach the client and family about the need for hand hygiene.
- D. Insert an indwelling urinary catheter to prevent skin breakdown.
Correct Answer: C
Rationale: In clients experiencing neutropenia, particularly due to chemotherapy, the immune system is significantly compromised, increasing the risk of infections. Hand hygiene is one of the most effective methods for preventing the spread of pathogens that can lead to infections. Teaching both the client and their family about the importance of frequent and proper handwashing helps create a safer environment and reduces the risk of infections, which can be critical in neutropenic patients.
During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which symptom as typical of the disease?
- A. Diarrhea
- B. Hypermenorrhea
- C. Abnormal bleeding
- D. Abdominal distention
Correct Answer: D
Rationale: Abdominal distention is a common symptom in advanced ovarian cancer due to several factors, including the accumulation of ascites (fluid in the abdominal cavity) and the presence of tumors that can increase abdominal girth. As the disease progresses, the pressure from growing masses or fluid buildup can lead to noticeable swelling and discomfort in the abdomen. This symptom often prompts further evaluation and can significantly impact the patient's quality of life.
After receiving a diagnosis of acute lymphocytic leukemia, a patient is visibly distraught, stating, I have no idea where to go from here. How should the nurse prepare to meet this patients psychosocial needs?
- A. Assess the patients previous experience with the health care system.
- B. Reassure the patient that treatment will be challenging but successful.
- C. Assess the patients specific needs for education and support.
- D. Identify the patients plan of medical care.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action?
- A. Measure abdominal girth.
- B. Irrigate the nasogastric tube.
- C. Continue to monitor the drainage.
- D. Notify the health care provider (HCP).
Correct Answer: D
Rationale: In the immediate postoperative period following a gastrectomy, any bloody drainage from the nasogastric (NG) tube is concerning and requires prompt evaluation. This could indicate potential complications such as bleeding from the surgical site, erosion, or other postoperative issues. Notifying the healthcare provider immediately is crucial to ensure that the patient receives timely assessment and intervention. The presence of blood may necessitate further diagnostic procedures, interventions, or changes in management to prevent serious complications.
The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm?
- A. Placing cool compresses on the affected arm
- B. Elevating the affected arm on a pillow above heart level
- C. Avoiding arm exercises in the immediate postoperative period
- D. Maintaining an intravenous site below the antecubital area on the affected side
Correct Answer: B
Rationale: After a mastectomy, particularly when lymph nodes are removed, there is an increased risk of lymphedema in the affected arm due to impaired lymphatic drainage. Elevating the affected arm above heart level helps promote lymphatic drainage and reduces the risk of swelling. This intervention facilitates the return of lymph fluid and helps prevent fluid accumulation in the arm.