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A patient's 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 patient's cancer cells spread?
- A. Hematologic spread
- B. Lymphatic circulation
- C. Invasion
- D. Angiogenesis
Correct Answer: B
Rationale: Lung cancer loves lymphatics its cells hitch rides via nodes, the most common metastasis route, hitting bones and liver downstream. Blood (hematologic) spread happens too, but lymph's king for lung primaries. Invasion's local creep, not distant jumps. Angiogenesis feeds tumors, not moves them. Nurses track this pattern, knowing lymph drainage from lungs seeds those far-off sites, a grim oncology reality shaping staging and prognosis.
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A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching?
- A. The patient ambulates several times a day in the room
- B. The patient's visitors bring in some fresh peaches from home
- C. The patient cleans with a warm washcloth after having a stool
- D. The patient uses soap and shampoo to shower every other day
Correct Answer: B
Rationale: Neutropenia post-chemo low neutrophils craves germ-free zones; fresh peaches from home carry bacteria, a teaching gap as raw produce risks infection in this immune-wrecked state. Ambulation's safe, hygiene's spot-on washcloths and showers cut germs. Nurses reteach, banning unwashed fruit, a vital shield in leukemia's neutropenic peril, ensuring clients grasp this microbial minefield.
When educating a female client on the signs and symptoms of myocardial infarction, the nurse recognizes which of the following should be included in the teaching?
- A. Pain usually resolves with rest and relaxation
- B. Older adults and women often present with atypical signs and symptoms
- C. Women experience intermittent claudication
- D. Substernal chest pain is the most common symptom in women
Correct Answer: B
Rationale: MI in women skews odd fatigue, nausea, not just chest pain, hit older females especially, a teaching must as atypical signs delay care. Rest eases angina, not MI. Claudication's PAD, not heart. Substernal pain's common, less so in women. Nurses stress this quirk, boosting recognition in this sneaky killer.
The client is admitted for heart failure and has edema, neck vein distension, and ascites. What is the most accurate way to monitor fluid gain or loss in this client?
- A. Auscultate the lungs for crackles or wheezing
- B. Weigh the client daily at the same time with the same scale
- C. Check for pitting edema in the dependent body parts
- D. Assess skin turgor and the condition of mucus membranes
Correct Answer: B
Rationale: Heart failure's fluid dance edema, JVD, ascites needs precise tracking. Daily weights, same time, same scale, catch 1 kg shifts (1 L fluid), the gold standard for gain or loss, outpacing lung sounds' subjectivity. Edema checks or turgor gauge trends, less exact. Nurses weigh in, ensuring diuretic tweaks hit the mark, a reliable ruler in this swollen saga.
For a patient who is experiencing side effects of radiation therapy, which task would be the most appropriate to delegate to the nursing assistant?
- A. Assist the patient to identify patterns of fatigue
- B. Recommend participation in a walking program
- C. Report the amount and type of food consumed from the tray
- D. Check the skin for redness and irritation after the treatment
Correct Answer: C
Rationale: Radiation side effects like fatigue and anorexia benefit from team care. Reporting food consumed from the tray suits nursing assistants observing and relaying intake data supports nutrition monitoring without requiring clinical judgment. Identifying fatigue patterns demands analysis, a nurse's role to adjust care plans. Recommending exercise exceeds assistants' scope physicians or RNs initiate such advice. Checking skin for redness post-treatment needs assessment skills to detect burns or infection, RN territory. Food reporting leverages assistants' observational role, aiding nurses in tracking radiation's impact on appetite, ensuring basic needs are flagged efficiently in a collaborative approach.
During hourly rounding the nurse enters a room where the client is unresponsive without pulse. What is the nurse's priority action?
- A. Begin ventilation at 1 breath every 6-8 seconds
- B. Start chest compressions at a rate of 100-120 compressions per minute
- C. Wait for the emergency response team for direction
- D. Call the family
Correct Answer: B
Rationale: No pulse, no response cardiac arrest kicks in chest compressions, 100-120/min, pumping life per ACLS, trumping breaths first in lone-rescuer mode. Waiting or calling delays; ventilation follows. Nurses hammer compressions, buying brain time, a priority slam in this code blue crash.