Nokea
An emergency department nurse is triaging a 77-year-old man who presents with uncharacteristic fatigue as well as back and rib pain. The patient denies any recent injuries. The nurse should recognize the need for this patient to be assessed for what health problem?
- A. Hodgkin disease
- B. Non-Hodgkin lymphoma
- C. Multiple myeloma
- D. Acute thrombocythemia
Correct Answer: C
Rationale: The correct answer is multiple myeloma (choice C). Back pain is a common presenting symptom in multiple myeloma, especially in older patients. This malignancy can lead to bone pain due to bone destruction and fractures. Hodgkin disease (choice A) and Non-Hodgkin lymphoma (choice B) typically present with symptoms like painless lymph node enlargement, fever, and weight loss. Acute thrombocythemia (choice D) is characterized by an increase in platelet count but is not typically associated with the symptoms described by the patient.
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The nurse has educated a client on precautions to take with thrombocytopenia. What statement by the client indicates a need to review the information?
- A. I will be careful if I need enemas for constipation.
- B. I will use an electric shaver instead of a razor.
- C. I should only eat soft food that is either cool or warm.
- D. I won't be able to play sports with my grandkids.
Correct Answer: A
Rationale: The correct answer is A because enemas can cause injury to a thrombocytopenic client due to the risk of bleeding. Choices B, C, and D are correct precautions for a client with thrombocytopenia. Using an electric shaver reduces the risk of cuts that could lead to bleeding. Eating soft, cool, or warm food helps prevent injuries to the oral mucosa. Avoiding activities like sports that carry a risk of injury is also advisable.
Nurse Jane is providing care for a client with superior vena cava syndrome. Which of the following interventions would be the priority?
- A. Elevate the head of the bed
- B. Administer steroids as prescribed
- C. Provide supplemental oxygen
- D. Administer diuretics as prescribed
Correct Answer: A
Rationale: The correct answer is to elevate the head of the bed. Elevating the head of the bed can help reduce the pressure on the superior vena cava, improve venous return, and facilitate breathing in clients with superior vena cava syndrome. Administering steroids (Choice B) may be necessary in some cases, but it is not the priority in the immediate care of a client with superior vena cava syndrome. Providing supplemental oxygen (Choice C) may help improve oxygenation but does not directly address the underlying issue of venous congestion. Administering diuretics (Choice D) may be contraindicated as it can further decrease preload and worsen the condition in superior vena cava syndrome.
Which of the following is a correct statement by the nurse to a patient under radiation therapy?
- A. Brachytherapy can be administered by a pregnant nurse
- B. Teletherapy makes the patient radioactive
- C. Brachytherapy is an internal radiation therapy
- D. Teletherapy requires proper disposal of feces since feces is not a source of radiation
Correct Answer: C
Rationale: The correct statement is that Brachytherapy is an internal radiation therapy. Brachytherapy involves placing radioactive sources inside or near the tumor, delivering a high radiation dose to the targeted area while minimizing exposure to surrounding healthy tissues. Choices A and B are incorrect because pregnant nurses should not administer radiation therapy and brachytherapy does not make the patient radioactive. Choice D is incorrect as feces is not a source of radiation in teletherapy, and it does not require special disposal.
A client in the emergency department reports difficulty breathing. The nurse assesses the client's appearance as depicted below: What action by the nurse is most important?
- A. Assess blood pressure and pulse.
- B. Attach the client to a pulse oximeter.
- C. Have the client rate his or her pain.
- D. Facilitate urgent radiation therapy.
Correct Answer: A
Rationale: The correct action by the nurse is to assess the client's blood pressure and pulse. Difficulty breathing can be a sign of various conditions, including cardiac issues. Assessing blood pressure and pulse helps in determining the client's hemodynamic status and identifying any cardiovascular compromise. Option B is less crucial as attaching the client to a pulse oximeter may provide oxygen saturation levels but does not directly assess cardiac output. Option C is not the priority in this situation as the client's difficulty breathing is a more urgent concern. Option D is incorrect as urgent radiation therapy is not indicated based on the client's presentation.
What advice should the oncology nurse give to a client planning a beach vacation after completing radiation treatments for cancer?
- A. Avoid getting salt water on the radiation site.
- B. Do not expose the radiation area to direct sunlight.
- C. Have a wonderful time and enjoy your vacation!
- D. Remember you should not drink alcohol for a year.
Correct Answer: B
Rationale: The correct answer is B because the skin at the radiation site is sensitive to sunlight, and exposure can cause further damage. It is crucial to protect the area from direct sunlight to prevent skin irritation or burns. Choice A is incorrect as salt water typically does not pose a significant risk to the radiation site. Choice C is a positive and encouraging response but does not provide necessary advice for post-radiation care. Choice D, while important in some cases, is not directly related to the client's beach vacation after completing radiation treatments.