Nokea
An oncology patient has just returned from the post-anesthesia care unit after an open hemicolectomy. This patient¢â‚¬â„¢s plan of nursing care should prioritize which of the following?
- A. Assess the patient hourly for signs of compartment syndrome.
- B. Assess the patient¢â‚¬â„¢s fine motor skills once per shift.
- C. Assess the patient¢â‚¬â„¢s wound for dehiscence every 4 hours.
- D. Maintain the patient¢â‚¬â„¢s head of bed at 45 degrees or more at all times.
Correct Answer: C
Rationale: After an open hemicolectomy (surgical removal of part of the colon), monitoring the surgical wound for signs of dehiscence (wound reopening) is a critical nursing priority. Dehiscence is a serious postoperative complication that can occur if the surgical site does not heal properly. Regular wound assessments every 4 hours allow the nurse to identify early signs of complications, such as redness, swelling, increased drainage, or separation of the wound edges. Early detection is key to preventing further complications, such as infection or evisceration (protrusion of abdominal organs through the wound).
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The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?
- A. The passage of flatus
- B. Absent bowel sounds
- C. The client¢â‚¬â„¢s ability to tolerate food
- D. Bloody drainage from the colostomy
Correct Answer: A
Rationale: The passage of flatus (gas) from the colostomy is an early sign that the bowel is beginning to function after surgery. This indicates that peristalsis, or the movement of the intestines, has resumed and that the digestive system is actively moving gas and eventually stool through the bowel and out of the colostomy. It's a positive sign that the bowel is recovering from the surgery and starting to work as intended.
A client has a platelet count of 9800/mm3. What action by the nurse is most appropriate?
- A. Assess the client for calf pain, warmth, and redness.
- B. Instruct the client to call for help to get out of bed.
- C. Obtain cultures as per the facility's standing policy.
- D. Place the client on protective Isolation Precautions.
Correct Answer: B
Rationale: A platelet count of 9800/mm³ indicates severe thrombocytopenia, placing the client at high risk for bleeding, even with minor trauma or injury. Instructing the client to call for help before getting out of bed ensures they receive assistance with mobility, which reduces the risk of falls or injuries that could lead to serious bleeding. Preventing any activity that could result in trauma is crucial when managing clients with very low platelet counts.
The clinic nurse is caring for a 42-year-old male oncology patient. He complains of extreme fatigue and weakness after his first week of radiation therapy. Which response by the nurse would best reassure this patient?
- A. These symptoms usually result from radiation therapy; however, we will continue to monitor your laboratory and x-ray studies.
- B. These symptoms are part of your disease and are an unfortunately inevitable part of living with cancer.
- C. Try not to be concerned about these symptoms. Every patient feels this way after having radiation therapy.
- D. Even though it is uncomfortable, this is a good sign. It means that only the cancer cells are dying.
Correct Answer: A
Rationale: Fatigue and weakness are common side effects of radiation therapy, often due to the body's response to radiation damage and the energy required to repair both cancerous and healthy cells affected by the treatment. Reassuring the patient that these symptoms are expected while also emphasizing ongoing monitoring (through lab and x-ray studies) provides both comfort and a sense of proactive care. It ensures the patient that their symptoms are being addressed in a safe and medically appropriate way.
The nurse knows that all of the following are risk factors for breast cancer except:
- A. Family history
- B. Nulliparity
- C. Chest xray
- D. Multiple sex partners
Correct Answer: D
Rationale: Multiple sex partners are not a recognized risk factor for breast cancer. Breast cancer is primarily influenced by hormonal, genetic, and environmental factors, not sexual activity or the number of sexual partners. Established risk factors for breast cancer include family history, hormonal factors such as early menarche, late menopause, and nulliparity (having no children), as well as certain environmental exposures.
A patient admitted with cancer asks the nurse about the difference between chemotherapy and radiation therapy. Which of the following responses by the nurse indicates a need for further teaching?
- A. Chemotherapy kills cancer cells
- B. Radiation therapy can be internal or external
- C. Radiation therapy is often external
- D. Chemotherapy is more likely to kill normal cells
Correct Answer: D
Rationale: While chemotherapy does affect normal, healthy cells-particularly those that divide rapidly-it is not "more likely" to kill normal cells compared to cancer cells. Chemotherapy targets rapidly dividing cells, which includes both cancer cells and some normal cells (like those in hair follicles, the gastrointestinal tract, and bone marrow). However, its primary goal is to kill cancer cells, and its effects on normal cells are a side effect, not the main function. Therefore, the statement that chemotherapy is "more likely" to kill normal cells is inaccurate and indicates a need for further teaching.