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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.
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A nurse in the oncology clinic is providing preoperative education to a client just diagnosed with cancer. The client has been scheduled for many days. What action by the nurse is best?
- A. Call the client at home the next day to review teaching.
- B. Give the client information about a cancer support group.
- C. Provide all the preoperative instructions in writing.
- D. Reassure the client that surgery will be over soon.
Correct Answer: A
Rationale: Clients are often overwhelmed at a sudden diagnosis of cancer and may be more overwhelmed at the idea of a major operation so soon. This stress significantly impacts the client's ability to understand, retain, and recall information. The nurse should call the client at home the next day to review the teaching and to answer questions. The client may or may not be ready to investigate a support group, but this does not help with teaching. Giving information in writing is important (if the client can read it), but in itself will not be enough. Telling the client about surgery will be over soon is giving false reassurance and does nothing for teaching.
A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important?
- A. Assessing the IV site every hour
- B. Educating the client on side effects
- C. Monitoring the client for nausea
- D. Providing warm packs for comfort
Correct Answer: A
Rationale: Intravenous chemotherapy can cause local tissue destruction if it extravasates into the surrounding tissues. Peripheral IV lines are more prone to this than centrally placed lines. The most important intervention is prevention, so the nurse should check hourly to ensure the IV site is patent, or more frequently depending on facility policy. Education and monitoring for side effects such as nausea are important for all clients receiving chemotherapy. Warm packs may be helpful for comfort, but if the client reports the IV site is painful, this is not the most appropriate action.
A client tells the oncology nurse about an upcoming vacation to be back to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate?
- A. Are you ensuring the radiation site is protected?
- 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 radiation site is extremely sensitive to sunlight after radiation therapy has been completed. The nurse should inform the client to avoid sun exposure to this area. This advice continues for 1 year after treatment has been completed. The other statements are not appropriate.
A client has thrombocytopenia. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Apply the client's shoes before getting the client out of bed.
- B. Assist with ambulation.
- C. Shave the client with a safety razor only.
- D. Use a lift sheet to move the client up in bed.
- E. Use the Waterpik on a low setting for oral care.
Correct Answer: A,B,D
Rationale: Clients with thrombocytopenia are at risk of significant bleeding even with minor injuries. The nurse instructs the UAP to put the client's shoes on before getting the client out of bed, assist with ambulation, and use a lift sheet when needed to reposition the client. An electric razor should be used instead of a safety razor, and a soft-bristled toothbrush is preferred over a Waterpik for oral care.
A nurse working with clients who experience alopecia knows that which is the best method of helping clients manage the psychosocial impacts of this problem?
- A. Assisting the client to plan for this event
- B. Reassuring the client that alopecia is temporary
- C. Referring the client to a support group
- D. Telling the client that there are worse side effects
Correct Answer: A
Rationale: Alopecia does not occur in all clients with cancer, but when it does, it can be devastating. The best action by the nurse is to teach the client about the possibility and to give the client multiple choices for preparing for it.