Nokea
Nurse Cecilia is caring for a client who has undergone a vaginal hysterectomy. The nurse avoids which of the following in the care of this client?
- A. Elevating the knee gatch on the bed
- B. Assisting with range-of-motion leg exercises
- C. Removal of antiembolism stockings twice daily
- D. Checking placement of pneumatic compression boots
Correct Answer: A
Rationale: The correct answer is A. Elevating the knee gatch on the bed should be avoided in the care of a client who has undergone a vaginal hysterectomy. This action can inhibit venous return, increasing the risk of deep vein thrombosis or thrombophlebitis. Choices B, C, and D are appropriate nursing interventions for postoperative care to prevent complications and promote circulation.
You may also like to solve these questions
A client with neutropenia is admitted to the hospital. What precaution is most important for the nurse to implement?
- A. Strict hand hygiene.
- B. Limit visitor contact with the client.
- C. Administer prophylactic antibiotics as ordered.
- D. Administer blood products as ordered.
Correct Answer: A
Rationale: The correct answer is A: Strict hand hygiene. Neutropenic clients have a low level of neutrophils, which are important in fighting infections. Therefore, maintaining strict hand hygiene is crucial in preventing the introduction of pathogens that could lead to infections. Limiting visitor contact (choice B) is important but not as critical as preventing the introduction of pathogens through proper hand hygiene. Administering prophylactic antibiotics (choice C) and blood products (choice D) are treatment measures and do not address the preventive aspect that hand hygiene provides.
The home health nurse is performing a home visit for an oncology patient discharged 3 days ago after completing treatment for non-Hodgkin lymphoma. The nurse's assessment should include examination for the signs and symptoms of what complication?
- A. Tumor lysis syndrome (TLS)
- B. Syndrome of inappropriate antidiuretic hormone (SIADH)
- C. Disseminated intravascular coagulation (DIC)
- D. Hypercalcemia
Correct Answer: A
Rationale: The correct answer is A: Tumor lysis syndrome (TLS). Tumor lysis syndrome is a potential complication after treatment for certain cancers, including non-Hodgkin lymphoma. The rapid breakdown of cancer cells in response to treatment can lead to metabolic abnormalities, such as hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia, which can be life-threatening. Choice B, Syndrome of inappropriate antidiuretic hormone (SIADH), is not typically associated with non-Hodgkin lymphoma treatment. Choice C, Disseminated intravascular coagulation (DIC), is more commonly seen in conditions such as sepsis or trauma, not directly related to non-Hodgkin lymphoma treatment. Choice D, Hypercalcemia, is not a common complication following treatment for non-Hodgkin lymphoma.
The healthcare professional working with oncology clients understands that which age-related change increases the older client's susceptibility to infection during chemotherapy?
- A. Decreased immune function.
- B. Diminished nutritional stores.
- C. Existing cognitive deficits.
- D. Poor physical reserves.
Correct Answer: A
Rationale: The correct answer is A: Decreased immune function. Aging leads to a decline in immune function, which increases susceptibility to infections during chemotherapy. This decline is due to changes in the immune system that occur with age. Choices B, C, and D are incorrect because while they may impact overall health in older clients, they do not directly increase susceptibility to infections during chemotherapy like decreased immune function does.
A nurse is caring for a patient who has a diagnosis of acute leukemia. What assessment most directly addresses the most common cause of death among patients with leukemia?
- A. Monitoring for infection
- B. Monitoring nutritional status
- C. Monitoring electrolyte levels
- D. Monitoring liver function
Correct Answer: A
Rationale: The correct answer is monitoring for infection. In patients with acute leukemia, the most common cause of death is usually infection or bleeding. By closely monitoring for signs of infection, such as fever, altered mental status, or elevated white blood cell count, healthcare providers can intervene promptly. Monitoring nutritional status (choice B) is important but does not directly address the most common cause of death among leukemia patients. Monitoring electrolyte levels (choice C) and liver function (choice D) are also important assessments in cancer patients; however, they are not the most direct assessment to address the leading cause of death in patients with leukemia.
As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement?
- A. I should avoid blowing my nose.
- B. I may need a platelet transfusion if my platelet count is too low.
- C. I should take aspirin for my headache as soon as I get home.
- D. I will count the number of pads and tampons I use when menstruating.
Correct Answer: C
Rationale: The correct answer is C. Taking aspirin is not recommended during periods of bone marrow suppression as it can increase the risk of bleeding. Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can impair platelet function, further exacerbating the risk of bleeding. Choices A, B, and D are all appropriate statements for a client at risk for bleeding and undergoing chemotherapy. Blowing the nose gently, being prepared for a platelet transfusion if needed, and monitoring menstrual bleeding are all important aspects of self-care during this period.