Nokea
Nurse Farah is caring for a client following a mastectomy. Which assessment finding indicates that the client is experiencing a complication related to the surgery?
- A. Pain at the incision site
- B. Arm edema on the operative side
- C. Sanguineous drainage in the Jackson-Pratt drain
- D. Complaints of decreased sensation near the operative site
Correct Answer: B
Rationale: Arm edema on the operative side (lymphedema) is a known complication after a mastectomy. This can indicate impaired lymphatic drainage, leading to fluid accumulation in the arm. Pain at the incision site is expected postoperatively and may not necessarily indicate a complication. Sanguineous drainage in the Jackson-Pratt drain is a common finding in the immediate postoperative period. Complaints of decreased sensation near the operative site could be related to nerve damage or surgical manipulation, but it is not a typical complication after a mastectomy.
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A patient from the oncology unit asks the nurse about metastasis. Which of the following statements by the nurse requires immediate intervention by the head nurse?
- A. Metastasis is the replication of cells
- B. Metastasis can happen in most parts of the body
- C. The replication of cancer cells and travel from one area to another
- D. Metastasis is the spread of cancer cells
Correct Answer: A
Rationale: The correct answer is A because metastasis refers to the spread of cancer cells to distant parts of the body, not the replication of cells. Choice B is correct as metastasis can indeed occur in various body parts. Choice C is incorrect as it inaccurately combines the concepts of replication and travel of cancer cells. Choice D is also correct as it accurately defines metastasis as the spread of cancer cells.
The patient is anxious about subjection to radiation therapy. Which of the following statements of the student nurse requires additional teaching?
- A. Teletherapy is radiation from an external source.
- B. Brachytherapy can be administered via oral or IV.
- C. Brachytherapy is a radiation from inside the patient's body.
- D. Chemotherapy is effective in killing all cancer cells.
Correct Answer: D
Rationale: The correct answer is D because the statement 'Chemotherapy is effective in killing all cancer cells' is incorrect. Chemotherapy does not kill all cancer cells and is not the same as radiation therapy. Chemotherapy targets rapidly dividing cells, including cancer cells, but it may not kill every single cancer cell. It is important for the student nurse to understand and communicate this distinction to the patient. Choices A, B, and C provide accurate information about teletherapy, brachytherapy, and chemotherapy, respectively, and do not require additional teaching.
The nurse is developing a plan of care for the client with multiple myeloma and includes which priority intervention in the plan?
- A. Encouraging fluids
- B. Providing frequent oral care
- C. Coughing and deep breathing
- D. Monitoring the red blood cell count
Correct Answer: A
Rationale: The correct answer is A: Encouraging fluids. In a client with multiple myeloma, encouraging fluids is a priority intervention to prevent kidney damage from high calcium levels. Adequate hydration helps maintain renal function and prevents complications. Providing frequent oral care (Choice B) is essential for clients at risk of mucositis or oral infections, such as those undergoing chemotherapy. Coughing and deep breathing exercises (Choice C) are commonly used for clients at risk of respiratory complications, like postoperative patients. Monitoring the red blood cell count (Choice D) is important for conditions like anemia but is not the priority in a client with multiple myeloma, where fluid management is crucial.
A patient with Hodgkin lymphoma is receiving chemotherapy. Which side effect is the nurse most concerned about?
- A. Nausea and vomiting
- B. Alopecia
- C. Fatigue
- D. Peripheral neuropathy
Correct Answer: D
Rationale: The correct answer is D, Peripheral neuropathy. This can be a serious and dose-limiting side effect of chemotherapy for Hodgkin lymphoma. Peripheral neuropathy can cause tingling, numbness, and pain in the hands and feet due to nerve damage. While nausea and vomiting, alopecia, and fatigue are common side effects of chemotherapy, they are not typically as concerning or dose-limiting as peripheral neuropathy in the context of Hodgkin lymphoma treatment.
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.