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Nurse Lisa is assessing a client who has just completed radiation therapy to the neck area. Which of the following findings is most concerning?
- A. Erythema in the treated area
- B. Difficulty swallowing
- C. Dry, peeling skin
- D. Hoarseness
Correct Answer: B
Rationale: Difficulty swallowing (dysphagia) following radiation therapy to the neck area is a significant concern because it can indicate serious complications such as esophageal stricture, inflammation, or damage to the surrounding tissues, including the esophagus. This can lead to malnutrition, dehydration, or aspiration, all of which require prompt intervention. Radiation therapy can cause irritation and scarring in the esophageal and throat tissues, which may progressively worsen if not treated. Therefore, dysphagia should be addressed immediately to prevent further complications.
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A client is having a catheter placed to deliver chemotherapy beads into a liver tumor via the femoral artery. What action by the nurse is most important?
- A. Assessing the client's abdomen beforehand.
- B. Ensuring that informed consent is on the chart.
- C. Marking the client's bilateral pedal pulses.
- D. Reviewing client teaching done previously.
Correct Answer: B
Rationale: Before any invasive procedure, such as placing a catheter to deliver chemotherapy beads into a liver tumor, it is essential to ensure that informed consent has been obtained from the client. This is a legal and ethical requirement that ensures the client understands the procedure, its risks, benefits, and alternatives. Ensuring that the signed consent is on the chart is the most important action the nurse can take before the procedure, as the procedure cannot legally proceed without it.
A client is admitted to the hospital with a suspected diagnosis of Hodgkin¢â‚¬â„¢s disease. Which assessment finding would the nurse expect to note specifically in the client?
- A. Fatigue
- B. Weakness
- C. Weight gain
- D. Enlarged lymph nodes
Correct Answer: D
Rationale: Hodgkin's disease (Hodgkin's lymphoma) is a type of cancer that originates in the lymphatic system, particularly affecting the lymph nodes. A hallmark sign of Hodgkin's disease is the painless enlargement of lymph nodes, often in the neck, armpit, or groin. These enlarged lymph nodes are typically firm and rubbery to the touch. This is one of the most distinctive and common early signs that healthcare providers look for when diagnosing the disease.
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).
The clinical nurse educator is presenting health promotion education to a patient who will be treated for non-Hodgkin lymphoma on an outpatient basis. The nurse should recommend which of the following actions?
- A. Avoiding direct sun exposure in excess of 15 minutes daily
- B. Avoiding grapefruit juice and fresh grapefruit
- C. Avoiding highly crowded public places
- D. Using an electric shaver rather than a razor
Correct Answer: C
Rationale: Patients with non-Hodgkin lymphoma (NHL) often experience a compromised immune system due to both the disease itself and the effects of treatments like chemotherapy and radiation, which cause myelosuppression (decreased production of blood cells, including white blood cells). This puts them at significant risk for infections. Avoiding crowded places is a crucial preventive measure, as it reduces the patient's exposure to pathogens that could lead to infections, which can be particularly severe due to their weakened immune system.
A client is receiving rituximab and asks how it works. What response by the nurse is best?
- A. It causes rapid lysis of the cancer cell membranes.
- B. It destroys the enzymes needed to create cancer cells.
- C. It prevents the start of cell division in the cancer cells.
- D. It sensitizes certain cancer cells to chemotherapy.
Correct Answer: C
Rationale: Rituximab is a monoclonal antibody that targets CD20, a protein found on the surface of certain B-cells, including some cancerous B-cells, such as in non-Hodgkin's lymphoma and chronic lymphocytic leukemia (CLL). Rituximab works by binding to the CD20 protein, which leads to the destruction of the cancerous B-cells through various mechanisms, including preventing the initiation of cell division. By blocking the division process, rituximab helps slow the growth and proliferation of cancer cells, allowing the immune system and additional treatments to clear them more effectively.