Nokea
Nurse Maria is preparing a care plan for a client receiving external radiation therapy. Which of the following interventions should be included?
- A. Use heating pads on the treated area
- B. Wear loose, soft clothing over the treated area
- C. Expose the treated area to sunlight
- D. Apply ice packs to the treated area
Correct Answer: B
Rationale: Radiation therapy can cause skin irritation, dryness, and sensitivity in the treated area. Wearing loose, soft clothing helps minimize friction and pressure on the skin, reducing irritation and promoting comfort. The skin in the treated area is often more sensitive and vulnerable to damage, so this intervention helps protect the skin while maintaining the client's comfort during the course of treatment.
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A nurse is planning care for a patient with leukemia who has been experiencing severe fatigue. What is the most appropriate intervention to include in the care plan?
- A. Encouraging the patient to remain in bed
- B. Scheduling frequent rest periods
- C. Providing a high-calorie diet
- D. Administering blood transfusions
Correct Answer: B
Rationale: In patients with leukemia, severe fatigue is a common symptom due to factors such as anemia, the disease process itself, and the effects of treatments like chemotherapy. The most appropriate intervention is to schedule frequent rest periods to help manage fatigue while encouraging a balance between rest and activity. This approach allows the patient to conserve energy for essential tasks and prevent exhaustion, without promoting complete inactivity, which can lead to deconditioning.
Nurse Mandy is teaching a client about the side effects of radiation therapy. Which of the following should the nurse emphasize?
- A. Radiation therapy is painless.
- B. You may experience hair loss.
- C. Fatigue is a common side effect.
- D. You may experience nausea and vomiting.
Correct Answer: C
Rationale: Fatigue is one of the most frequent and profound side effects of radiation therapy. It often occurs because radiation can damage both cancerous and healthy cells, and the body requires energy to repair the damage caused by the treatment. Fatigue from radiation can be cumulative, meaning it may worsen as treatments progress, and can significantly affect the client's daily activities, requiring the nurse to educate the client on energy conservation techniques.
Nurse Joy is caring for a client with an internal radiation implant. When caring for the client, the nurse should observe which of the following principles?
- A. Limit the time with the client to 1 hour per shift
- B. Do not allow pregnant women into the client's room
- C. Remove the dosimeter badge when entering the client's room
- D. Individuals younger than 16 years old may be allowed to go in the room as long as they are 6 feet away from the client
Correct Answer: B
Rationale: Clients with internal radiation implants (also known as brachytherapy) emit a small amount of radiation, which can pose a risk to others. Pregnant women are particularly vulnerable to the harmful effects of radiation because it can affect both the mother and the developing fetus. Radiation exposure can lead to birth defects, miscarriage, or other developmental issues, so pregnant women should avoid any exposure by not entering the client's room.
A nurse is planning the care of a patient who has been diagnosed with essential thrombocythemia (ET). What nursing diagnosis should the nurse prioritize when choosing interventions?
- A. Risk for Ineffective Tissue Perfusion
- B. Risk for Imbalanced Fluid Volume
- C. Risk for Ineffective Breathing Pattern
- D. Risk for Ineffective Thermoregulation
Correct Answer: A
Rationale: Essential thrombocythemia (ET) is a myeloproliferative disorder characterized by an abnormally high platelet count, which increases the risk of hypercoagulation and thrombosis (blood clot formation). These clots can impair blood flow to tissues, leading to ineffective tissue perfusion. Thrombotic events, such as strokes, deep vein thrombosis, or myocardial infarctions, are common complications of ET, making Risk for Ineffective Tissue Perfusion the most critical nursing diagnosis to prioritize. The goal of nursing interventions will be to prevent clot formation and ensure adequate blood flow to tissues.
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.