Nokea
The client diagnosed with cancer has been undergoing systemic treatments and has red blood cell deficiency. Which signs and symptoms should the nurse teach the client to manage?
- A. Nausea associated with cancer treatment.
- B. Shortness of breath and fatigue.
- C. Controlling mucositis and diarrhea.
- D. The emotional aspects of having cancer.
Correct Answer: B
Rationale: RBC deficiency (anemia) causes shortness of breath and fatigue (B), which clients should manage. Nausea (A), mucositis/diarrhea (C), and emotions (D) are unrelated to anemia.
You may also like to solve these questions
The client, who underwent a right mastectomy with lymph node dissection, is being admitted to a nursing unit from the PACU. When settling the client in bed, which action by the NA requires the nurse to intervene?
- A. Placing a blood pressure cuff on the left arm for vital signs
- B. Taping a sign to the side rail stating no IV or lab draws on the right
- C. Elevating the bed to 90 degrees and keeping the right arm dependent
- D. Asking if the client feels ready to allow family to enter the room
Correct Answer: C
Rationale: A. BPs, venipunctures, and injections should not be done on the affected arm, so taking the BP on the left arm would be appropriate. B. It would be appropriate for the NA to tape a sign at the side rail to remind others of the restrictions following a mastectomy. C. The client should be placed in a semi-Fowler’s position with the arm on the affected side elevated on a pillow to promote restoring arm function and to prevent arm edema. D. It would be beneficial for the NA and nurse to be sensitive to the client’s readiness for family presence.
The nurse working in the bloodmobile is screening clients to determine if they qualify for blood donation of whole blood. Besides asking for identification and age, which questions should the nurse ask during the screening interview?
- A. “If you have a tattoo, on what date did you receive the tattoo?”
- B. “Have you had any close contact with anyone with HIV or hepatitis?”
- C. “If you smoke, when was the last time you smoked tobacco products?”
- D. “When were you last immunized for rubella, mumps, or varicella?”
- E. “Did you receive blood products anywhere outside of the United States?”
Correct Answer: A, B, D, E
Rationale: Persons ineligible to donate blood include those with a history of a recent tattoo. B. Persons ineligible to donate blood include those who’ve had close contact with a person with HIV or hepatitis. C. Persons who smoke tobacco products may donate blood unless they have a recent history of asthma. D. Persons ineligible to donate blood include those immunized for rubella, mumps, or varicella within the last month. E. Persons ineligible to donate blood include those receiving transfusions in the United Kingdom, Gibraltar, or the Falkland Islands because of the increased likelihood of transmitting Creutzfeldt-Jakob disease.
The client who was recently admitted with gastric cancer appears pale and weak and states feeling fatigued. In reviewing the client’s laboratory results, which component of the CBC should the nurse most associate with the client’s gastric cancer and identify as the causative factor for the fatigue?
- A. White blood cell 12,200/mm3
- B. Hemoglobin 7.9 g/dL
- C. Serum protein 5.9 g/dL
- D. Blood urea nitrogen 22 mg/dL
Correct Answer: B
Rationale: A. The elevation in the WBC (normal is 4500–10,000/mm3 or microL) is concerning because it could indicate an infection, but the elevation would not necessarily be related to the gastric cancer. B. The presenting symptoms are indicative of anemia, which is common in gastric cancer due to chronic blood loss, or as a result of pernicious anemia (due to loss of intrinsic factor). The low Hgb (normal is 12–15 g/dL) may be the causative factor for the fatigue. C. The serum protein is slightly low (normal is 6.0–8.0 g/dL) and could be indicative of nutritional problems associated with the gastric cancer, but it is not specific to the signs and symptoms described in the question, and it is not part of a CBC. D. The BUN (normal is 5–25 mg/dL) is within normal parameters and is measuring kidney function or hydration status. It is not part of the CBC.
The nurse writes a diagnosis of 'potential for fluid volume deficit related to bleeding' for a client diagnosed with disseminated intravascular coagulation (DIC). Which would be an appropriate goal for this client?
- A. The client’s clot formations will resolve in two (2) days.
- B. The saturation of the client’s dressings will be documented.
- C. The client will use lemon-glycerin swabs for oral care.
- D. The client’s urine output will be greater than 30 mL per hour.
Correct Answer: D
Rationale: DIC risks bleeding/fluid loss; urine output >30 mL/hr (D) indicates adequate volume. Clot resolution (A) is unrealistic, dressing saturation (B) is an intervention, and swabs (C) are unrelated.
A home-care nurse is following up with the client who was diagnosed with liver cancer 3 months ago. Which assessment information should the nurse communicate to the HCP?
- A. Client is weak and pale and remained in bed throughout the visit
- B. Client’s weight has remained unchanged since the previous visit.
- C. Client reports itching is relieved with diphenhydramine cream.
- D. Client’s pain level averages a 7 on a 0 to 10 scale with scheduled opioids.
Correct Answer: D
Rationale: A. Finding that the client with liver cancer is weak and pale would be important to document, but it does not warrant immediate communication to the HCP because it may be expected. B. The client’s weight being stable would not necessitate communication to the HCP, but a significant decrease would. C. Abdominal itching may occur with liver cancer, but the fact that it is relieved with diphenhydramine (Benadryl) is positive and would not necessitate a call to the HCP. D. The client’s pain level is high and does not seem to be controlled with the current opioid schedule. The nurse should notify the HCP to request a change in analgesic medication, dosing schedule, or administration route.