Nokea
The client hospitalized with cervical cancer is receiving radiation therapy via a temporary radioactive cervical implant. Which nursing actions would be appropriate for this client?
- A. Minimize anxiety and confusion by telling the client the reason for the time and distance limitations.
- B. Utilize the unit’s common film badge that indicates the cumulative radiation exposure while caring for the client.
- C. Organize cares to limit the amount of time spent in direct contact with the client receiving internal radiation.
- D. Use shielding if delivering care within close proximity to the client, such as checking placement of the implant.
- E. Encourage frequent oral care with warm saline rinses to help with irritation of oral mucosa.
Correct Answer: A, C, D
Rationale: A. Safety measures for caring for someone undergoing internal radiation therapy include limiting time, distance, and shielding. It would be important to make the client aware of the time and distance limitations to help ease anxiety. B. A personal, not shared, film badge should be worn so cumulative radiation exposure can be measured accurately. C. Organizing care would be appropriate in order to limit the exposure to radiation. D. Shielding is important for keeping caregivers safe from potential radiation exposure. E. The implant is placed in the vaginal canal and has no impact on oral mucosa.
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The client diagnosed with anemia is admitted to the emergency department with dyspnea, cool pale skin, and diaphoresis. Which assessment data warrant immediate intervention?
- A. The vital signs are T 98.6°F, P 116, R 28, and BP 88/62.
- B. The client is allergic to multiple antibiotic medications.
- C. The client has a history of receiving chemotherapy.
- D. ABGs are pH 7.35, Pco2 44, Hco3 22, Pao2 92.
Correct Answer: A
Rationale: Tachycardia, tachypnea, and hypotension (A) indicate severe anemia with hypoxia, requiring immediate action. Allergies (B), chemo history (C), and normal ABGs (D) are secondary.
The client with Hodgkin’s lymphoma receives radiation treatments. The nurse should monitor the client for which specific symptoms of radiation pneumonitis?
- A. Tachypnea, hypotension, and fever
- B. Cough, elevated temperature, and dyspnea
- C. Bradypnea, cough, and decreased urine output
- D. Cough, tachycardia, and altered mental status
Correct Answer: B
Rationale: A. Hypotension is a symptom that is not common in radiation pneumonitis. B. Cough, fever, and dyspnea are classic symptoms in radiation pneumonitis due to a decrease in the surfactant in the lung. C. Decreased urine output is a symptom that is not common in radiation pneumonitis. D. Altered mental status is a symptom that is not common in radiation pneumonitis.
The client received two (2) units of packed red blood cells of 250 mL with 63 mL of preservative each during the shift. There was 240 mL of saline remaining in the 500-mL bag when the nurse discarded the blood tubing. How many milliliters of fluid should be documented on the intake and output record?
Correct Answer: 886
Rationale: Each unit = 250 mL RBC + 63 mL preservative = 313 mL. Two units = 313 × 2 = 626 mL. Saline used = 500 – 240 = 260 mL. Total intake = 626 + 260 = 886 mL.
The 33-year-old client diagnosed with Stage IV Hodgkin’s lymphoma is at the five (5)-year remission mark. Which information should the nurse teach the client?
- A. Instruct the client to continue scheduled screenings for cancer.
- B. Discuss the need for follow-up appointments every five (5) years.
- C. Teach the client that the cancer risk is the same as for the general population.
- D. Have the client talk with the family about funeral arrangements.
Correct Answer: A
Rationale: Post-remission Hodgkin’s requires ongoing cancer screenings (A) due to recurrence/second cancer risk. Follow-ups are more frequent than 5 years (B), risk remains elevated (C), and funeral plans (D) are premature.
The nurse is caring for the client following a total laryngectomy for treatment of laryngeal cancer. The nurse should plan consultations with which members of the multidisciplinary team?
- A. Physical therapist
- B. Dietitian
- C. Speech therapist
- D. Dentist
- E. Occupational therapist
- F. Social worker
Correct Answer: A, B, C, F
Rationale: Total laryngectomy is removal of the entire larynx as well as the hyoid bone, the true vocal cords, the false vocal cords, the epiglottis, the cricoid cartilage, and two to three tracheal rings. The physical therapist is needed for neck exercises. B. The dietitian is needed to ensure adequacy of oral intake. C. The speech therapist is needed for other forms of communication and swallowing. D. The dentist is not routinely consulted when caring for a laryngectomy client. E. An occupational therapist is not routinely consulted when caring for a laryngectomy client. F. The social worker is needed for contact with outside resources to assist the client in ongoing needs.