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The client is admitted for heart failure and has edema, neck vein distension, and ascites. What is the most accurate way to monitor fluid gain or loss in this client?
- A. Auscultate the lungs for crackles or wheezing
- B. Weigh the client daily at the same time with the same scale
- C. Check for pitting edema in the dependent body parts
- D. Assess skin turgor and the condition of mucus membranes
Correct Answer: B
Rationale: Heart failure's fluid dance edema, JVD, ascites needs precise tracking. Daily weights, same time, same scale, catch 1 kg shifts (1 L fluid), the gold standard for gain or loss, outpacing lung sounds' subjectivity. Edema checks or turgor gauge trends, less exact. Nurses weigh in, ensuring diuretic tweaks hit the mark, a reliable ruler in this swollen saga.
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The nurse is caring for a 39-year-old woman with a family history of breast cancer. She requested a breast tumor marking test and the results have come back positive. As a result, the patient is requesting a bilateral mastectomy. This surgery is an example of what type of oncologic surgery?
- A. Salvage surgery
- B. Palliative surgery
- C. Prophylactic surgery
- D. Reconstructive surgery
Correct Answer: C
Rationale: A bilateral mastectomy here is prophylactic removing nonvital breasts to prevent cancer in a high-risk patient with a positive tumor marker and family history. It's about risk reduction, not treatment of existing disease. Salvage surgery tackles recurrence after a less aggressive initial approach, like resecting a regrown tumor. Palliative surgery eases symptoms (e.g., pain from obstruction) in advanced cases, not prevention. Reconstructive surgery restores form or function post-treatment, like breast reconstruction after curative mastectomy. Prophylactic fits this preemptive strike, driven by genetic or familial risk (e.g., BRCA mutations), a growing trend in oncology to outpace cancer's onset, guided by nurses supporting informed, tough choices.
The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider?
- A. Generalized muscle aches
- B. Crackles heard at the lung bases
- C. Complaints of nausea and anorexia
- D. Oral temperature of 100.6°F (38.1°C)
Correct Answer: B
Rationale: IL-2 can spark capillary leak crackles at lung bases signal pulmonary edema, an emergency needing fast action over aches , nausea , or low fever , all common. Nurses in oncology flag this fluid in lungs kills quick, demanding stat calls.
It is the start of your second successive night shift on the labour ward. You have only managed to sleep for 4 h in the previous day. Your usual sleep requirement is 8 h per night. Appropriate statements regarding this situation include:
- A. Your total cumulative sleep deficit is 8 h.
- B. Your alertness will increase between 3 a.m. and 7 a.m. due to natural fluctuation in your circadian rhythm.
- C. Unintentional dural puncture during epidural insertion is more likely to occur during a night shift than during normal working hours.
- D. Sleeping for an extra 4 h will eliminate the sleep deficit.
Correct Answer: C
Rationale: Night shifts disrupt sleep and performance. After one night with 4 hours sleep (8-hour need), the deficit is 4 hours; a second night compounds it variably, but total' implies current state 8 hours overstates it without further context. Alertness dips 3-7 a.m. (circadian nadir), not increases, heightening fatigue. Night-shift studies (e.g., anaesthesia journals) show increased errors like dural puncture due to fatigue, reduced dexterity, and decision-making capacity, especially with sleep deprivation. Four extra hours reduce, not eliminate, a deficit if it's 4-12 hours cumulatively. Modafinil promotes wakefulness, not daytime sleep. The night-shift risk of dural puncture reflects fatigue's real-world impact on technical skills.
According to Johnson and Chang (2014) the role of the nurse and other health professions in chronic disease is to:
- A. Support the person in managing their condition more effectively
- B. Provide care to manage the disease process
- C. Ensure the patient takes their medications and avoids all risk factors
- D. Decide as a team on the best approach to manage the condition and direct the implementation of this care
Correct Answer: A
Rationale: Nurses in chronic care empower supporting self-management beats just treating, enforcing meds, or dictating plans. It's about patients steering their diabetes or asthma, with pros as guides, not bosses. Care's given, compliance nudged, teams plan, but support's the heart, a chronic win where autonomy rules.
Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient?
- A. IL-2 enhances the body's immunologic response to tumor cells.
- B. IL-2 prevents bone marrow depression caused by chemotherapy.
- C. IL-2 protects normal cells from harmful effects of chemotherapy.
- D. IL-2 stimulates malignant cells in the resting phase to enter mitosis.
Correct Answer: A
Rationale: IL-2, a BRM, revs up immunity T-cells and NK cells to hunt renal cell carcinoma, a tumor responsive to this kick. It doesn't shield marrow or normal cells chemo's still rough. It's not pushing cancer mitosis that's chemo's gig. Nurses in oncology clarify this IL-2's an immune booster, a lifeline when mets rage, not a chemo sidekick.