Nokea
The client is receiving a vesicant antineoplastic for treatment of cancer. Which assessment finding would require the nurse to take immediate action?
- A. Extravasation
- B. Stomatitis
- C. Nausea and vomiting
- D. Bone pain
Correct Answer: A
Rationale: The nurse needs to monitor IV administration of antineoplastics (especially vesicants) to prevent tissue necrosis to blood vessels, skin, muscles, and nerves. Stomatitis, nausea/vomiting, and bone pain can be symptoms of the disease process or treatment mode but does not require immediate action.
You may also like to solve these questions
The nurse working on a bone marrow unit knows that it is a priority to monitor which of the following in a client who has just undergone a stem cell transplant?
- A. Monitor the client's toilet patterns.
- B. Monitor the client closely to prevent infection.
- C. Monitor the client's physical condition.
- D. Monitor the client's heart rate.
Correct Answer: B
Rationale: Until transplanted stem cells begin to produce blood cells, these clients have no physiologic means to fight infection, which makes them very prone to infection. They are at high risk for dying from sepsis and bleeding before engraftment. Therefore, a nurse must closely monitor clients and take measures to prevent infection. Monitoring client's toilet patterns, physical condition, and heart rate does not prevent the possibility of the client getting an infection.
A client asks the nurse what is causing the fatigue following radiotherapy. What is the nurse's best response?
- A. The cancer is spreading to other parts of the body.
- B. The cancer cells are dying in large numbers.
- C. Fighting off infection is an exhausting venture.
- D. Substances are released when tumor cells are destroyed.
Correct Answer: D
Rationale: Fatigue results from substances being released when tumor cells are destroyed during radiotherapy. The spreading of cancer can cause many symptoms dependent on location and type of cancer, but it is not a significant factor in the development of fatigue with radiotherapy. The production of healthy cells can increase metabolic rate, but death of cancer cells does not support fatigue in this case. Fighting infection can cause fatigue, but there is no evidence provided to support the presence of infection in this client.
Which of the following advice does the nurse offer clients who are undergoing unsealed radiation therapy to reduce exposure?
- A. Avoid drinking plenty of fluids.
- B. Avoid eating for 3 hours after therapy.
- C. Avoid applying skin moisturizers.
- D. Avoid kissing and sexual contact.
Correct Answer: D
Rationale: Clients who are undergoing unsealed radiation therapy are advised to avoid kissing and sexual contact due to the spread of radioactivity. Clients are encouraged to drink plenty of fluids to help flush radioactive substances. Clients may be asked to apply mild moisturizers and are not asked to avoid eating after the therapy.
The nurse is providing client teaching for a client undergoing chemotherapy. What dietary modifications should the nurse advise?
- A. Eat wholesome meals.
- B. Avoid spicy and fatty foods.
- C. Avoid intake of fluids.
- D. Eat warm or hot foods.
Correct Answer: B
Rationale: The nurse advises a client undergoing chemotherapy to avoid hot and very cold liquids and spicy and fatty foods. The nurse also encourages the client to have small meals and appropriate fluid intake.
The nurse is caring for a client is scheduled for chemotherapy followed by autologous stem cell transplant. Which of the following statements by the client indicates a need for further teaching?
- A. I hope they find a bone marrow donor who matches.'
- B. The doctor will remove cells from my bone marrow before beginning chemotherapy.'
- C. I will receive chemotherapy until most of the cancer is gone, and then I will get my own stem cells back.'
- D. I will need to be in protective isolation for up to 3 months after treatment.'
Correct Answer: A
Rationale: An autologous stem cell transplant comes from the client not from a donor. The doctor will remove the stem cells from the bone marrow before beginning chemotherapy and treat the client until most if not all the cancer is eliminated before reinfusing the stem cells. Clients are at risk for infection and will be closely monitored for at least 3 months, but not in protective isolation.