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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.
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The client diagnosed with sickle cell disease is experiencing a vaso-occlusive crisis. Which priority interventions should the nurse implement?
- A. Maintain IV fluids and administer pain medication prn.
- B. Encourage frequent ambulation in the hallways.
- C. Administer oxygen via nasal cannula at 10 LPM.
- D. Monitor the client’s red blood cell count every four (4) hours.
Correct Answer: A
Rationale: IV fluids and pain medication (A) prevent sickling and manage vaso-occlusive crisis pain. Ambulation (B) risks hypoxia, 10 LPM oxygen (C) is excessive, and RBC monitoring (D) is not primary.
The nurse is caring for a client diagnosed with acute myeloid leukemia. Which assessment data warrant immediate intervention?
- A. T 99, P 102, R 22, and BP 132/68.
- B. Hyperplasia of the gums.
- C. Weakness and fatigue.
- D. Pain in the left upper quadrant.
Correct Answer: D
Rationale: Left upper quadrant pain (D) suggests splenic rupture, a life-threatening AML complication. Vitals (A) are stable, gum hyperplasia (B) is expected, and fatigue (C) is common.
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.
The nurse writes a client problem of 'activity intolerance' for a client diagnosed with anemia. Which intervention should the nurse implement?
- A. Pace activities according to tolerance.
- B. Provide supplements high in iron and vitamins.
- C. Administer packed red blood cells.
- D. Monitor vital signs every four (4) hours.
Correct Answer: A
Rationale: Pacing activities (A) conserves energy in anemia-related activity intolerance. Supplements (B) and transfusions (C) are medical, and vitals (D) are routine, not primary.
The client is diagnosed with sickle cell crisis. The nurse is calculating the client’s intake and output (I&O) for the shift. The client had 20 ounces of water, eight (8) ounces of apple juice, three (3) cartons of milk with four (4) ounces each, 1,800 mL of IV fluids for the last 12 hours, and a urinary output of 1,200. What is the client’s total intake for this shift?
Correct Answer: 2840
Rationale: Oral intake: 20 oz water + 8 oz juice + (3 × 4 oz milk) = 36 oz. 1 oz = 30 mL, so 36 × 30 = 1,080 mL. IV fluids = 1,800 mL. Total intake = 1,080 + 1,800 = 2,840 mL. Output (1,200 mL) is not included.