Nokea
The nurse is caring for a client who is postoperative following a pelvic exenteration, and the health care provider changes the client's diet from NPO status to clear liquids. The nurse should check which priority item before administering the diet?
- A. Bowel sounds
- B. Ability to ambulate
- C. Incision appearance
- D. Urine specific gravity
Correct Answer: A
Rationale: The correct answer is A: Bowel sounds. Checking for bowel sounds is crucial before administering any diet to ensure the gastrointestinal tract is functioning properly following surgery. This assessment helps prevent complications such as paralytic ileus. Choices B, C, and D are not the priority in this situation. While the ability to ambulate, incision appearance, and urine specific gravity are important assessments, ensuring bowel function takes precedence in this postoperative scenario.
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An oncology patient will begin a course of chemotherapy and radiation therapy for the treatment of bone metastases. What is one means by which malignant disease processes transfer cells from one place to another?
- A. Adhering to primary tumor cells
- B. Inducing mutation of cells of another organ
- C. Phagocytizing healthy cells
- D. Invading healthy host tissues
Correct Answer: D
Rationale: The correct answer is D: Invading healthy host tissues. Invasion is the process where malignant cells grow into surrounding healthy tissues, allowing the cancer to spread to other parts of the body. Choices A, B, and C are incorrect. Adhering to primary tumor cells does not involve the transfer of cells to other locations, inducing mutation of cells of another organ is not a mechanism of cell transfer, and phagocytizing healthy cells refers to the process of engulfing and digesting cells, which is not a method of cancer cell transfer.
A nurse provides care on a bone marrow transplant unit and is preparing a female patient for a hematopoietic stem cell transplantation (HSCT) the following day. What information should the nurse emphasize to the patient's family and friends?
- A. Your family should gather at the bedside in case there is a negative outcome.
- B. Ensure she abstains from eating any food 24 hours before the procedure.
- C. Wear a hospital gown when entering the patient's room.
- D. Avoid visiting if you've had a recent infection.
Correct Answer: D
Rationale: The correct answer is D: 'Avoid visiting if you've had a recent infection.' Before a hematopoietic stem cell transplantation, it is essential for visitors to refrain from visiting if they have had a recent illness or vaccination to minimize the risk of infection to the patient. Choice A is incorrect because emphasizing a negative outcome is not beneficial to the patient or their family. Choice B is incorrect as it is not necessary to abstain from food for a hematopoietic stem cell transplantation. Choice C is irrelevant to the situation as wearing a hospital gown is not the key information for family and friends to be aware of.
The nurse has educated a client on precautions to take with thrombocytopenia. What statement by the client indicates a need to review the information?
- A. I will be careful if I need enemas for constipation.
- B. I will use an electric shaver instead of a razor.
- C. I should only eat soft food that is either cool or warm.
- D. I won't be able to play sports with my grandkids.
Correct Answer: A
Rationale: The correct answer is A because enemas can cause injury to a thrombocytopenic client due to the risk of bleeding. Choices B, C, and D are correct precautions for a client with thrombocytopenia. Using an electric shaver reduces the risk of cuts that could lead to bleeding. Eating soft, cool, or warm food helps prevent injuries to the oral mucosa. Avoiding activities like sports that carry a risk of injury is also advisable.
The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which is a late sign of this oncological emergency?
- A. Headache
- B. Dysphagia
- C. Constipation
- D. Electrocardiographic changes
Correct Answer: D
Rationale: The correct answer is D, Electrocardiographic changes. In clients with metastatic prostate cancer, hypercalcemia can lead to various signs and symptoms. Electrocardiographic changes are considered a late sign of hypercalcemia, indicating severe electrolyte imbalance. Headache (choice A), dysphagia (choice B), and constipation (choice C) are earlier signs of hypercalcemia and may precede the development of more severe symptoms like electrocardiographic changes.
A clinic nurse is working with a patient who has a long-standing diagnosis of polycythemia vera. How can the nurse best gauge the course of the patient's disease?
- A. Document the color of the patient's palms and face during each visit.
- B. Follow the patient's erythrocyte sedimentation rate over time.
- C. Document the patient's response to erythropoietin injections.
- D. Follow the trends of the patient's hematocrit.
Correct Answer: D
Rationale: The course of polycythemia vera can be best ascertained by monitoring the patient's hematocrit, which should remain below 45%. Hematocrit levels are a key indicator in assessing the progression of the disease. Choices A, B, and C are not the most appropriate methods for gauging the course of polycythemia vera. Monitoring the color of the patient's palms and face, or their response to erythropoietin injections, may not provide an accurate reflection of the disease's progression. Similarly, while erythrocyte sedimentation rate can be affected in polycythemia vera, it is not the primary marker for monitoring the disease's course.