Nokea
The nurse is caring for a patient who is receiving chemotherapy for leukemia. Which of the following observations require intervention by the nurse?
- A. The patient ambulates several times a day in the room.
- B. The patient's temperature is 38.2°C (100.8°F).
- C. The patient cleans with a warm washcloth after having a stool.
- D. The patient uses soap and shampoo to shower every other day.
Correct Answer: B
Rationale: Any temperature above 38°C (100.4°F) in a patient receiving chemotherapy should be investigated immediately. The patient should ambulate in the room rather than the hospital hallway to avoid exposure to other patients or visitors. Because overuse of soap can dry the skin and increase infection risk, showering every other day is acceptable. Careful cleaning after having a bowel movement will help to prevent skin breakdown and infection.
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The nurse is teaching a patient who is postmenopausal and has stage III breast cancer about the expected outcomes of her cancer treatment. Which patient statement indicates that the teaching has been effective?
- A. After cancer has not recurred for 5 years, it is considered cured.
- B. The cancer will be cured if the entire tumour is surgically removed.
- C. Cancer is never considered cured, but the tumour can be controlled with surgery, chemotherapy, and radiation.
- D. I will need to have follow-up examinations for many years after I have treatment before I can be considered cured.
Correct Answer: D
Rationale: The risk of recurrence varies by the type of cancer. For breast cancer in postmenopausal women the patient needs at least 20 disease-free years to be considered cured. Some cancers are considered cured after a shorter time span, or after surgery, but stage III breast cancer will require additional therapies and ongoing follow-up.
After the nurse has finished teaching a patient who is scheduled to receive external beam radiation for abdominal cancer about appropriate diet, which dietary selection by the patient indicates that the teaching has been effective?
- A. Fresh fruit salad
- B. Roasted chicken
- C. Whole wheat toast
- D. Cream of potato soup
Correct Answer: B
Rationale: To minimize the diarrhea that is commonly associated with bowel radiation, the patient should avoid foods high in roughage, such as fruits and whole grains. Lactose intolerance may develop secondary to radiation, so dairy products also should be avoided.
A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. Which of the following interventions should the nurse implement?
- A. Teach about the importance of nutrition during treatment.
- B. Have the patient eat large meals when nausea is not present.
- C. Offer dry crackers and carbonated fluids during chemotherapy.
- D. Administer prescribed antiemetics 1 hour before the treatments.
Correct Answer: D
Rationale: Treatment with antiemetics before chemotherapy may help prevent nausea. Although nausea may lead to poor nutrition, there is no indication that the patient needs instruction about nutrition. The patient should eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea.
The nurse is caring for a patient undergoing external radiation and has developed a dry desquamation of the skin in the treatment area. Which of the following patient statements indicates that the nurse's teaching about management of the skin reaction has been effective?
- A. I can buy some aloe gel to use on the area.
- B. I will expose the treatment area to a sun lamp daily.
- C. I can use ice packs to relieve itching in the treatment area.
- D. I will scrub the area with warm water to remove the scales.
Correct Answer: A
Rationale: Aloe gel and cream may be used on the radiated skin area. Ice and sunlamps may injure the skin. Treatment areas should be cleaned gently to avoid further injury.
Which of the following findings in a patient who is receiving interleukin-2 indicates a need for rapid action by the nurse?
- A. Generalized muscle aches
- B. Complaints of nausea and anorexia
- C. Oral temperature of 38.1°C (100.6°F)
- D. Capillary leak syndrome with 2+ edema
Correct Answer: D
Rationale: Capillary leak syndrome is a serious adverse effect of interleukin-2 therapy, leading to fluid retention and potential complications like pulmonary edema, requiring immediate intervention. Muscle aches, nausea, and a slightly elevated temperature are common side effects but are less urgent.