Nokea
The nurse is caring for four clients on a post-surgical unit. The nurse understands that monitoring the client for which post-operative complication takes priority?
- A. Nausea
- B. Constipation
- C. Pneumonia
- D. Urinary retention
Correct Answer: C
Rationale: Post-op lungs falter pneumonia from atelectasis or aspiration tops risks, a breathing threat per ABCs over nausea's discomfort. Constipation or retention nag, not kill. Nurses watch breathing, pushing incentive spirometry, a priority catch in this surgical haze.
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The nurse is assessing a client with severe anemia. Which clinical manifestation does the nurse expect to see in this client?
- A. Bradycardia
- B. Pale, cool skin
- C. Hypertension
- D. Warm, flushed skin
Correct Answer: B
Rationale: Severe anemia starves oxygen pale, cool skin reflects shunted flow and low hemoglobin, a classic find as body compensates. Bradycardia's rare; tachycardia revs to pump more. Hypertension doesn't fit BP may drop. Warm, flushed skin suits overload, not anemia. Nurses expect pallor, tying it to blood's oxygen flop, a sign guiding transfusion or iron.
A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority?
- A. Helping clients adjust to their appearance
- B. Reassuring clients that this change is temporary
- C. Referring clients to a reputable wig shop
- D. Teaching measures to prevent scalp injury
Correct Answer: D
Rationale: Alopecia, or hair loss, is a common chemotherapy side effect due to drugs targeting rapidly dividing cells, including hair follicles. While emotional support is vital, the priority is client safety. Teaching measures to prevent scalp injury such as avoiding harsh brushing or sun exposure takes precedence because the scalp becomes vulnerable without hair's protective barrier, risking cuts, infections, or burns. Helping clients adjust to appearance and reassuring them about regrowth address psychosocial needs but don't mitigate physical risk. Referring to a wig shop is practical but secondary to safety. In oncology nursing, prioritizing physical protection aligns with the hierarchy of needs, ensuring the client avoids complications like infection, especially if immunocompromised, before addressing emotional impacts.
The clinic nurse is caring for a 42-year-old male oncology patient. He complains of extreme fatigue and weakness after his first week of radiation therapy. Which response by the nurse would best reassure this patient?
- A. These symptoms usually result from radiation therapy; however, we will continue to monitor your laboratory and x-ray studies
- B. These symptoms are part of your disease and are an unfortunately inevitable part of living with cancer
- C. Try not to be concerned about these symptoms. Every patient feels this way after having radiation therapy
- D. Even though it is uncomfortable, this is a good sign. It means that only the cancer cells are dying
Correct Answer: A
Rationale: Radiation zaps energy fatigue and weakness are par for the course, tied to inflammation and repair in treated tissues. Saying this, plus promising lab and imaging checks, reassures him it's expected, not a red flag, and keeps him in the loop. Blaming cancer alone dodges the treatment link, unsettling him. Dismissing it as universal or a good sign' feels flippant normal cells die too. Nurses in oncology lean on honesty and vigilance, easing fears while tracking for worse issues like anemia or infection.
Which of the following is a treatment option for a client with sickle cell disease?
- A. NPO diet
- B. Blood product administration
- C. Pain management with nonsteroidal anti-inflammatory drugs (NSAIDs) only
- D. Arthrocentesis
Correct Answer: B
Rationale: Sickle cell's vaso-occlusion and anemia crave blood transfusions boost oxygen, unsickling cells, a go-to fix. NPO starves, NSAIDs alone weak for crisis pain, arthrocentesis irrelevant. Nurses bank on blood, easing hypoxia, a lifeline in this hemoglobin havoc, trumping lesser aids.
Post exposure prophylaxis against Human Immunodeficiency Virus (HIV):
- A. is probably not effective when commenced 36 hours post exposure
- B. is administered intramuscularly
- C. is generally well-tolerated by patients
- D. when given, precludes the need for follow up serology
Correct Answer: C
Rationale: HIV PEP tolerable pills, not IM, works past 36 hours, needs serology, safe in pregnancy. Nurses dose this chronic shield easy.