The nurse is caring for the client receiving combination chemotherapy of oxaliplatin, fluorouracil, and leucovorin. The nurse should assess the client for which common side effects of this chemotherapy regimen?
- A. Neurotoxicities and diarrhea
- B. Cardiomyopathy and dysphagia
- C. Renal insufficiency and gastritis
- D. Photophobia and stomatitis
Correct Answer: A
Rationale: A. Neurotoxicity and diarrhea occur frequently in clients receiving the medication regimen of oxaliplatin (Eloxatin), fluorouracil (5-FU), and leucovorin (Wellcovorin). B. Cardiomyopathy and dysphagia are not common side effects of these chemotherapy agents. C. Renal insufficiency and gastritis are not common side effects of these chemotherapy agents. D. Photophobia and stomatitis are not common side effects of these chemotherapy agents.
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The laboratory results for a male client diagnosed with leukemia include RBC count 2.1 x 106/mm3, WBC count 150 x 103/mm3, platelets 22 x 103/mm3, K+ 3.8 mEq/L, and Na+ 139 mEq/L. Based on these results, which intervention should the nurse teach the client?
- A. Encourage the client to eat foods high in iron.
- B. Instruct the client to use an electric razor when shaving.
- C. Discuss the importance of limiting sodium in the diet.
- D. Instruct the family to limit visits to once a week.
Correct Answer: B
Rationale: Low platelets (22,000) increase bleeding risk; an electric razor (B) prevents cuts. Iron (A) is for anemia, sodium (C) is normal (139), and limiting visits (D) is excessive.
A 5-year-old boy is admitted because he bled profusely when he lost his first baby tooth. After a workup, he is diagnosed as having classic hemophilia. His mother asks the nurse if his two younger sisters will also develop hemophilia. What is the best answer for the nurse to give?
- A. They will not develop the disease.'
- B. Statistically, one of them is likely to develop the disease.'
- C. They are not likely to get the disease, but they may be carriers.'
- D. If it doesn't show up by the time they start school, they are unlikely to develop the condition.'
Correct Answer: C
Rationale: Hemophilia is an X-linked recessive disorder. Females are unlikely to develop the disease but may be carriers, especially if the mother is a carrier.
Which of the following would be the best lunch for a client with folic acid deficiency anemia?
- A. Bologna sandwich and vegetable soup
- B. Grilled cheese sandwich and tomato soup
- C. Coleslaw and cream of mushroom soup
- D. Spinach salad and bean soup
Correct Answer: D
Rationale: Spinach and beans are rich in folate, making this lunch ideal for folic acid deficiency anemia.
The client is placed on neutropenia precautions. Which information should the nurse teach the client?
- A. Shave with an electric razor and use a soft toothbrush.
- B. Eat plenty of fresh fruits and vegetables.
- C. Perform perineal care after every bowel movement.
- D. Some blood in the urine is not unusual.
Correct Answer: A
Rationale: Neutropenia precautions include electric razors and soft toothbrushes (A) to prevent bleeding/infection. Fresh produce (B) risks infection, perineal care (C) is routine, and hematuria (D) is abnormal.
The nurse is caring for the client who had a left modified radical mastectomy (a total mastectomy with axillary node dissection and removal of the lining over the pectoralis major muscle). Which action by the nurse is appropriate?
- A. Have the client elevate the left arm above the head
- B. Ensure that IV access sites are only on the right side
- C. Have the client view the incision site as soon as possible
- D. Initiate left arm strengthening within 24 hours of surgery
Correct Answer: B
Rationale: A. The arm on the operative side should be elevated on a pillow, but not above the head. B. All IV access sites should be located on the nonoperative side to prevent circulatory impairment. C. Having the client look at the incision should be at the client’s readiness, not as soon as possible. D. Only ROM to the lower arm should be carried out for the first few days after surgery, with exercises and ROM to the shoulder after the drains are removed.
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