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.
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The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate?
- A. Clamp the Penrose drain.
- B. Change the dressing as prescribed.
- C. Notify the healthcare provider (HCP).
- D. Remove and replace the perineal packing.
Correct Answer: B
Rationale: In this scenario, the appropriate nursing intervention for serosanguineous drainage from the wound is to change the dressing as prescribed. This helps in maintaining wound cleanliness, preventing infection, and promoting proper wound healing. Clamping the Penrose drain (Choice A) is not indicated as the drainage is from the wound itself, not the drain. Notifying the healthcare provider (Choice C) may be necessary if there are signs of infection or other concerning issues, but changing the dressing should be done first. Removing and replacing the perineal packing (Choice D) is not the priority in this situation unless specifically prescribed by the healthcare provider after assessing the wound.
The nurse is admitting an oncology patient to the unit prior to surgery. The nurse reads in the electronic health record that the patient has just finished radiation therapy. With knowledge of the consequent health risks, the nurse should prioritize assessments related to what health problem?
- A. Cognitive deficits
- B. Impaired wound healing
- C. Cardiac tamponade
- D. Tumor lysis syndrome
Correct Answer: B
Rationale: The correct answer is B: Impaired wound healing. Patients who have undergone radiation therapy are at risk for impaired wound healing due to tissue damage. While cognitive deficits, cardiac tamponade, and tumor lysis syndrome can be concerns for oncology patients, the immediate priority following radiation therapy is assessing for impaired wound healing to prevent complications post-surgery.
After undergoing mastectomy, a patient demonstrates understanding of the nurse's instructions by doing which of the following?
- A. Dangle arms at the bedside
- B. Lie down on the affected chest
- C. Drink plenty of fluids immediately after surgery
- D. Elevate the affected arm
Correct Answer: D
Rationale: The correct answer is to elevate the affected arm. Elevating the affected arm helps prevent lymphedema after a mastectomy. Choices A, B, and C are incorrect. 'Dangling arms at the bedside' does not provide any benefit after a mastectomy. 'Lying down on the affected chest' can cause discomfort and possible complications. 'Drinking plenty of fluids immediately after surgery' is not related to preventing lymphedema post-mastectomy.
A young adult patient has received the news that her treatment for Hodgkin lymphoma has been deemed successful and that no further treatment is necessary at this time. The care team should ensure that the patient receives regular health assessments in the future due to the risk of what complication?
- A. Iron-deficiency anemia
- B. Hemophilia
- C. Hematologic cancers
- D. Genitourinary cancers
Correct Answer: C
Rationale: The correct answer is C: Hematologic cancers. Survivors of Hodgkin lymphoma are at a high risk of developing second cancers, with hematologic cancers being the most common complication. Regular health assessments are crucial for early detection and management. Iron-deficiency anemia (A) is not a typical long-term complication of Hodgkin lymphoma treatment. Hemophilia (B) is a genetic bleeding disorder unrelated to Hodgkin lymphoma. Genitourinary cancers (D) are not the most common complication seen in survivors of Hodgkin lymphoma.
A client is receiving rituximab. What assessment by the nurse takes priority?
- A. Blood pressure.
- B. Temperature.
- C. Oral mucous membranes.
- D. Pain.
Correct Answer: A
Rationale: When a client is receiving rituximab, the nurse's priority assessment should be monitoring the blood pressure. Rituximab can lead to infusion-related reactions, such as hypotension. Therefore, assessing the client's blood pressure is crucial to detect and manage any potential adverse reactions promptly. While monitoring temperature, oral mucous membranes, and pain are essential aspects of care, they are not the priority when a client is receiving rituximab.