Nokea
The nurse working on a bone marrow unit knows that it is a priority to monitor which of the following in a client who has just undergone a stem cell transplant?
- A. Monitor the client's toilet patterns.
- B. Monitor the client closely to prevent infection.
- C. Monitor the client's physical condition.
- D. Monitor the client's heart rate.
Correct Answer: B
Rationale: Until transplanted stem cells begin to produce blood cells, these clients have no physiologic means to fight infection, which makes them very prone to infection. They are at high risk for dying from sepsis and bleeding before engraftment. Therefore, a nurse must closely monitor clients and take measures to prevent infection. Monitoring client's toilet patterns, physical condition, and heart rate does not prevent the possibility of the client getting an infection.
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The nurse is providing client teaching for a client undergoing chemotherapy. What dietary modifications should the nurse advise?
- A. Eat wholesome meals.
- B. Avoid spicy and fatty foods.
- C. Avoid intake of fluids.
- D. Eat warm or hot foods.
Correct Answer: B
Rationale: The nurse advises a client undergoing chemotherapy to avoid hot and very cold liquids and spicy and fatty foods. The nurse also encourages the client to have small meals and appropriate fluid intake.
Chemotherapy has been used for the past 3 months to treat a client with pancreatic cancer. The CA 19-9 levels are rising. Which explanation would the nurse attribute as the most likely cause?
- A. It is normal for this antigen to rise for up to 6 months.
- B. The client is having an adverse response to the chemotherapy.
- C. The chemotherapy is effectively destroying the cancer cells.
- D. The cancer is growing despite the chemotherapy treatment.
Correct Answer: D
Rationale: Elevation of specific tumor markers, such as CA 19-9, is indicative of progression and proliferation of the cancer cells. If the chemotherapy was successful in the treating of the pancreatic cancer cells, the tumor marker would be decreased. Increased production of antibody development is not a usual adverse reaction of chemotherapy.
The nurse is caring for a thyroid cancer client following oral radioactive iodine treatment. Which teaching point is most important?
- A. Shield your throat area when near others.'
- B. Flush the toilet several times after every use.'
- C. Prepare food separately from family members.'
- D. Use disposable utensils for the next month.'
Correct Answer: B
Rationale: Iodine 131 is a systemic internal radiation that is excreted through body fluids, especially urine. Flushing the toilet several times after each use will avoid the exposure of others to radioactive exposure. Shielding the throat area is not effective because this form of treatment is systemic. Preparing food separately is not necessary, but the use of separate eating utensils will be necessary for the first 8 days.
Which of the following advice does the nurse offer clients who are undergoing unsealed radiation therapy to reduce exposure?
- A. Avoid drinking plenty of fluids.
- B. Avoid eating for 3 hours after therapy.
- C. Avoid applying skin moisturizers.
- D. Avoid kissing and sexual contact.
Correct Answer: D
Rationale: Clients who are undergoing unsealed radiation therapy are advised to avoid kissing and sexual contact due to the spread of radioactivity. Clients are encouraged to drink plenty of fluids to help flush radioactive substances. Clients may be asked to apply mild moisturizers and are not asked to avoid eating after the therapy.
The nurse understands that the client should be given human papillomavirus (HPV) vaccine per the health care provider's orders. What does this vaccine help prevent?
- A. Lung cancer
- B. Breast cancer
- C. Cervical cancer
- D. Leukemia
Correct Answer: C
Rationale: The vaccines that are approved for use in the United States include the human papillomavirus (HPV), which may help prevent women from getting cervical cancer. There are no vaccines for the prevention of lung cancer, breast cancer, or leukemia.