Nokea
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.
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A patient who has severe pain associated with terminal liver cancer is being cared for at home by family members. Which of the following findings indicates that teaching regarding pain management has been effective?
- A. The patient agrees to take the medications by the IV route in order to improve analgesic effectiveness.
- B. The patient uses the ordered opioid pain medication whenever the pain is greater than 5 (0-10 scale).
- C. The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs.
- D. The patient states that nonopioid analgesics may be used when the maximal dose of the opioid is reached without adequate pain relief.
Correct Answer: C
Rationale: For persistent cancer pain, analgesics should be taken on a scheduled basis, with additional doses as needed for breakthrough pain. Taking the medications only when pain reaches a certain level does not provide effective pain control. Although nonopioid analgesics also may be used, there is no maximum dose of opioid. Opioids are given until pain control is achieved. The IV route is not more effective than the oral route, and the oral route is preferred.
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.
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.
The nurse is caring for a patient with tumour lysis syndrome (TLS) who is taking allopurinol. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the medication?
- A. Uric acid level
- B. Serum potassium
- C. Serum phosphate
- D. Blood urea nitrogen
Correct Answer: A
Rationale: Allopurinol is used to decrease uric acid levels. BUN, potassium, and phosphate levels are also increased in TLS but are not affected by allopurinol therapy.
The nurse is teaching a patient who has a new diagnosis of acute leukemia about the complications associated with chemotherapy. The patient is restless and is looking away, never making eye contact. After the teaching, the patient asks the nurse to repeat all of the information. Based on this assessment, which of the following nursing diagnoses is most likely for this patient?
- A. Ineffective denial related to ineffective coping strategies (leukemia diagnosis)
- B. Acute confusion related to pain (infiltration of leukemia cells into the central nervous system)
- C. Anxiety related to threat of death (leukemia diagnosis)
- D. Deficient knowledge (of chemotherapy) related to insufficient interest in learning
Correct Answer: C
Rationale: The patient who has a new cancer diagnosis is likely to have high anxiety, which may impact learning and require that the nurse repeat and reinforce information. The patient's history of a recent diagnosis suggests that infiltration of the leukemia is not a likely cause of the confusion. The patient asks for the information to be repeated, indicating that lack of interest in learning and denial are not etiological factors.