a client in the emergency department reports difficulty breathing the nurse assesses the clients appearance as depicted below what action by the nurse
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Nursing Elites

ATI RN

Oncology Test Bank

1. A client in the emergency department reports difficulty breathing. The nurse assesses the client’s appearance as depicted below: What action by the nurse is most important?

Correct answer: A

Rationale: The correct action by the nurse is to assess the client's blood pressure and pulse. Difficulty breathing can be a sign of various conditions, including cardiac issues. Assessing blood pressure and pulse helps in determining the client's hemodynamic status and identifying any cardiovascular compromise. Option B is less crucial as attaching the client to a pulse oximeter may provide oxygen saturation levels but does not directly assess cardiac output. Option C is not the priority in this situation as the client's difficulty breathing is a more urgent concern. Option D is incorrect as urgent radiation therapy is not indicated based on the client's presentation.

2. When preparing for the patient's subsequent care after completing the full course of treatment for acute lymphocytic leukemia without a significant response, what action should the nurse take?

Correct answer: D

Rationale: In cases where a patient does not respond appreciably to therapy, it is crucial to identify and respect the patient's choices regarding treatment, including preferences for end-of-life care. Option A is incorrect because it focuses on spiritual support rather than the patient's care preferences. Option B is incorrect as it assumes non-adherence to treatment without evidence. Option C is incorrect as it suggests an alternative treatment approach without considering the patient's wishes for end-of-life care.

3. A 58-year-old male patient has been hospitalized for a wedge resection of the left lower lung lobe after a routine chest x-ray shows carcinoma. The patient is anxious and asks if he can smoke. Which statement by the nurse would be most therapeutic?

Correct answer: C

Rationale: Choice C is the most therapeutic response as it acknowledges the patient's anxiety and encourages reflection on his behavior. This approach can help the patient explore his feelings and thoughts about smoking in relation to his surgery, promoting self-awareness and potentially opening the door for a constructive discussion. Choices A and B are more directive and may not address the underlying anxiety and need for reflection. Choice D is also somewhat permissive about smoking before surgery, which may not be in the patient's best interest.

4. A nurse is providing education to a patient with polycythemia vera about self-care strategies. What advice should the nurse include?

Correct answer: B

Rationale: The correct advice for a patient with polycythemia vera is to drink plenty of fluids. This helps in reducing the risk of thrombosis by keeping the blood less viscous. Avoiding hot showers (Choice A) is not directly related to managing polycythemia vera. While avoiding tight and restrictive clothing (Choice C) can help improve circulation, it is not the most crucial advice for these patients. Avoiding prolonged sitting (Choice D) is important to prevent blood clots but is not as critical as staying well-hydrated.

5. A patient from the oncology unit asks the nurse about metastasis. Which of the following statements by the nurse requires immediate intervention by the head nurse?

Correct answer: A

Rationale: The correct answer is A because metastasis refers to the spread of cancer cells to distant parts of the body, not the replication of cells. Choice B is correct as metastasis can indeed occur in various body parts. Choice C is incorrect as it inaccurately combines the concepts of replication and travel of cancer cells. Choice D is also correct as it accurately defines metastasis as the spread of cancer cells.

Similar Questions

A nurse in the oncology clinic is providing preoperative education to a client just diagnosed with cancer. The client has been scheduled for surgery in 3 days. What action by the nurse is best?
A nurse is caring for a patient diagnosed with essential thrombocythemia (ET) who is at risk for thromboembolic events. What nursing intervention is most appropriate for this patient?
An oncology nurse educator is providing health education to a patient who has been diagnosed with skin cancer. The patient’s wife has asked about the differences between normal cells and cancer cells. What characteristic of a cancer cell should the educator cite?
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 patient diagnosed with polycythemia vera presents to the clinic for routine bloodwork. What should the nurse monitor for in this patient as a priority?

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