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. 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.

3. The nurse is assessing a client with leukemia who is receiving chemotherapy. Which of the following findings would be of most concern?

Correct answer: D

Rationale: The correct answer is D, 'Mouth sores.' Mouth sores (stomatitis) are a common and potentially serious side effect of chemotherapy. They can lead to difficulty eating, increased risk of infection, and overall decreased quality of life for the client. While alopecia, fatigue, and nausea/vomiting are also common side effects of chemotherapy, they are generally manageable and do not pose the same level of immediate concern as the development of mouth sores in a client undergoing chemotherapy.

4. Nurse Kent is teaching a male client to perform monthly testicular self-examinations. Which of the following points would be appropriate to make?

Correct answer: A

Rationale: Testicular cancer is indeed highly treatable and curable, particularly when detected early through regular self-examinations. The survival rates for testicular cancer are very high, with many cases being treatable even if the cancer has spread, thanks to effective treatment options such as surgery, chemotherapy, and radiation therapy. Educating clients on the importance of early detection through monthly testicular self-examinations can empower them to recognize any changes early, increasing the likelihood of successful treatment.

5. A patient was admitted with gastric cancer. The patient asks the nurse about things to expect while receiving chemotherapy. Which of the following statements of the nurse shows incompetence?

Correct answer: A

Rationale: While hair loss (alopecia) is a common side effect of chemotherapy due to the damage to rapidly dividing hair follicle cells, the statement that hair will grow back "immediately" is inaccurate and misleading. Hair regrowth after chemotherapy takes time, typically starting a few weeks to months after treatment ends. The new hair may also have a different texture or color initially. Therefore, this statement indicates a lack of understanding and could give the patient unrealistic expectations, which is why it shows incompetence.

Similar Questions

A patient with advanced leukemia is responding poorly to treatment. The nurse finds the patient tearful and trying to express his feelings, but he is clearly having difficulty. What is the nurses most appropriate action?
When working with clients experiencing alopecia, what is the best method for a nurse to help them manage the psychosocial impact of this issue?
A patient’s most recent diagnostic imaging has revealed that his lung cancer has metastasized to his bones and liver. What is the most likely mechanism by which the patient’s cancer cells spread?
Which of the following is a correct statement by the nurse to a patient under radiation therapy?
A client is receiving rituximab and asks how it works. What response by the nurse is best?

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