Nursing Elites

1. A client is receiving chemotherapy for the treatment of cancer. The nurse monitors the client for which of the following signs indicating a complication of the therapy?

• A. Alopecia
• B. Weight gain
• C. Elevated temperature
• D. Decreased hemoglobin level

Correct answer: C

Rationale: The correct answer is C: Elevated temperature. A fever may indicate infection, a common and serious complication of chemotherapy, requiring prompt intervention. Choice A, Alopecia, is a common side effect of chemotherapy but not a sign of a complication. Choice B, Weight gain, is not typically a sign of a complication of chemotherapy. Choice D, Decreased hemoglobin level, may occur due to chemotherapy but is not a direct sign of a complication.

2. 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.

3. 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?

• A. Hematologic spread
• B. Lymphatic circulation
• C. Invasion
• D. Angiogenesis

Correct answer: B

Rationale: In the case of lung cancer that has metastasized to the bones and liver, lymphatic circulation is a key mechanism by which cancer cells spread from the primary tumor site to distant organs. Cancer cells can invade nearby lymphatic vessels and travel through the lymphatic system, eventually reaching lymph nodes and spreading to other tissues and organs. This route is significant in the metastasis of many types of cancer, including lung cancer.

4. Nurse Casey is preparing to administer chemotherapy to a client with leukemia. The nurse wears gloves and a gown to administer the medication and to prevent exposure to the agent by which of the following routes?

• A. By ingestion
• B. By skin contact
• C. By absorption
• D. By inhalation

Correct answer: D

Rationale: Chemotherapeutic agents can be hazardous to healthcare workers if they are exposed to the drugs during preparation or administration. One of the primary risks is inhalation, where small particles or aerosols of the drug can become airborne and be inhaled, potentially causing harm to the nurse. Protective gear such as gloves and a gown, as well as masks or respirators in some cases, helps prevent this type of exposure.

5. A nurse knows that the patient with stage 3 based on Ann-arber staging has:

• A. 2 or more lymph node involvement and outside the lymph nodes
• B. 2 or more lymph node involvement on one side of the body
• C. 2 or more lymph nodes on the breasts
• D. 2 or more lymph node involvement on both sides of the body

Correct answer: D

Rationale: In the Ann Arbor staging system for lymphomas, Stage 3 indicates that the disease has spread beyond the initial lymph node region to involve lymph nodes on both sides of the diaphragm (i.e., the areas above and below the diaphragm). This includes lymphatic involvement in both the thoracic and abdominal regions, signifying a more advanced disease state.

Similar Questions