a nurse is caring for a client who is receiving radiation therapy for breast cancer which of the following side effects should the nurse monitor for
Logo

Nursing Elites

ATI RN

ATI RN Exit Exam 2023

1. A client receiving radiation therapy for breast cancer may experience which of the following side effects that the nurse should monitor for?

Correct answer: C

Rationale: During radiation therapy for breast cancer, one common side effect is skin irritation due to the impact of radiation on the skin cells. This side effect should be closely monitored by the nurse. Fatigue may also occur as a side effect of radiation therapy, but skin irritation is more specific to the treatment area and is a priority in this case. Nausea and weight gain are not typically associated with radiation therapy for breast cancer, making them incorrect choices.

2. A nurse is assessing a client who is experiencing acute pain. Which of the following manifestations should the nurse expect?

Correct answer: C

Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common manifestation of acute pain caused by increased sympathetic nervous system activity. This response is the body's way of trying to regulate body temperature during the stress response. Choices A, B, and D are incorrect. Hypertension (Choice A) and tachycardia (not bradycardia as in Choice B) are more likely responses to acute pain due to sympathetic nervous system activation. Piloerection (Choice D), also known as goosebumps, is not a typical manifestation of acute pain.

3. A nurse is planning care for a client who is 1 day postoperative following a total knee arthroplasty. Which of the following interventions should the nurse include?

Correct answer: C

Rationale: Encouraging the client to ambulate as soon as possible is essential in preventing complications like deep vein thrombosis post knee arthroplasty. While keeping the affected leg elevated and applying ice packs can be beneficial in certain situations, early ambulation takes precedence in this case. Performing range-of-motion exercises hourly may not be necessary and could potentially cause more harm than good if not done correctly or excessively.

4. A nurse is preparing to administer an intermittent enteral feeding to a client who has an NG tube. Which of the following actions should the nurse take?

Correct answer: D

Rationale: Verifying the pH of the gastric aspirate is the correct action to take before administering an intermittent enteral feeding through an NG tube. This step ensures proper tube placement in the stomach, as the gastric aspirate should have an acidic pH (usually below 5). Heating the feeding solution, elevating the head of the bed, or flushing the tube with saline are not directly related to verifying tube placement and are not the immediate actions needed before administering the feeding.

5. A client is being taught about the use of hypnosis during labor. Which of the following statements is appropriate?

Correct answer: B

Rationale: The correct answer is B because hypnosis during labor aims to increase control over pain perception, helping manage labor pain without the need for medication. Choice A is incorrect as hypnosis doesn't primarily focus on biofeedback. Choice C is incorrect because hypnosis doesn't rely on therapeutic touch. Choice D is incorrect because hypnosis doesn't just provide instructions to minimize pain but rather helps individuals gain control over their pain perception.

Similar Questions

What is the first intervention for a patient experiencing anaphylactic shock?
When teaching a client about nutritional intake, what should be included?
A client who has glaucoma and a new prescription for timolol eyedrops is receiving teaching from a nurse. Which of the following statements indicates an understanding of the teaching?
A nurse is providing teaching to a client who is postoperative following a cataract extraction. Which of the following statements should the nurse include?
A client with diabetes mellitus is receiving discharge instructions from a nurse. Which statement by the client indicates an understanding of the teaching?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses