Nursing Elites

1. Nurse Lisa is assessing a client who has just completed radiation therapy to the neck area. Which of the following findings is most concerning?

• A. Erythema in the treated area
• B. Difficulty swallowing
• C. Dry, peeling skin
• D. Hoarseness

Correct answer: B

Rationale: Difficulty swallowing (dysphagia) following radiation therapy to the neck area is a significant concern because it can indicate serious complications such as esophageal stricture, inflammation, or damage to the surrounding tissues, including the esophagus. This can lead to malnutrition, dehydration, or aspiration, all of which require prompt intervention. Radiation therapy can cause irritation and scarring in the esophageal and throat tissues, which may progressively worsen if not treated. Therefore, dysphagia should be addressed immediately to prevent further complications.

2. Nurse Maria is preparing a care plan for a client receiving external radiation therapy. Which of the following interventions should be included?

• A. Use heating pads on the treated area
• B. Wear loose, soft clothing over the treated area
• C. Expose the treated area to sunlight
• D. Apply ice packs to the treated area

Correct answer: B

Rationale: Radiation therapy can cause skin irritation, dryness, and sensitivity in the treated area. Wearing loose, soft clothing helps minimize friction and pressure on the skin, reducing irritation and promoting comfort. The skin in the treated area is often more sensitive and vulnerable to damage, so this intervention helps protect the skin while maintaining the client’s comfort during the course of treatment.

3. Nurse Mike is providing care to a client with chronic myelogenous leukemia (CML). The nurse knows that the client is at risk for tumor lysis syndrome. Which of the following laboratory values requires immediate intervention?

• A. Increased uric acid level
• B. Increased serum potassium level
• C. Increased serum sodium level
• D. Increased fibrinogen level

Correct answer: A

Rationale: The correct answer is A: Increased uric acid level. In tumor lysis syndrome, rapid cell destruction releases large amounts of potassium, phosphate, and nucleic acids into the bloodstream. Uric acid can accumulate rapidly, leading to hyperuricemia, which can result in kidney damage due to urate crystal deposition. Immediate intervention is necessary to prevent renal complications. Choices B, C, and D are incorrect because while electrolyte imbalances are common in tumor lysis syndrome, hyperuricemia with potential kidney damage is the priority concern that requires immediate attention.

4. A 62-year-old woman diagnosed with breast cancer is scheduled for a partial mastectomy. The oncology nurse explained that the surgeon will want to take tissue samples to ensure the disease has not spread to adjacent axillary lymph nodes. The patient has asked if she will have her lymph nodes dissected, like her mother did several years ago. What alternative to lymph node dissection will this patient most likely undergo?

• A. Lymphadenectomy
• B. Needle biopsy
• C. Open biopsy
• D. Sentinel node biopsy

Correct answer: D

Rationale: Sentinel lymph node biopsy is a minimally invasive alternative to more extensive lymph node dissection. This procedure involves identifying and removing the first lymph node(s) to which a tumor drains, known as the sentinel node(s), to determine if cancer has spread beyond the primary site. Choices A, B, and C are incorrect because lymphadenectomy refers to the surgical removal of lymph nodes, needle biopsy involves sampling tissue with a needle for analysis, and open biopsy refers to the surgical removal of a sample of tissue for examination, none of which specifically serve as an alternative to lymph node dissection in this context.

5. The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm?

• A. Placing cool compresses on the affected arm
• B. Elevating the affected arm on a pillow above heart level
• C. Avoiding arm exercises in the immediate postoperative period
• D. Maintaining an intravenous site below the antecubital area on the affected side

Correct answer: B

Rationale: After a mastectomy, particularly when lymph nodes are removed, there is an increased risk of lymphedema in the affected arm due to impaired lymphatic drainage. Elevating the affected arm above heart level helps promote lymphatic drainage and reduces the risk of swelling. This intervention facilitates the return of lymph fluid and helps prevent fluid accumulation in the arm.

Similar Questions