nurse maria is preparing a care plan for a client receiving external radiation therapy which of the following interventions should be included
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Nursing Elites

ATI RN

ATI Oncology Questions

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

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.

2. 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?

Correct answer: B

Rationale: Administering anticoagulant therapy is crucial to prevent thromboembolic events in patients with ET.

3. The nurse is instructing a client to perform a testicular self-examination (TSE). What information should the nurse provide about the procedure?

Correct answer: B

Rationale: The correct answer is B. The best time to perform a testicular self-examination is after a warm shower when the scrotal skin is relaxed. This makes it easier to detect any abnormalities. Choice A is incorrect because the examination should ideally be done while standing. Choice C is incorrect as the client should use both hands to roll each testicle between the thumb and fingers to feel for any lumps or changes in size. Choice D is incorrect because testicular self-examinations are recommended to be done monthly, not every 6 months, to monitor changes in the testicles.

4. A nurse is caring for a client admitted for Non-Hodgkin’s lymphoma and chemotherapy. The client reports nausea, flank pain, and muscle cramps. What action by the nurse is most important?

Correct answer: A

Rationale: The client's symptoms of nausea, flank pain, and muscle cramps are suggestive of tumor lysis syndrome (TLS), a potentially life-threatening complication of chemotherapy in which cancer cells break down rapidly, releasing large amounts of intracellular components into the bloodstream. This leads to imbalances in electrolytes (elevated potassium, phosphate, and uric acid levels, with low calcium levels), which can cause severe metabolic disturbances, including kidney damage, arrhythmias, and muscle cramps. Checking serum electrolytes and uric acid levels is crucial for diagnosing and managing TLS early, preventing further complications.

5. The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?

Correct answer: A

Rationale: The passage of flatus (gas) from the colostomy is an early sign that the bowel is beginning to function after surgery. This indicates that peristalsis, or the movement of the intestines, has resumed and that the digestive system is actively moving gas and eventually stool through the bowel and out of the colostomy. It’s a positive sign that the bowel is recovering from the surgery and starting to work as intended.

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