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
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ATI Oncology Questions

1. 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.

2. Nurse Ben is reviewing the laboratory results of a client undergoing chemotherapy. Which of the following values would require immediate intervention?

Correct answer: D

Rationale: An absolute neutrophil count of 500/mm3 indicates severe neutropenia, putting the client at high risk for infection. Neutrophils are crucial in fighting off infections; a low count increases susceptibility to infections. Platelet count, white blood cell count, and hemoglobin levels are within normal ranges and do not require immediate intervention in this scenario.

3. The nurse knows that all of the following are risk factors for breast cancer except:

Correct answer: D

Rationale: Multiple sex partners are not a recognized risk factor for breast cancer. Breast cancer is primarily influenced by hormonal, genetic, and environmental factors, not sexual activity or the number of sexual partners. Established risk factors for breast cancer include family history, hormonal factors such as early menarche, late menopause, and nulliparity (having no children), as well as certain environmental exposures.

4. A client is admitted with superior vena cava syndrome. What action by the nurse is most appropriate?

Correct answer: C

Rationale: The correct answer is to gently inquire about advance directives. Superior vena cava syndrome is often a late-stage manifestation, indicating a serious condition. Discussing advance directives with the client is crucial to ensure their wishes are known in case of deterioration. Administering allopurinol (Choice A) is not indicated for superior vena cava syndrome. Assessing the client’s serum potassium level (Choice B) is not the priority when managing this syndrome. Emergency surgery (Choice D) is not typically the initial treatment for superior vena cava syndrome.

5. A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority?

Correct answer: D

Rationale: The correct answer is D: Teaching measures to prevent scalp injury. Alopecia makes the scalp more vulnerable to injury, so educating clients on protective measures is crucial. Choices A and B focus on emotional support and reassurance, which are important but secondary to physical safety. Referring clients to a wig shop (choice C) addresses appearance but does not directly address the physical risk associated with scalp vulnerability.

Similar Questions

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An older adult patient is undergoing diagnostic testing for chronic lymphocytic leukemia (CLL). What assessment finding is certain to be present if the patient has CLL?
A patient from the oncology unit asks the nurse about metastasis. Which of the following statements by the nurse requires immediate intervention by the head nurse?
The nurse is instructing a client on ways to reduce the risk of lymphedema after a mastectomy. Which of the following should be emphasized?

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