Cancer

Question 1

A client admitted with a diagnosis of metastatic cancer has been receiving chemotherapy for 3 months. The client’s lab values include RBC 3.8 million/ mm3, WBC 2,000/ mm3, Hgb 9.3 g/dL, platelets 50,000/ mm3. Which of the following nursing diagnoses is MOST appropriate for this patient?

1. Decreased cardiac output.
2. Ineffective thermoregulation.
3. Risk for injury.
4. Ineffective airway clearance.

Answer 1

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Strategy: Determine how each answer choice relates to the lab values

(1) will increase due to decreased oxygenation caused by anemia; normal RBC male: 4.3-5.9 million/mm3; female: 3.5-5.5 million/mm3; decreased with anemia, causes heart rate and respirations to increase; normal WBC 4,500-11,000/mm3; decreased (leukopenia) causes susceptibility to infection; normal Hgb: male 13.5-17.5 g/dL, female 12-16 g/dL; decreased with anemia
(2) no change in temperature
(3) correct—due to low platelet count, normal platelets 150,000-400,000/ mm3, decrease causes problems with blood clotting
(4) no information about airway problems

Question 2

A charge nurse develops assignments for the evening shift. The nurse notes that a client with a tracheostomy with purulent drainage and a pending culture and sensitivity (C&S;) is sharing a room with a client diagnosed with neutropenia. Which of the following actions by the charge nurse is MOST appropriate?

1. Assign an experienced nurse to care for both clients in the same room.
2. Assign each client a separate nurse.
3. Place the client diagnosed with neutropenia in a private room and assign the same nurse to care for both clients.
4. Place the client diagnosed with neutropenia in a private room and assign different nurses to care for each client.

Answer 2

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Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired?

(1) should be in a private room away from roommate with infection
(2) should be in a private room away from roommate with infection
(3) should be cared for by different nurses
(4) correct—infection in a neutropenic individual may cause morbidity and fatality; place the neutropenic client in a private room; limit and screen visitors and hospital staff with potentially communicable illnesses

Question 3

The nurse changes the dressing on a woman who had a mastectomy 2 days ago. After the nurse removes the old dressing, the client turns her head away. Which of the following is the BEST response by the nurse?

1. "I notice that you turn your head away as if you don't want to look at your incision."
2. "It's good that you turn your head away while I am doing this sterile procedure."
3. "Your incision looks like it's healing nicely."
4. "Why don't you look at the incision while I have the old dressing off?"

Answer 3

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Strategy: Remember therapeutic communication.

(1) correct—states observation
(2) doesn’t help patient confront feelings
(3) doesn’t deal with avoidance behavior
(4) nontherapeutic to ask why, causes patient to be defensive