external beam radiation is planned for a patient with cervical cancer what instructions should the nurse give to the patient to prevent complications
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Nursing Elites

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ATI Learning System PN Medical Surgical Final Quizlet

1. What instructions should the nurse give to a patient with cervical cancer who is planned to receive external-beam radiation to prevent complications from the effects of the radiation?

Correct answer: C

Rationale: When a patient with cervical cancer is receiving external-beam radiation, the radiation to the abdomen can affect organs in its path, such as the bowel, leading to complications like frequent diarrhea. Cleaning the perianal area carefully after each bowel movement is crucial to decrease the risk of skin breakdown and infection. Testing stools for blood is not necessary since inflammation associated with radiation may lead to occult blood in stools. Maintaining a low-residue diet is actually recommended to prevent bowel irritation. Radiation to the abdomen does not cause stomatitis, so inspecting the mouth and throat for thrush is not directly related to the effects of external-beam radiation in this context.

2. A client with cirrhosis of the liver is being cared for by the healthcare team. Which clinical manifestation indicates that the client has developed hepatic encephalopathy?

Correct answer: A

Rationale: Asterixis, also known as flapping tremor, is a characteristic sign of hepatic encephalopathy, a severe complication of liver cirrhosis. Hepatic encephalopathy results from the liver's inability to detoxify substances in the body, leading to neurologic manifestations such as changes in mental status, confusion, and asterixis.

3. A client with a history of diabetes mellitus presents with confusion, sweating, and palpitations. What should the nurse do first?

Correct answer: A

Rationale: The correct first action for a client presenting with confusion, sweating, and palpitations, suggestive of hypoglycemia, is to check the client's blood glucose level. This step helps to confirm if the symptoms are due to low blood sugar levels and guides appropriate interventions. Administering insulin without knowing the current blood glucose level can be dangerous and is not recommended as the initial step. Offering a high-protein snack may be necessary after confirming hypoglycemia, but checking the blood glucose level takes precedence. Measuring blood pressure is not the priority in this situation; addressing hypoglycemia is the immediate concern.

4. What should be monitored to evaluate the effectiveness of enoxaparin in a patient with deep vein thrombosis (DVT)?

Correct answer: C

Rationale: The international normalized ratio (INR) is the appropriate parameter to monitor the effectiveness of enoxaparin in preventing clot formation in patients with deep vein thrombosis (DVT). INR reflects the clotting ability of the blood and is commonly used to assess the therapeutic range of anticoagulant medications, such as enoxaparin, which is crucial in managing and preventing thrombotic events like DVT.

5. A client with heart failure is prescribed furosemide (Lasix). Which instruction should the nurse include in the client's teaching plan?

Correct answer: B

Rationale: In heart failure, fluid retention is a concern. Furosemide helps manage this by promoting diuresis. Instructing the client to report weight gain exceeding 2 pounds in a day is crucial as it can indicate fluid accumulation, prompting timely intervention to prevent worsening heart failure symptoms and complications.

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A client with type 1 diabetes mellitus is admitted with hyperglycemia. Which laboratory result requires the most immediate intervention?
A client with hepatic encephalopathy exhibits confusion, difficulty arousing from sleep, and rigid extremities. Based on these clinical findings, what stage of hepatic encephalopathy should the nurse document?
A 35-year-old woman presents with abdominal pain, diarrhea, and weight loss. She has a history of recurrent mouth ulcers and a perianal fistula. What is the most likely diagnosis?
A client with a severe head injury is admitted to the intensive care unit (ICU). Which finding should the nurse report to the healthcare provider immediately?

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