nurse farah is caring for a client following a mastectomy which assessment finding indicates that the client is experiencing a complication related to
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Nursing Elites

ATI RN

Oncology Test Bank

1. Nurse Farah is caring for a client following a mastectomy. Which assessment finding indicates that the client is experiencing a complication related to the surgery?

Correct answer: B

Rationale: Arm edema on the operative side (lymphedema) is a known complication after a mastectomy. This can indicate impaired lymphatic drainage, leading to fluid accumulation in the arm. Pain at the incision site is expected postoperatively and may not necessarily indicate a complication. Sanguineous drainage in the Jackson-Pratt drain is a common finding in the immediate postoperative period. Complaints of decreased sensation near the operative site could be related to nerve damage or surgical manipulation, but it is not a typical complication after a mastectomy.

2. Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients would the nurse assess first?

Correct answer: C

Rationale: A potassium level of 2.8 mEq/L is critically low and requires immediate intervention.

3. A client is receiving rituximab and asks how it works. What response by the nurse is best?

Correct answer: C

Rationale: Rituximab is a monoclonal antibody that targets CD20, a protein found on the surface of certain B-cells, including some cancerous B-cells, such as in non-Hodgkin's lymphoma and chronic lymphocytic leukemia (CLL). Rituximab works by binding to the CD20 protein, which leads to the destruction of the cancerous B-cells through various mechanisms, including preventing the initiation of cell division. By blocking the division process, rituximab helps slow the growth and proliferation of cancer cells, allowing the immune system and additional treatments to clear them more effectively.

4. The nurse has taught a client with cancer ways to prevent infection. What statement by the client indicates that more teaching is needed?

Correct answer: D

Rationale: Clients with cancer, especially those undergoing chemotherapy or other immunosuppressive treatments, are at increased risk for infections due to a weakened immune system. Changing a litter box exposes the client to pathogens such as Toxoplasma gondii and other harmful bacteria or parasites found in cat feces, which could lead to serious infections. It is recommended that immunocompromised individuals avoid activities like changing litter boxes to reduce their risk of exposure to infectious agents. A family member or caregiver should handle this task to protect the client.

5. Nurse Kate is reviewing the complications of conization with a client who has microinvasive cervical cancer. Which complication, if identified by the client, indicates a need for further teaching?

Correct answer: D

Rationale: The correct answer is D, 'Ovarian perforation.' Ovarian perforation is not a complication associated with conization; therefore, if the client identifies this as a potential complication, it indicates a need for further teaching. Choices A, B, and C are incorrect: Infection, hemorrhage, and cervical stenosis are potential complications of conization, so identifying them would not necessarily indicate a need for further teaching.

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