the nurse is caring for a client following radical neck dissection and creation of a tracheostomy which assessment finding would indicate an immediate
Logo

Nursing Elites

ATI RN

Oncology Test Bank

1. The nurse is caring for a client following radical neck dissection and creation of a tracheostomy. Which assessment finding would indicate an immediate need for intervention?

Correct answer: D

Rationale: Inspiratory stridor is the correct answer as it suggests airway obstruction, a critical issue requiring immediate intervention. Frequent swallowing (choice A) is a common postoperative finding and does not indicate an immediate need for intervention. The presence of mucous membranes (choice B) is a normal finding and does not require immediate intervention. Bubbling in the water-seal chamber (choice C) of a chest tube drainage system is an expected finding and indicates proper functioning of the system, not an immediate need for intervention.

2. A patient with a myelodysplastic syndrome is being treated on the medical unit. What assessment finding should prompt the nurse to contact the patients primary care provider?

Correct answer: C

Rationale: Patients with myelodysplastic syndrome (MDS) have a dysfunctional bone marrow that leads to ineffective blood cell production, including white blood cells, which are crucial for fighting infections. As a result, they are at high risk for infections. Even a slight elevation in temperature, such as 37.5°C (99.5°F), could be an early sign of infection in an immunocompromised patient. Early detection and treatment of infections are critical in MDS patients, as infections can quickly become severe or life-threatening due to their compromised immune system.

3. A patient has a diagnosis of multiple myeloma and the nurse is preparing health education in preparation for discharge from the hospital. What action should the nurse promote?

Correct answer: B

Rationale: Renal function must be monitored closely in the patient with multiple myeloma.

4. Nurse Joy is caring for a client with an internal radiation implant. When caring for the client, the nurse should observe which of the following principles?

Correct answer: B

Rationale: Clients with internal radiation implants (also known as brachytherapy) emit a small amount of radiation, which can pose a risk to others. Pregnant women are particularly vulnerable to the harmful effects of radiation because it can affect both the mother and the developing fetus. Radiation exposure can lead to birth defects, miscarriage, or other developmental issues, so pregnant women should avoid any exposure by not entering the client's room.

5. A nursing student is caring for a patient with acute myeloid leukemia who is preparing to undergo induction therapy. In preparing a plan of care for this patient, the student should assign the highest priority to which nursing diagnosis?

Correct answer: B

Rationale: The correct answer is B: Risk for Infection. Induction therapy for acute myeloid leukemia suppresses the immune system, making the patient highly susceptible to infections due to neutropenia. Preventing infections is crucial in these patients to avoid complications. Activity Intolerance (Choice A) may be a concern, but infection prevention is of higher priority. Acute Confusion (Choice C) and Risk for Spiritual Distress (Choice D) are not the immediate priorities in this situation.

Similar Questions

A client is diagnosed as having a positive reaction to the Mantoux test. Which of the following is the most appropriate nursing action?
A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which condition?
A patient with multiple myeloma is receiving chemotherapy and is at risk for bone fractures. What intervention should the nurse prioritize to reduce this risk?
A patient with advanced leukemia is responding poorly to treatment. The nurse finds the patient tearful and trying to express his feelings, but he is clearly having difficulty. What is the nurses most appropriate action?
A nurse is planning the care of a patient who has been admitted to the medical unit with a diagnosis of multiple myeloma. In the patients care plan, the nurse has identified a diagnosis of Risk for Injury. What pathophysiologic effect of multiple myeloma most contributes to this risk?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses