1. Client in terminal stage of cancer is being transferred to hospice care. Which information should the nurse include in the teaching plan?
a. focus of care is on controlling symptoms and relieving pain.
b.Multidisciplinary team provides care.
c. Bereavement care is provided to the family.
2.Client has undergone laryngectomy and is now receiving radiation therapy to the head and neck. What adverse effects of external radiation should the nurse monitor for?
a.Xerostomia
b. Stomatitis
c.Dysgeusia
3.Client with bladder cancer has undergone surgical removal of the bladder with construction of an ileal conduit. What findings indicate that the client is developing complications
a.Dusky appearance of the stoma
b.Stoma protruding from skin
c.Sharp abdominal pain with rigidity.
4.Client with lung cancer is scheduled to undergo a left pneumonectomy. A chest tube will be inserted as part of the surgery. In what area will you expect to see the chest tube inserted?
a. Removal of the left lung requires that the chest tube be inserted at the base of the left lung.
5.Adult client with Hodgkins disease who weighs 143 lbs is to receive vincristine(Oncovin) 25mcg/kg IV. What is the correct dose in mcgs?
a. 1,625 mcg
Perfusion Interventions and Rationales
1 - Assess Pulses Hourly
Assessing the pulses is a critical step in maintaining the healthy perfusion of a client.
2 -Measuring for and application of elastic compression stockings.
In order to prevent clots and improve or maintain adequate perfusion.
3 -Recording and interpreting an ECG.
ECG record of the heart's activity is essential to monitor for abnormal electrical activity.
Cellular Regulation Interventions and Rationales
1 -Assess patient's signs and symptoms of pain and administer pain medication as prescribed.
Assessment allows for pain control and comfort management in the client with cancer. Also allows for care plan modifications, if needed.
2-Perform comfort measures to promote relaxation, such as bathing, repositioning, and relaxation techniques.
These measures reduce muscle tension or spasm, redistribute pressure on body parts, and help patient focus on non-pain-related subjects.
3-Provide patient with information to help increase pain tolerance, such as reasons for pain and length of time it will last.
This educates the patient and encourages compliance in trying alternative pain relief management.
INR OF 4
Normal INR value is 2.0 to 3.0. This patient would probably be on warfarin therapy.
Interventions
1-Monitor physiologic responses for values that remain in normal ranges.
Early bleeding compensatory mechanisms can alter respirations, pulse and blood pressure.
2-Examine surgical and wound dressings.
Measure the amount of bleeding and patient experiences and compare with the normal expected blood loss.
3-Teach about intended effects of the medication that increase the risk for bleeding or prolong clotting.
This enables the patient to avoid situations that could cause bleeding - shaving, harsh tooth brushing, contact sports.
a. focus of care is on controlling symptoms and relieving pain.
b.Multidisciplinary team provides care.
c. Bereavement care is provided to the family.
2.Client has undergone laryngectomy and is now receiving radiation therapy to the head and neck. What adverse effects of external radiation should the nurse monitor for?
a.Xerostomia
b. Stomatitis
c.Dysgeusia
3.Client with bladder cancer has undergone surgical removal of the bladder with construction of an ileal conduit. What findings indicate that the client is developing complications
a.Dusky appearance of the stoma
b.Stoma protruding from skin
c.Sharp abdominal pain with rigidity.
4.Client with lung cancer is scheduled to undergo a left pneumonectomy. A chest tube will be inserted as part of the surgery. In what area will you expect to see the chest tube inserted?
a. Removal of the left lung requires that the chest tube be inserted at the base of the left lung.
5.Adult client with Hodgkins disease who weighs 143 lbs is to receive vincristine(Oncovin) 25mcg/kg IV. What is the correct dose in mcgs?
a. 1,625 mcg
Perfusion Interventions and Rationales
1 - Assess Pulses Hourly
Assessing the pulses is a critical step in maintaining the healthy perfusion of a client.
2 -Measuring for and application of elastic compression stockings.
In order to prevent clots and improve or maintain adequate perfusion.
3 -Recording and interpreting an ECG.
ECG record of the heart's activity is essential to monitor for abnormal electrical activity.
Cellular Regulation Interventions and Rationales
1 -Assess patient's signs and symptoms of pain and administer pain medication as prescribed.
Assessment allows for pain control and comfort management in the client with cancer. Also allows for care plan modifications, if needed.
2-Perform comfort measures to promote relaxation, such as bathing, repositioning, and relaxation techniques.
These measures reduce muscle tension or spasm, redistribute pressure on body parts, and help patient focus on non-pain-related subjects.
3-Provide patient with information to help increase pain tolerance, such as reasons for pain and length of time it will last.
This educates the patient and encourages compliance in trying alternative pain relief management.
INR OF 4
Normal INR value is 2.0 to 3.0. This patient would probably be on warfarin therapy.
Interventions
1-Monitor physiologic responses for values that remain in normal ranges.
Early bleeding compensatory mechanisms can alter respirations, pulse and blood pressure.
2-Examine surgical and wound dressings.
Measure the amount of bleeding and patient experiences and compare with the normal expected blood loss.
3-Teach about intended effects of the medication that increase the risk for bleeding or prolong clotting.
This enables the patient to avoid situations that could cause bleeding - shaving, harsh tooth brushing, contact sports.
Are you kidding me, seriously-seriously .