Glossary of NC4
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- Which measure should the nurse plan for a patient with thrombocytopenia resulting from cancer chemo?
- Apply pressure to the venipuncture site for five minutes
Rationale: Thrombocytopenia= depletion of platelets places the patient at increased risk for bleeding. Applying pressure is an appropriate measure against this risk.
- which pt with an ileal conduit displays a need for additional teaching?
- secures face plate with tape
Rationale: Tape is used around skin barrier, never on the pouch
- Which disorder places a pt at an increased risk of cancer?
- Down Syndrome
Rationale: These pt have an increased risk of leukemia
- In assessing a pt with oral lesions s/t chemo, nurse should also assess?
- perianal area
rationale:r/for infection is related to pathogen entry site such as mucous membranes, IV sites.
- A nurse must recommend which of the following for a pt. with anticipated alopecia?
- Acquire a wig which matches hair color prior to chemo.
rationale: selecting a wig before hair falls out make for matching texture and color.
- A childs with Wilms Tumor should not be palpated where?
- On the abdomen
Rationale: palpating will increase seeding of tumor
- A pt with stage 4 adenocarcinoma of right lung has a regualr resp. rate, circumoral cyanosis, small amount of yellow mucus when coughing, which is an appropriate diagnosis?
- Impaired Gas Exchange
Rationale: Tumor has metastisized. Gas exchange is impaired as amount of can cer grows.
- How do we prevent lymphedema?
- pt avoid dangling arm, sleep on unaffected side, wear loos fitting clothes, wear gloves when working with strong acids or detergents, Do not cut cuticles rather use lotion.
- A pt with a radical mastectomy has had blood samples and blood pressure drawn on the unaffected arm, WHY?
- To decrease risk of infection
rationale:both procedures require constriction of the arm which if affected arm placing the pt at an increased risk of infection
- A toddler with leukemia has stomatitis, which statement declares teaching has been effective?
- I can prepare my childs favorite foods such as mash potatoes & chocolate milk
rationale: these foods are bland and easy to chew.
- Which statement made by a pt should alert the nurse to provide addt. teaching regarding breast ca.?
- Thank god I can just examine one breast!
rationale: BSE should include the entire chest wall and axilla.
- Pt with ca. is in a state of cachexia, what should the nurse include in the care plan?
- Eat six small meals per day & report any weight loss
rationale: a pt. with cachexia needs addtional nutrition. small frequent meals work best with these pt.
- What is appropriate for visitors of a pt receiving internal radiation therapy?
- Maintain distance of 6 feet from isotope source
- when preparing a plan to meet learning needs of pt with cancer, who is undergoing chemo, the nurse should include which instruction?
- Use recommended antiemetic drug prior to therapy
- A pt with a colostomy is disharged, what do we include in discharge instructions?
- pouch opening 1/8 inch bigger than stoma, clean with mild soap and pat dry, change bag when 1-3rd full . change bag q 3-7 days
- when teaching BSE to adults what is the best indication learning has occurred?
- return demonstration
- A pt with cancer asks if there are alternative treatments for ca, nurse response?
- Describe therapies you want to explore
- Chemotherapy should be witheld when?
- when bone marrow suppression occurs
- when a pt with ca. develops pain what is an accurate inital nursing action?
- ask pt. to rate severity of pain on a scale
- A pt with neutropenia is put in a private room why?
- minimize risk of infection
- which findings in a pt with neuroblastoma in the abdomen indicate distant metastasis?
- periorbital edema indicates distant metastasis, bone pain & weakness, weight loss & anorexia are linked to generalized metastasis
- Pt. with a mastectomy is one day postop. what is the greatest risk at this time?
- pulmonary complications
rationale: due to location of surgery
- A pt with colorectal ca. develops stomatitis r/t chemo which is a dietary intervention?
- increase fluids to maintain electrolyte balance & promote excretion of waste
- which intervention should be included for a pt with multiple myeloma
- good hydration
rationale: hypercalcemia is a common complication of myeloma. maintaining hydration is important
- a pt had a radical modified mastectomy what should be included immediately post op?
- maintain cont. elevation of right arm on pillow
rationale: elevation helps relieve pain after mastectomy
- how can prostate ca be diagnosed?
- yearly DRE
- which indicates a need for further teaching for a home care pt with leukemia?
- I keep fresh cut clowers in my room
rationale:live plants/flowers pose a risk for infection
- a pt will qualify for hospice if -
- life expectancy 6 months or less, spouse works full time, receives palliative therapy, pt resides in LTC facility or elsewhere
- two different chemotherapy drugs are administered why?
- increase numbers of tumor cells killed
- a pt with a laryngectomy can attend which support group?
- Lost chord club
- a family is diagnosed with dysfunctional grieving r/t pt. advanced vaginal ca. What is a primary nursing goal?
- have family members deal feelings of guilt, fear, anger in a supportive setting
- what are s/s of myelosuppresion?
- elevated temp. & gingival bleeding
rationale:these are signs of bone marrow suppression and pose a risk for infection
- Hodgkins Diet?
- High protein High carb, low residue
Rationale: diet should be nutritious and not irritating to GI tract (low fiber)
- What color should a stoma be after colostomy surgery?
- light pink to red
dark red or black indicates infection or necrosis
- what is tumor lysis syndrome?
- when contents of cells destroyed by chemo are released into body causes electrolyte imbalance. Increasing fluids help the body rid excess fluid.
- After abdominal perineal resection for rectal ca. what is an intervention?
- a sidelying position
rationale: it will be less uncomfortable while wound is healing
- a pt with a bone marrow transplant must report all of the following
- intermittent claudication (indicates vein obstruction), constipation (increases risk of bleeding), rash (transplant rejection
- a pt. with ca. is receiving morphine what diet is appropriate?
- High fluid High Fiber diet
- what foods can cause cancer?
- smoked foods, salted foods
- how does a radical prostactectomy affect sex?
- causes impotence
- A child with CF has certain dietary needs what are they?
- Good hydration, pancreatic enzymes mixed with food
- what s/s of HPS?
- projectile vomiting, palpable epigastric mass
- Intolerance to lactose, do not give milk or lactose containing products due to infant missing enzyme GALT which is necessary in body to break down galactose into glucose
- a mentally challenged child is about to undergo surgery, what is an nursing action to meet childs need?
- Ask parents what childs use for words
- which factor affects children with CP
- feeding difficulties r/t abnormal postures and decrease in muscle tone
- Infant with Hydrocephalus what is a priority diagnosis?
- altered cerebral perfusion r/t ICP
- which toys help a CF toddler attain goals of therapy?
- push=pull toys
rationale: stimulates mucus secretion
- a 25 month old toddler can sit up with support but does not walk, what is an important nursing measure?
- refer child to developmental testing
- s/s of Down Syndrome
- protruding tongue, palmar crease
- goal for infant with neurogenic bladdr r/t meningomyelocele?
- preserving renal function
- which statement indicates teaching was effective for a pt discharged regarding prevention of reoccurence of Rheumatic fever
- I will take precuations the rest of my life
rationale: this disease poses risk to heart and joints and has lifelong consequences.
- a pt taking an ACE inhibitor may experience?
- orthopnea and cough,must be taken prior to meals.
- which statement by a pt taking sub. NTG indicates the need for additonal teaching?
- I repeat dosage q 30 mins. NTG is given repeatedly q 5 mins up to 3 doses if no relief of cp see er/md
- which action for a pt. with SC Anemia indicates need for more teaching?
- restricts fluids
rationale:dehydration is common
- Schilling test?
- urine collected for 24 hours
- what is indicative of dig. toxicity?
- abdominal pain, yellow halos, hypokalemia
- what physiological change is expected in an adult
- atrial irritability; enlarged left atrium
- s/s of iron deficiency anemia
- smooth sore red tongue, brittle nails & hair; ferritin levels low;H * H low
- a pt expresses powerlessness r/t chronic disease, what intervention can a nurse provide?
- provide a choice of foods for breakfast meal
- Sinoatrial arrest, bradydysrhythmias,AV block may be treated with what drug?
- Epinephrine used for?
- Lidocaine used for?
- s/s of DVT
- pain in affected area and unilateral edema
- a pt with angina should avoid?
- extreme temperatures
- which indicates successful treatment of CHF?
- cardiac output of 4-7 l/min, central venous presure 0-8 mm hg, systemic vascular resistance 800-1500 dynes/sec, pulmonary artery wedge pressure 4-12mmhg
- common side effects of digitalis
- reduces edema, nausea
- lab results indicative of DIC
- PT & PTT increased, fibrinogen decreased, fibrin split products are increased
- what does a pacemaker do?
- provide electric stimulus to the heart
- A pt has an abdominal aortic aneursysm, what is an emergent s/s?
- severe back pain
- Phase 1 rehabiliation is started when?
- When the pt. is hemodynamically stable
- PE is treated with?
- Digoxin & Lasix
- Dressler Syndrome is treated with?
- Third Degree AV Block treated with?
- Cardiogenic Shock treated with?
- NTG and Dopamine
- which assesment data validate a diagnosis of excess fluid volume r/t right sided heart failure
- pedal edema
- Why take Cromolyn?
- helps pt tolerate activity (asthma)
- A pt with bronchospams may experience what complication?
- respiratory arrest
- Cyanosis is indicative of what?
- impaired circulation or impaired airway patency
- what cause the abnormal ABG in lobar pneumonia?
- exudate infiltrates the alveoli
- bubbling must be cont. in suction chamber
- occasional bubbles in suct chamber indicate problem
- intermittent or absent bubbling in water seal chamber are correct
- cont. bubbling in water seal chamber indicate a problem
- What does Incentive Spirometry do?
- maximizes the amount of air inhaled while maintaining relatively low airway pressure
- s/s of LTB
- stridor on inspiration, low grade fever
- s/s of epiglottitis
- croupy cough, drooling, agitation
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