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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