2. A nurse is caring for a client who is undergoing brachytherapy.

Which of the following

precautions should be followed? (Select all that apply.)
X The client should have a private room.
X Health care personnel should wear a dosimeter flm badge.
Visitors should stay 4 feet away from the client.
Visitors can stay as long as they lie.
X Children and pregnant women should not visit the client.
X Lead container should be kept in the room.
X Tongs should be kept in the room.
!rachytherapy is internal radiation administered close to the target tissue. A pri"ate room#
dosimeter $lm badge# restricted "isitation by children and pregnant women# and eeping
a lead container and tongs in the room in case of accidental loss of radioacti"e material
are appropriate precautions. Visitors should stand % feet away from the client and limit
the time "isiting to &' min.
()*+,- )onnection. /eduction of /is 0otential# 0otential for )omplications of 1iagnostic
2ests32reatments30rocedures
)ancer 2reatment 4ptions
562 0( A17*2 8+19)A* S7/:9)A* (7/S9(:
&. A nurse is caring for a client who had a mastectomy for breast cancer. 2he client has been
prescribed tamo;ifen ((ol"ade;). Which of the following should indicate to the nurse that the
client needs further teaching?
A. <9 may e;perience hot =ashes.>
!. <9 may e;perience nausea and "omiting.>
C. I may lose weight.
1. <9 may ha"e "aginal bleeding.>
4. A nurse is caring for a client who is recei"ing immunotherapy in the outpatient clinic. Which
of the following should the nurse recommend for inclusion in the plan of care? (Select all that
apply.)
:et 2' min of direct sunlight a day.
X !onitor "or changes in vision.
X #eport $u%like symptoms to provider.
X #eport changes in hearing.
X !onitor "or unsteady gait or balance.
?. A nurse should now that which of the following is the most reliable indicator of pain?
A. !lood pressure
!. @acial e;pression
). 0ulse
&. 'erbal description o" pain
A clientAs "erbal description of pain is the most reliable indicator of pain. (on"erbal and
physiological indicators# howe"er# should also be included in the pain assessment.
()*+,- )onnection. 0hysiological Adaptation# Alterations in !ody Systems
2. A client who has breathrough cancer pain has been prescribed o;ycodone (4;y)ontin). Which
of the following side eBects of o;ycodone should the nurse monitor for and be prepared to
inter"ene when present? (Select all that apply.)
X (rthostatic hypotension
X Constipation
Coint pain
X )ruritis
X #espiratory depression
Side eBects of o;ycodone can include orthostatic hypotension# constipation# respiratory
depression# and pruritis. Da"e nalo;one a"ailable to re"erse the respiratory depression.
AdEust diet or use stool softeners if needed for constipation. 0ruritis can be treated with an
antihistamine or discontinued if an allergic reaction is suspected. Coint pain is not a usual
$nding with o;ycodone.
()*+,- )onnection. 0harmacological 2herapies# 0harmacological 0ain 8anagement
&. A nurse is caring for a client who is to undergo neurolytic ablation. 2he nurse should recogniFe
that this treatment is used only when other measures ha"e failed due to the ris of
A. increased pain.
!. myelosuppression.
). thrombocytopenia.
&. irreversible nerve damage.
(eurolytic ablation causes permanent ner"e destruction. 9t is usually used only after other
pain relief methods ha"e been unsuccessful.
()*+,- )onnection. /eduction of /is 0otential# 0otential for )omplications of 1iagnostic
2ests32reatments30rocedures
0ain 8anagement for )lients with )ancer
0( A17*2 8+19)A* S7/:9)A* (7/S9(: 55&
4. 8atch the alternati"e approach to cancer pain in the left column to its description in the right
column.
* 1istraction A. Stimulation of ner"e pathways by small needles
C /ela;ation !. *istening to music
+ Acupuncture ). 8editation
0/+40 )A/+
?. A %6GyearGold client is undergoing an endoscopy# which will reHuire moderate sedation. Which of
the following $ndings in the clientAs history indicates the need for further data collection?
A. Distory of gout
!. Allergic to bee stings
). Distory of :9 bleed
&. Chronic obstructive pulmonary disease
2. An adult woman on a cardiac unit is e;periencing episodes of paro;ysmal supra"entricular
tachycardia (0SV2). After performing all other possible inter"entions# the pro"ider decides to
perform cardio"ersion and to use midaFolam (Versed) to rela; the client for the procedure.
A nurse checs the chart to "erify that all the necessary steps ha"e been completed prior to
administering the midaFolam. Which of the following $ndings should the nurse e;pect to see in
the chart? (Select all that apply.)
X ,igned in"ormed consent
X +llergy history
X *aseline vital signs and cardiac rhythm
X !edications administered
X &ocumentation o" the last time the client ate or drank
2ype and cross match
&. Which of the following preoperati"e client $ndings should be reported to the clientAs pro"ider?
(Select all that apply.)
Serum potassium &.5 m+H3*
Serum sodium ?4I m+H3*
X ,erum creatinine -.. mg/dL
X )rothrombin time o" -0 seconds
X *lood glucose -01 mg/dL
X 2*C 345.16/mm0
4. 2he surgeon is behind schedule and ass the licensed practical nurse (*0() to complete the
consent form. Which of the following statements by the *0( is correct?
A. <9 can ha"e surgery personnel discuss the procedure with the client.>
!. <9 can ha"e the /( discuss the surgical complications you foresee.>
C. I can witness the client7s signature on the "orm.
1. <9 can discuss the surgical complications you foresee.>
select all p. ?'2&
ch. 66 04S240 )are
?. A client who had a hysterectomy resumed a regular diet earlier in the day. (ow the client is
reporting nausea and has "omited once. Which of the following actions should the nurse tae
$rst?
+. !onitor "or bowel sounds.
!. Administer an antiemetic.
). )hec the clientAs pain le"el.
1. 0lace the client on (04 status.
0t. had abd s; J days ago. *0( obser"es serosanguieous drainage. Which
are appropriate actions.
, /eport the $nding to the charge nurse
, /einforce coughing# but a"oid forceful coughing. Supine position w3 nees
bent is good.
, Splint the incision upon m"mt.