Saunders CH 48: Hematological and Oncological Disorders

518. The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor? 1. Age younger than 50 years 2. History of colorectal polyps 3. Family history of colorectal cancer 4. Chronic inflammatory bowel disease

1. Colorectal cancer risk factors include age older than 50 years, a family history of the disease, colorectal polyps, and chronic inflammatory bowel disease.

520. The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function? 1. The passage of flatus 2. Absent bowel sounds 3. The client's ability to tolerate food 4. Bloody drainage from the colostomy

1 Rationale: Following abdominal perineal resection, the nurse would expect the colostomy to begin to function within 72 hours after surgery, although it may take up to 5 days. The nurse should assess for a return of peristalsis, listen for bowel sounds, and check for the passage of flatus. Absent bowel sounds would not indicate the return of peristalsis. The client would remain NPO (nothing by mouth) until bowel sounds return and the colostomy is functioning. Bloody drain- age is not expected from a colostomy.

510. The nurse is caring for a client who is postoperative following a pelvic exenteration and the health care provider changes the client's diet from NPO (noth- ing by mouth) status to clear liquids. The nurse should check which priority item before adminis- tering the diet? 1. Bowel sounds 2.Abilitytoambulate 3. Incision appearance 4. Urine specific gravity

1 Rationale: The client is kept NPO until peristalsis returns, usu- ally in 4 to 6 days. When signs of bowel function return, clear fluids are given to the client. If no distention occurs, the diet is advanced as tolerated. The most important assessment is to assess bowel sounds before feeding the client. Options 2, 3, and 4 are unrelated to the data in the question.

509. The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment? 1. The client's pain rating 2. Nonverbal cues from the client 3. The nurse's impression of the client's pain 4. Pain relief after appropriate nursing intervention

1 Rationale: The client's self-report is a critical component of pain assessment. The nurse should ask the client to describe the pain and listen carefully to the words the client uses to describe the pain. Nonverbal cues from the client are important but are not the most appropriate pain assessment measure. The nurse's impression of the client's pain is not appropriate in determining the client's level of pain. Assessing pain relief is an important measure, but this option is not related to the sub- ject of the question.

523. A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the health care provider will request which prescriptions? Select all that apply. 1. Radiation 2. Chemotherapy 3. Increased fluid intake 4. Decreased oral sodium intake 5. Serum sodium level determination 6. Medication that is antagonistic to antidiuretic hormone

1, 2, 5, 6. Cancer is a common cause of syndrome of inappropriate antidiuretic hormone (SIADH). In SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. The syndrome is managed by treating the condition and cause and usually includes fluid restriction, increased sodium intake, and medication with a mechanism of action that is antagonistic to antidiuretic hormone. Sodium levels are monitored closely because hypernatremia can develop suddenly as a result of treatment. The immediate institution of appropriate cancer therapy, usually radiation or chemotherapy, can cause tumor regression so that antidiuretic hormone synthesis and release processes return to normal.

513. The nurse is caring for a client with lung cancer and bone metastasis. What signs/symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply. 1. Facial edema in the morning 2. Serum calcium level of 12 mg/dL 3. Weight loss of 20 lb in 1 month 4. Serum sodium level of 136 mg/dL 5. Serum potassium level of 3.4 mg/dL 6. Numbness and tingling of the lower extremities

1, 2, 6. Oncological emergencies include sepsis, disseminated intravascular coagulation, syndrome of inappropriate antidiuretic hormone, spinal cord compression, hypercalcemia, superior vena cava syndrome, and tumor lysis syndrome. Blockage of blood flow to the venous system of the head resulting in facial edema is a sign of superior vena cava syndrome. A serum calcium level of 12 mg/dL indicates hypercalcemia. Numbness and tingling of the lower extremities could be a sign of spinal cord compression. Mild hypokalemia and weight loss are not oncological emergencies. A sodium level of 136 mg/dL is a normal level.

516. The nurse is conducting a history and monitoring laboratory values on a client with multiple mye- loma. What assessment findings should the nurse expect to note? Select all that apply. 1. Pathological fracture 2. Urinalysis positive for nitrites 3. Hemoglobin level of 15.5 g/dL (155 mmol/L) 4. Calcium level of 8.6 mg/dL (2.15 mmol/L) 5. Serum creatinine level of 2.0 mg/dL (176.6 mcmol/L)

1,2,5 Rationale: Multiple myeloma is a B-cell neoplastic condition characterized by abnormal malignant proliferation of plasma cells and the accumulation of mature plasma cells in the bone marrow. The client with malignant melanoma may experience pathologic fractures, hypercalcemia, anemia, recurrent infec- tions, and renal failure. A serum calcium level of 8.6 mg/dL (2.15 mmol/L) and a hemoglobin level of 15.5 g/dL (155mmol/L) are normal values. Therefore, the correct answers are pathological fractures, positive urinalysis for nitrites, and a serum creatinine level of 2.0 mg/dL (176.6 mcmol/L).

504. The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder? 1. Increased calcium level 2. Increased white blood cells 3. Decreased blood urea nitrogen level 4. Decreased number of plasma cells in the bone marrow

1. Findings indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue, and an elevated blood urea nitrogen level. An increased white blood cell count may or may not be present and is not related specifically to multiple myeloma.

505. The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan? 1. Encouraging fluids 2. Providing frequent oral care 3. Coughing and deep breathing 4. Monitoring the red blood cell count

1. Hypercalcemia caused by bone destruction is a priority concern in the client with multiple myeloma. The nurse should administer fluids in adequate amounts to maintain a urine output of 1.5 to 2 L/day; this requires about 3 L of fluid intake per day. The fluid is needed not only to dilute the calcium overload but also to prevent protein from precipitating in the renal tubules. Options 2, 3, and 4 may be components of the plan of care but are not the priority in this client.

515. The nurse is caring for a client who is postoperative following a pelvic exenteration and the health care provider changes the client's diet from NPO (nothing by mouth) status to clear liquids. The nurse should check which priority item before adminis- tering the diet? 1. Bowel sounds 2.Abilitytoambulate 3. Incision appearance 4. Urine specific gravity

2 Rationale: The TSE is recommended monthly after a warm bath or shower when the scrotal skin is relaxed. The client should stand to examine the testicles. Using both hands, with fingers under the scrotum and thumbs on top, the client should gently roll the testicles, feeling for any lumps.

506. When caring for a client with an internal radiation implant, the nurse should observe which principles? Select all that apply. 1. Limiting the time with the client to 1 hour per shift. 2. Keeping pregnant women out of the client's room. 3. Placing the client in a private room with a private bath. 4. Wearing a lead shield when providing direct client care. 5. Removing the dosimeter film badge when entering the client's room. 6. Allowing individuals younger than 16 years old in the room as long as they are 6 feet away from the client

2, 3, 4 Rationale: The time that the nurse spends in the room of a cli- ent with an internal radiation implant is 30 minutes per 8-hour shift. The client must be placed in a private room with a private bath. Lead shielding can be used to reduce the transmission of radiation. The dosimeter film badge must be worn when in the client's room. Children younger than 16 years of age and preg- nant women are not allowed in the client's room.

528. A client is diagnosed as having a bowel tumor. The nurse should monitor the client for which complications of this type of tumor? Select all that apply. 1. Flatulence 2. Peritonitis 3. Hemorrhage 4. Fistula formation 5. Bowel perforation 6. Lactose intolerance

2, 3, 4, 5. Complications of bowel tumors include bowel perforation, which can result in hemorrhage and peritonitis. Other complications include bowel obstruction, and fistula formation. Flatulence can occur but is not a complication; lactose intolerance also is not a complication of intestinal tumor.

514. 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? 1. Rupture of the bladder 2. The development of a vesicovaginal fistula 3. Extreme stress caused by the diagnosis of cancer 4. Altered perineal sensation as a side effect of radiation therapy

2. A vesicovaginal fistula is a genital fistula that occurs between the bladder and vagina. The fistula is an abnormal opening between these two body parts and, if this occurs, the client may experience drainage of urine through the vagina. The client's complaint is not associated with options 1, 3, or 4.

529. The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? 1. Placing cool compresses on the affected arm 2. Elevating the affected arm on a pillow above heart level 3. Avoiding arm exercises in the immediate postoperative period 4. Maintaining an intravenous site below the antecubital area on the affected side

2. Following mastectomy, the arm should be elevated above the level of the heart. Simple arm exercises should be encouraged. No blood pressure readings, injections, intravenous lines, or blood draws should be performed on the affected arm. Cool compresses are not a suggested measure to prevent lymphedema from occurring.

519. The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? 1. Clamp the Penrose drain. 2. Change the dressing as prescribed. 3. Notify the health care provider (HCP). 4. Remove and replace the perineal packing.

2. Immediately after surgery, profuse serosanguineous drainage from the perineal wound is expected. Therefore the nurse should change the dressing as prescribed. A Penrose drain should not be clamped because this action will cause the accumulation of drainage within the tissue. The nurse does not need to notify the HCP at this time. Penrose drains and packing are removed gradually over a period of 5 to 7 days as prescribed. The nurse should not remove the perineal packing.

521. The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common symptom of this type of cancer? 1. Dysuria 2. Hematuria 3. Urgency on urination 4. Frequency of urination

2. The most common symptom in clients with cancer of the bladder is hematuria. The client also may experience irritative voiding symptoms such as frequency, urgency, and dysuria, and these symptoms often are associated with carcinoma in situ. Dysuria, urgency, and frequency of urination are also signs of a bladder infection.

517. Agastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropri- ate action? 1. Measure abdominal girth. 2. Irrigate the nasogastric tube. 3. Continue to monitor the drainage. 4. Notify the health care provider (HCP).

3 Rationale: Following gastrectomy, drainage from the nasogastric tube is normally bloody for 24 hours postoperatively changes to brown-tinged, and is then yellow or clear. Because bloody drainage is expected in the immediate postoperative period, the nurse should continue to monitor the drainage. The nurse does not need to notify the HCP at this time. Measuring abdominal girth is performed to detect the development of distention. Following gastrectomy, a nasogastric tube should not be irrigated unless there are specific HCP prescriptions to do so

508. The nurse should plan to implement which inter- vention in the care of a client experiencing neutro- penia as a result of chemotherapy? 1. Restrict all visitors. 2. Restrict fluid intake. 3. Teach the client and family about the need for hand hygiene. 4. Insert an indwelling urinary catheter to prevent skin breakdown.

3 Rationale: In the neutropenic client, meticulous hand hygiene education is implemented for the client, family, visitors, and staff. Not all visitors are restricted, but the client is protected from persons with known infections. Fluids should be encour- aged. Invasive measures such as an indwelling urinary catheter should be avoided to prevent infections.

522. The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care? 1. "I change my pouch every week." 2. "I change the appliance in the morning." 3. "I empty the urinary collection bag when it is two-thirds full." 4. "When I'm in the shower I direct the flow of water away from my stoma."

3 Rationale:Theurinarycollectionbagshouldbechangedwhen it is one-third full to prevent pulling of the appliance and leak- age. The remaining options identify correct statements about the care of a urinary stoma.

526. As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement? 1. "I should avoid blowing my nose." 2. "I may need a platelet transfusion if my platelet count is too low." 3. "I'm going to take aspirin for my headache as soon as I get home." 4. "I will count the number of pads and tampons I use when menstruating."

3. During the period of greatest bone marrow suppression (the nadir), the platelet count may be low, less than 20,000 cells/mm3. The correct option describes an incorrect statement by the client. Aspirin and nonsteroidal antiinflammatory drugs and products that contain aspirin should be avoided because of their antiplatelet activity. Options 1, 2, and 4 are correct statements by the client to prevent and monitor bleeding.

524. The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency? 1. Cyanosis 2. Arm edema 3. Periorbital edema 4. Mental status changes

3. Superior vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens, the client experiences edema of the hands and arms. Cyanosis and mental status changes are late signs.

507. While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action? 1. Call the health care provider (HCP). 2. Reinsert the implant into the vagina. 3. Pick up the implant with gloved hands and flush it down the toilet. 4. Pick up the implant with long-handled forceps and place it in a lead container.

4 Rationale: In the event that a radiation source becomes dis- lodged, the nurse would first encourage the client to lie still until the radioactive source has been placed in a safe, closed container. The nurse would use long-handled forceps to place the source in the lead container that should be in the client's room. The nurse should then call the radiation oncologist and document the event and the actions taken. It is not within the scope of nursing practice to insert a radiation implant.

527. The community health nurse is instructing a group of young female clients about breast self- examination. The nurse should instruct the clients to perform the examination at which time? 1. At the onset of menstruation 2. Every month during ovulation 3. Weekly at the same time of day 4. 1 week after menstruation begins

4 Rationale: The breast self-examination should be performed regularly, 7 days after the onset of the menstrual period. Per- forming the examination weekly is not recommended. At the onset of menstruation and during ovulation, hormonal changes occur that may alter breast tissue.

512. During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which symptom as typical of the disease? 1. Diarrhea 2. Hypermenorrhea 3. Abnormal bleeding 4. Abdominal distention

4. Clinical manifestations of ovarian cancer include abdominal distention, urinary frequency and urgency, pleural effusion, malnutrition, pain from pressure caused by the growing tumor and the effects of urinary or bowel obstruction, constipation, ascites with dyspnea, and ultimately general severe pain. Abnormal bleeding, often resulting in hypermenorrhea, is associated with uterine cancer.

511. A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client? 1. Fatigue 2. Weakness 3. Weight gain 4. Enlarged lymph nodes

4. Hodgkin's disease is a chronic progressive neoplastic disorder of lymphoid tissue characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Weight loss is most likely to be noted. Fatigue and weakness may occur but are not related significantly to the disease.

525. The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which is a late sign of this oncological emergency? 1. Headache 2. Dysphagia 3. Constipation 4. Electrocardiographic changes

4. Hypercalcemia is a manifestation of bone metastasis in late-stage cancer. Headache and dysphagia are not associated with hypercalcemia. Constipation may occur early in the process. Electrocardiogram changes include shortened ST segment and a widened T wave.