cancer, immune response, wound

13. A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective? a. "I can buy some aloe vera gel to use on the area."

ANS: A Aloe vera gel and cream may be used on the radiated skin area. Ice and sunlamps may injure the skin. Treatment areas should be cleaned gently to avoid further injury

12. The nurse is caring for a patient with colon cancer who is scheduled for external radiation therapy to the abdomen. Which information obtained by the nurse would indicate a need for patient teaching? a. The patient swims a mile 3 days a week.

ANS: A The patient is instructed to avoid swimming in salt water or chlorinated pools during the treatment period. The patient does not need to change habits of eating frequently or showering with a mild soap. A history of dental caries will not impact the patient who is scheduled for abdominal radiation.

23. The home health nurse cares for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment? b. "I rarely have the energy to get out of bed."

ANS: B Fatigue can be a dose-limiting toxicity for use of biologic therapies. Flulike symptoms, such as muscle aches and chills, are common side effects with interferon use.

23. The home health nurse cares for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment? b. "I rarely have the energy to get out of bed."

ANS: B Fatigue can be a dose-limiting toxicity for use of biologic therapies. Flulike symptoms, such as muscle aches and chills, are common side effects with interferon use. Patients are advised to use acetaminophen every 4 hours.

16. A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to maintain the patient's self-esteem? b. Encourage the patient to purchase a wig or hat and wear it once hair loss begins.

ANS: B The patient is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats.

11. A patient with Hodgkin's lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." Which intervention should the nurse add to the plan of care? b. Establish time to take a short walk almost every day.

ANS: B Walking programs are used to keep the patient active without excessive fatigue. Having a hospital bed does not necessarily address the fatigue. The better option is to stay as active as possible while combating fatigue. Fatigue is expected during treatment and is not an indication of depression. Minimizing activity may lead to weakness and other complications of immobility.

The nurse teaches a patient diagnosed with systemic lupus erythematosus (SLE) about plasmapheresis. What instructions about plasmapheresis should the nurse include in the teaching plan? b. Plasmapheresis will remove antibody-antigen complexes from circulation.

ANS: B Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and complement from blood. T lymphocytes, foreign antibodies, eosinophils, and basophils do not directly contribute to the tissue damage in SLE.

14. A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. Which action, if taken by the nurse, is most appropriate? c. Administer prescribed antiemetics 1 hour before the treatments.

ANS: C Treatment with antiemetics before chemotherapy may help prevent nausea. The patient should eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea. The acidity of citrus fruits may be further irritating to the stomach.

The nurse, who is reviewing a clinic patient's medical record, notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is most appropriate?

ANS: C Because there is an increased risk for adverse reactions after a patient misses a scheduled dose of allergen, the nurse should check with the health care provider before administration of the injection. A skin test is used to identify the allergen and would not be used at this time. An additional dose for the week may increase the risk for a reaction.

Which patient should the nurse assess first? c. Patient who is sneezing after having subcutaneous immunotherapy

ANS: C Sneezing after subcutaneous immunotherapy may indicate impending anaphylaxis and assessment and emergency measures should be initiated.

5. A patient's 6 3-cm leg wound has a 2-mm black area surrounded by yellow-green semiliquid material. Which dressing will the nurse use for wound care? a. Dry gauze dressing (Kerlix) b. Nonadherent dressing (Xeroform) c. Hydrocolloid dressing (DuoDerm) d. Transparent film dressing (Tegaderm)

ANS: C The wound requires debridement of the necrotic areas and absorption of the yellow-green slough. A hydrocolloid dressing such as DuoDerm would accomplish these goals. Transparent film dressings are used for red wounds or approximated surgical incisions. Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb wound drainage or debride the wound.

31. The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in therapy with the health care provider? d. Increase in carcinoembryonic antigen (CEA)

ANS: D An increase in CEA indicates that the chemotherapy is not effective for the patient's cancer and may need to be modified.

2. The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect? d. Hematuria

ANS: D The adverse effects of intravesical chemotherapy are confined to the bladder.

The nurse is caring for a patient undergoing plasmapheresis. The nurse should assess the patient for which clinical manifestation? d. Numbness and tingling

ANS: D Numbness and tingling may occur as the result of the hypocalcemia caused by the citrate used to prevent coagulation. The other clinical manifestations are not associated with plasmapheresis.

12. The charge nurse observes a new graduate performing a dressing change on a stage II left heel pressure ulcer. Which action by the new graduate indicates a need for further education about pressure ulcer care? d. The new graduate cleans the ulcer with a sterile dressing soaked in half-strength peroxide.

ANS: D Pressure ulcers should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions by the new graduate are appropriate.

A patient is undergoing plasmapheresis for treatment of systemic lupus erythematosus. The nurse explains that plasmapheresis is used in her treatment to:

C. exchange her plasma that contains antinuclear antibodies with a substitute fluid

The nurse advises a friend who asks him to administer his allergy shots that:

D. immunotherapy should only be administered in a setting where emergency equipment and drugs are available

Which type of wound dressing is easy to use over irregularly shaped wounds and forms a nonsticky gel on contact with a draining wound? 2 Alginate

2 Alginates form a nonsticky gel on contact with a draining wound. They are easy to use over irregularly shaped wounds and generally require a secondary dressing.

A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider? d. There is a 2-cm wheal at the site of the allergen injection.

ANS: D A local reaction larger than quarter size may indicate that a decrease in the allergen dose is needed. An increase in IgG indicates that the therapy is effective. Redness and swelling at the site are not unusual. Because immunotherapy usually takes 1 to 2 years to achieve an effect, an improvement in the patient's symptoms is not expected after a few months

8. The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective? d. "I will need to have follow-up examinations for many years after I have treatment before I can be considered cured."

ANS: D The risk of recurrence varies by the type of cancer. Some cancers are considered cured after a shorter time span or after surgery, but stage III breast cancer will require additional therapies and ongoing follow-up.

36. Which action should the nurse take when caring for a patient who is receiving chemotherapy and complains of problems with concentration? d. Suggest use of a daily planner and encourage adequate rest and sleep.

ANS: D Use of tools to enhance memory and concentration such as a daily planner and adequate rest are helpful for patients who develop "chemo-brain" while receiving chemotherapy. Patients should be encouraged to exercise the brain through new activities. Chemo-brain may be short- or long-term. There is no urgent need to report common chemotherapy side effects to the provider.

8. The nurse will plan to use wet-to-dry dressings when providing care for a patient with a a. pressure ulcer with pink granulation tissue. b. surgical incision with pink, approximated edges. c. full-thickness burn filled with dry, black material. d. wound with purulent drainage and dry brown areas.

ANS: D Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue.

30. The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider? d. Crackles heard at the lower scapular border ANS: D

d. Crackles heard at the lower scapular border ANS: D Capillary leak syndrome and acute pulmonary edema are possible toxic effects of interleukin-2. The patient may need oxygen and the nurse should rapidly notify the health care provider. The other findings are common side effects of interleukin-2.

A patient has begun immunotherapy for the treatment of intractable environmental allergies. When administering the patient's immunotherapy, which of the following is the nurse's priority action? D. Monitoring for signs and symptoms of an adverse reaction

d. When administering immunotherapy, it is imperative to closely monitor the patient for any signs of an adverse reaction.

32. The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider? d. White blood cell (WBC) count of 2700/µL ANS: D

d. White blood cell (WBC) count of 2700/µL ANS: D The low WBC count places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that WBC growth factors such as filgrastim (Neupogen) are needed. Although the other laboratory data indicate decreased levels, they do not indicate any immediate life-threatening adverse effects of the chemotherapy.

A patient is suffering from moderate to heavy drainage (exudates) from his wound. What are the types of wound dressings that the nurse should use for this patient? Select all that apply. 1 Foam dressing 2 Alginate dressing 3 Gauze and nonwoven dressings 4 Nonadherent dressing 5 Hydrocolloidal dressing

1, 2, 5 Foam dressings, alginate dressings, and hydrocolloidal dressings are best suited for moderate to heavy drainage or exudates. These dressings provide protection from infection and can also hold large amount of exudates.

A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment? 3 Assessment of the patient's circulation distal to the location of the dressing

3 Any compression dressing requires vigilant assessment of the circulation distal to the dressing site, because tissue and nerve damage are significant risks.

A nurse is providing care to a patient who is scheduled for mechanical debridement. What are methods of mechanical debridement? Select all that apply. 1 Autolytic 2 Enzymatic 3 Whirlpool 4 Wound irrigation 5 Wet-to-dry dressings

3, 4, 5 There are four types of debridement: surgical, mechanical, autolytic, and enzymatic. Mechanical debridement has three methods: wet-to-dry dressings, wound irrigation, and whirlpool. Whirlpool is used when minimal debris is present. Wound irrigation involves debriding the wound with high irrigation pressure. Wet-to-dry dressings involve application of open-mesh gauze moistened with normal saline. It is packed on or into a wound surface and allowed to dry. Autolytic and enzymatic are different types of debridement and are not methods of mechanical debridement. Text Reference - p. 183

A nurse is preparing for the discharge of a patient with a pressure ulcer and includes the caregiver in the education. What should the nurse include in the home care instructions? 4 Teach the caregiver the "no touch" technique for changing the dressing

4 It is important to practice the "no touch" technique when changing the dressing to avoid wound contamination.

2. A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Sponge patient with cool water. b. Administer intravenous antibiotics. c. Perform wet-to-dry dressing change. d. Administer acetaminophen (Tylenol).

ANS: B, D, A, C The first action should be to administer the antibiotic because treating the infection that has caused the fever is the most important aspect of fever management. The next priority is to lower the high fever, so the nurse should administer acetaminophen to lower the temperature set point. A cool sponge bath should be done after the acetaminophen is given to lower the temperature further. The wet-to-dry dressing change will not have an immediate impact on the infection or fever and should be done last.

11. Which nursing action will be included when the nurse is doing a wet-to-dry dressing change for a patient's stage III sacral pressure ulcer? a. Administer the ordered PRN oral opioid 30 minutes before the dressing change.

ANS: A Mechanical debridement with wet-to-dry dressings is painful, and patients should receive pain medications before the dressing change begins.

28. A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching? b. The patient's visitors bring in some fresh peaches from home.

ANS: B Fresh, thinned-skin fruits are not permitted in a neutropenic diet because of the risk of bacteria being present. The patient should ambulate in the room rather than the hospital hallway to avoid exposure to other patients or visitors. Because overuse of soap can dry the skin and increase infection risk, showering every other day is acceptable. Careful cleaning after having a bowel movement will help prevent skin breakdown and infection.

15. The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? b. Stop the infusion if swelling is observed at the site.

ANS: B Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication generally should be given slowly to avoid irritation of the vein.

7. The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement, if made by the patient, indicates that teaching was effective? c. "The biopsy will help decide the treatment for my enlarged prostate."

ANS: C A biopsy is used to determine whether the prostate enlargement is benign or malignant, and determines the type of treatment that will be needed. A biopsy does not give information about metastasis, life expectancy, or the impact of cancer on the patient's life.