Cancer & Thermoregulation

The nurse is caring for a client who is receiving asparaginase. The nurse should monitor the client for improvement of which condition? 1. Lung cancer 2. Breast cancer 3. Metastatic prostate cancer 4. Acute lymphocytic leukemia

4. Acute lymphocytic leukemia Asparaginase is indicated for the treatment of acute lymphocytic leukemia. Lung cancer, breast cancer, and metastatic prostate cancer are treated with other antineoplastic agents.

The nurse is caring for a client with a diagnosis of breast cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value? 1. 2000 mm3 (2.0 × 109/L) 2. 5800 mm3 (5.8 × 109/L) 3. 8400 mm3 (8.4 × 109/L) 4. 11,500 mm3 (11.5 × 109/L)

1. 2000 mm3 (2.0 × 109/L) The normal WBC count ranges from 5000 to 10,000 mm3 (5 to 10 × 109/L). The client who has a decrease in the number of circulating WBCs is immunosuppressed. The nurse implements neutropenic precautions when the client's values fall sufficiently below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. The remaining options are normal values.

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

Capecitabine has been prescribed for a client with breast cancer, and the client asks the nurse about the side effects of the medication. The nurse responds that a frequent side effect of this medication is which finding? 1. Diarrhea 2. Weakness 3. Irritability 4. Increased appetite

1. Diarrhea Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. Frequent side effects include diarrhea, nausea, vomiting, stomatitis, hand and foot syndrome (painful palmar-plantar erythema and swelling with paresthesias, tingling, and blistering), fatigue, anorexia, and dermatitis. Weakness, irritability, and increased appetite are not side effects of this medication.

The nurse has admitted a client to the clinical nursing unit after undergoing a right mastectomy. The nurse should plan to place the right arm in which position? 1. Elevated on a pillow 2. Level with the right atrium 3. Dependent to the right atrium 4. Elevated above shoulder level

1. Elevated on a pillow The client's operative arm should be positioned so that it is elevated on a pillow and not exceeding shoulder elevation. This position promotes optimal drainage from the limb, without impairing the circulation to the arm. If the arm is positioned flat (option 2) or dependent (option 3), this could increase the edema in the arm, which is contraindicated because of lymphatic disruption caused by surgery.

A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention should be implemented to alleviate the child's fears? 1. Encourage the child's parents to stay with the child. 2. Encourage play with other children of the same age. 3. Advise the family to visit only during the scheduled visiting hours. 4. Provide a private room, allowing the child to bring favorite toys from home.

1. Encourage the child's parents to stay with the child. Although the preschooler already may be spending some time away from parents at a day-care center or preschool, illness adds a stressor that makes separation more difficult. The child may ask repeatedly when parents will be coming for a visit or may constantly want to call the parents. Options 3 and 4 increase stress related to separation anxiety. Option 2 is unrelated to the subject of the question and, in addition, may not be appropriate for a child who may be immunocompromised and at risk for infection.

A woman has just been told by the primary health care provider that she has breast cancer. The woman responds, "Oh, no! Does this mean I'm going to die?" The nurse interprets the woman's initial reaction as which response? 1. Fear 2. Rage 3. Denial 4. Anxiety

1. Fear The woman's reaction is one of fear. The woman has verbalized the object of fear (dying), which makes anxiety incorrect. There is no evidence of rage or denial in the woman's statement.

A female client with a diagnosis of breast cancer is taking cyclophosphamide. The client calls the health care clinic and tells the nurse that the medication is upsetting her stomach. Which instruction should the nurse provide to the client? 1. Take the medication with food. 2. Avoid drinking fluids while taking the medication. 3. Try to take the medication with a small amount of orange juice. 4. Continue to take the medication on an empty stomach, and lie down after taking the medication.

1. Take the medication with food. Hemorrhagic cystitis is a toxic effect that can occur with the use of this medication. The medication should be taken on an empty stomach, but if the client complains of gastrointestinal (GI) upset, it can be taken with food. The client who is taking cyclophosphamide needs to be instructed to drink copious amounts of fluids during the administration of this medication. Orange juice probably would cause and increase the GI upset. Option 4 will not assist in relieving the discomfort experienced by the client.

A client is having a diagnostic workup for colorectal cancer. Which factors in the client's history place the client at increased risk for this type of cancer? Select all that apply. 1. A high-fiber diet 2. A diet high in fats 3. Minimal alcohol intake 4. A diet high in carbohydrates 5. A history of inflammatory bowel disease 6. A maternal grandfather who had a history of heart disease

2. A diet high in fats 4. A diet high in carbohydrates 5. A history of inflammatory bowel disease A high-fiber diet actually lessens the chances of developing colorectal cancer. This type of cancer most often occurs in populations with diets low in fiber and high in refined carbohydrates, fats, and meats. Other risk factors include a family history of the disease, rectal polyps, and active inflammatory disease of at least 10 years' duration.

The community health nurse is creating a poster for an educational session for a group of women and will be discussing the risk factors associated with breast cancer. Which risk factors for breast cancer should the nurse list on the poster? Select all that apply. 1. Multiparity 2. Early menarche 3. Early menopause 4. Family history of breast cancer 5. High-dose radiation exposure to chest 6. Previous cancer of the breast, uterus, or ovaries

2. Early menarche 4. Family history of breast cancer 5.High-dose radiation exposure to chest 6.Previous cancer of the breast, uterus, or ovaries Risk factors for breast cancer include nulliparity or first child born after age 30 years; early menarche; late menopause; family history of breast cancer; high-dose radiation exposure to the chest; and previous cancer of the breast, uterus, or ovaries. In addition, specific inherited mutations in BReast CAncer (BRCA)1 and BRCA2 increase the risk of female breast cancer; these mutations are also associated with an increased risk for ovarian cancer.

Capecitabine has been prescribed for a client with breast cancer, and the client asks the nurse about the action of the medication. The nurse formulates a response based on which mechanism of action of this medication? 1. Promotes DNA synthesis 2. Interferes with protein synthesis 3. Assists with the processing of RNA 4. Processes enzymes needed for cellular growth

2. Interferes with protein synthesis Capecitabine is an antimetabolite that inhibits enzymes necessary for the synthesis of essential cellular components. It interferes with DNA synthesis, RNA processing, and protein synthesis. Capecitabine does not promote DNA synthesis, assist with the processing of RNA, or process enzymes needed for cellular growth.

The nurse has applied a hypothermia blanket to a client with a fever. The nurse should inspect the skin frequently to detect which condition that is a complication of hypothermia blanket use? 1. Frostbite 2. Skin breakdown 3. Arterial insufficiency 4. Venous insufficiency

2. Skin breakdown When a hypothermia blanket is used, the skin is inspected frequently for pressure points, which over time could lead to skin breakdown. The hypothermia blanket decreases the blood flow to pressure areas and can cause numbness, making it so that the client is not aware of damage to the skin. The temperature of the blanket is not cold enough to cause frostbite. Arterial insufficiency and venous insufficiency are not complications of hypothermia blanket use.

The community health nurse is preparing an educational session for a group of women and will be discussing the primary prevention strategies and treatment measures for breast cancer. What information should the nurse include in the educational session? 1. Older women are more likely to get mammograms. 2. Treatment decisions are based on a woman's overall health. 3. Women younger than age 65 are more likely to get breast cancer. 4. A woman's age is the main factor used to decide which screening methods to use.

2. Treatment decisions are based on a woman's overall health. Breast cancer occurs most often in women who are 65 years of age or older, and older women are less likely to have mammograms. Rather than using the woman's age to decide on screening and treatment measures, the woman's overall health is used to make these determinations, since health status has a greater influence on tolerance to treatment.

A client calls the ambulatory care clinic and tells the nurse that she found an area that looks like the peel of an orange when performing breast self-examination (BSE) but found no other changes. What is the nurse's best response to this client? 1. "Good job performing your BSE. I am sure that is nothing to be concerned about." 2. "Make sure you tell the primary health care provider about your finding at the next regularly scheduled visit." 3. "I am glad you called to report this finding. Can you come to the clinic to see your primary health care provider tomorrow?" 4. "Do you have a thermometer? You need to take your temperature and call back if you have a fever over 101º F (38.3º C)."

3. "I am glad you called to report this finding. Can you come to the clinic to see your primary health care provider tomorrow?" Peau d'orange or orange peel appearance of the skin over the breast is associated with late breast cancer. Therefore, the nurse would arrange for the client to come to the clinic as soon as possible. Peau d'orange is not indicative of an infection.

Capecitabine has been prescribed for a client with breast cancer. The nurse should tell the client that which blood test will be done periodically while the client is taking this medication? 1. Liver function tests 2. Bilirubin level assay 3. Complete blood count (CBC) 4. Triglyceride level determination

3. Complete blood count (CBC) Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. Bone marrow depression can occur from the use of this medication, and a CBC and blood chemistry studies should be done periodically. Liver function tests, bilirubin level assay, and triglyceride levels are unnecessary.

The nurse is analyzing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory value would the nurse specifically note as a result of the massive cell destruction that occurred from the chemotherapy? 1. Anemia 2. Decreased platelets 3. Increased uric acid level 4. Decreased leukocyte count

3. Increased uric acid level Hyperuricemia is especially common following treatment for leukemias and lymphomas, because chemotherapy results in massive cell kill. Although options 1, 2, and 4 also may be noted, an increased uric acid level is related specifically to cell destruction.

A client with colon cancer has received a course of chemotherapy with fluorouracil. The nurse should tell the client to report which finding immediately? 1. Alopecia 2. Headache 3. Stomatitis and diarrhea 4. Changes in color vision

3. Stomatitis and diarrhea Fluorouracil should be discontinued as soon as reactions (stomatitis, diarrhea) occur. Dosage can also be limited by palmar-plantar erythrodysesthesia syndrome (also called hand-foot syndrome), characterized by tingling, burning, redness, flaking, swelling, and blistering of the palms and soles. Alopecia is common and would not require immediate reporting. Headache and vision changes are not associated with fluorouracil.

A female client with carcinoma of the breast is admitted to the hospital for treatment with intravenously administered doxorubicin. The client tells the nurse that she has been told by her friends that she is going to lose all her hair. What is the most appropriate nursing response? 1. "Your friends are correct." 2. "You will not lose your hair." 3. "Hair loss may occur, but it will grow back just as it is now." 4. "Hair loss may occur, and it will grow back, but it may have a different color or texture."

4. "Hair loss may occur, and it will grow back, but it may have a different color or texture." Alopecia (hair loss) can occur after the administration of many antineoplastic medications. Alopecia is reversible, but the new hair growth may have a different color and texture. Therefore, options 1, 2, and 3 are incorrect.

The nurse is reviewing the record of a client who arrives at the primary health care clinic. The nurse notes that the client is taking letrozole. The nurse should suspect that the client has which disorder? 1. Hypothyroidism 2. Diabetes mellitus 3. Chronic kidney disease 4. Advanced breast cancer

4. Advanced breast cancer Letrozole is used in the palliative treatment for advanced breast cancer in the postmenopausal woman with disease progression after treatment with antiestrogen therapy. The conditions in options 1, 2, and 3 are not treated with this medication.

The nurse is caring for a client diagnosed with breast cancer receiving combination chemotherapy. Which nursing intervention is the most appropriate? 1. Give 2 agents from the same medication class. 2. Give 2 agents with like nadirs at the same time. 3. Test the client's knowledge about each agent's nadir. 4. Avoid giving agents with the same nadirs and toxicities at the same time.

4. Avoid giving agents with the same nadirs and toxicities at the same time. Each chemotherapeutic agent has a specific nadir. Chemotherapy agents are usually given in combinations (also called regimens or protocols). The goal of administering combination chemotherapy in cycles or specific sequences is to produce additive or synergistic therapeutic effects. Administering several medications with different mechanisms of action and different onsets of nadirs and toxicities enhances tumor cell destruction while minimizing medication resistance and overlapping toxicities.

The nurse is providing care to a client who has undergone modified right mastectomy for the treatment of breast cancer. Which activity should the nurse incorporate into the plan of care? 1. Keep suction drains fully inflated to provide adequate suction. 2. Perform venipunctures and blood pressures on the operative side only. 3. Inform the client that drains will be removed on the second postoperative day. 4. Maintain head of the bed elevation at 30 degrees with the right arm elevated on a pillow.

4. Maintain head of the bed elevation at 30 degrees with the right arm elevated on a pillow. The client should have the head of the bed elevated at least 30 degrees with the affected arm elevated on a pillow. Keeping the affected arm elevated promotes lymphatic fluid return after removal of lymph nodes and channels. Gentle suction must be maintained on the drain bulb to prevent fluid accumulation at the operative site. With short hospital stays, drainage tubes are usually removed about 1 to 3 weeks after hospital discharge when the client returns for an office visit. All staff must avoid using the affected arm for measuring blood pressure, giving injections, or drawing blood.

The nurse is collecting subjective and objective data from a client and notes that the client is taking capecitabine. The nurse determines that this medication has been prescribed to treat which condition? 1. Hypothyroidism 2. Kidney dysfunction 3. Cushing's syndrome 4. Metastatic breast cancer

4. Metastatic breast cancer Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. It also is used to treat colon cancer. It is not used to treat hypothyroidism, kidney dysfunction, or Cushing's syndrome.

A 27-year-old client is undergoing evaluation of lumps in her breasts. In determining whether the client could have fibrocystic breast disorder, the nurse should ask her whether the breast lumps seem to become more prominent or troublesome at which time? 1. After menses 2. Before menses 3. During menses 4. At any time, regardless of the menstrual cycle

2. Before menses The nurse assesses the client with fibrocystic breast disorder for worsening of symptoms (breast lumps, painful breasts, and possible nipple discharge) before the onset of menses. This is associated with cyclical hormone changes. Therefore, the other options are incorrect.

A client with acute myelocytic leukemia is being treated with busulfan. Which laboratory value would the nurse specifically monitor during treatment with this medication? 1. Clotting time 2. Uric acid level 3. Potassium level 4. Blood glucose level

2. Uric acid level Busulfan can cause an increase in the uric acid level. Hyperuricemia can produce uric acid nephropathy, renal stones, and acute kidney injury. Options 1, 3, and 4 are not specifically related to this medication.

The nurse has a prescription to administer a medication to a client who is experiencing shivering as a result of hyperthermia. Which medication should the nurse anticipate to be prescribed? 1. Buspirone 2. Fluphenazine 3. Chlorpromazine 4. Prochlorperazine

3. Chlorpromazine Chlorpromazine is used to control shivering in hyperthermic states. It is a phenothiazine and has antiemetic and antipsychotic uses, especially when psychosis is accompanied by increased psychomotor activity. Buspirone is an anxiolytic. Prochlorperazine is a phenothiazine that is an antiemetic and antipsychotic. Fluphenazine is a phenothiazine that is used as an antipsychotic.

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. Warming the crib pad 2. Closing the doors to the room 3. Drying the infant with a warm blanket 4. Turning on the overhead radiant warmer

3. Drying the infant with a warm blanket Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation. Hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress, and heat from the newborn's body is transferred to the colder object (direct contact). Warming the crib pad assists in preventing hypothermia by conduction. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface (indirect contact).

The nurse has instructed the client in the correct technique for breast self-examination (BSE). For a portion of the examination, the client will lie down. The nurse should teach the client to put the pillow in which location for self-examination of the right breast? 1. Under the left scapula 2. Under the left shoulder 3. Under the right shoulder 4. Under the small of the back

3. Under the right shoulder The nurse would instruct the client to lie down and place a towel or pillow under the shoulder on the side of the breast to be examined. If the right breast is to be examined, the pillow would be placed under the right shoulder and vice versa. Therefore, options 1, 2, and 4 are incorrect.

The nurse has provided teaching for an adult client about screening for colon cancer. Which statement by the client indicates that education was effective? 1. "I should have an annual fecal occult blood test." 2. "I should have an annual colonoscopy when I become 60." 3. "I will have a colonoscopy before the fecal occult blood test." 4. "I will not need to have further fecal occult blood tests after a colonoscopy."

1. "I should have an annual fecal occult blood test." Fecal occult blood testing for colorectal cancer should be done annually for both men and women. Less invasive diagnostic testing such as a fecal occult blood test will be performed first. Colonoscopy is done at age 50 and then every 10 years.

The nurse has provided discharge instructions to a client who underwent a right mastectomy with axillary lymph node dissection. Which statement made by the client indicates a need for further instruction regarding home care measures? 1. "It is all right to use a straight razor to shave under my arms." 2."I must be sure to use thick potholders when I am cooking." 3. "I must be sure not to have blood pressures taken or blood drawn from my right arm." 4. "I should inform all of my other health care providers that I have had this surgical procedure."

1. "It is all right to use a straight razor to shave under my arms." After mastectomy with axillary lymph node dissection, the client is at risk for arm edema and infection. The client should be instructed regarding home care measures to prevent these complications. The client should be told to avoid activities such as carrying heavy objects or having blood pressure measurements taken on the affected arm. The client also should be instructed in the techniques to avoid trauma to the affected arm, such as using an electric razor to shave under the arms, using gloves when working in the garden, and using or wearing thick potholders when cooking.

A client who is receiving chemotherapy for breast cancer develops myelosuppression. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply. 1. Avoid contact sports. 2. Wash hands frequently. 3. Increase intake of fresh fruits and vegetables. 4. Avoid crowded places such as shopping malls. 5. Treat a sore throat with over-the-counter products. 6. Avoid people who have received live attenuated vaccines.

1. Avoid contact sports. 2. Wash hands frequently. 4. Avoid crowded places such as shopping malls. 6. Avoid people who have received live attenuated vaccines. Effective measures should be used to protect the client from infection and bleeding. A variety of interventions are essential to keep the client who is receiving chemotherapy safe. Live attenuated vaccines can easily infect clients with myelosuppression, and crowded places usually have people who are sick and coughing and sneezing, which can easily cause illness in myelosuppressed clients. Contact sports can result in injury or bleeding, and hand washing is the mainstay of asepsis and protection from infection. The client with myelosuppression should not eat fresh fruits and vegetables because of the risk of contamination or infection. All foods should be thoroughly cooked. Option 5 is incorrect because many over-the-counter products contain acetaminophen or aspirin, which could potentially mask an elevated temperature. Additionally, aspirin is an antiplatelet and can cause bleeding. Clients receiving chemotherapy should not take any other medications without direction from the primary health care provider.

A client admitted to the hospital is taking capecitabine for breast cancer. The nurse should monitor the client for which symptom that is a side or adverse effect of the medication? 1. Dyspnea 2. Dizziness 3. Headache 4. Constipation

1. Dyspnea Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. Adverse effects include bone marrow depression, cardiovascular toxicity, and respiratory toxicity. Headache, constipation, and dizziness are not adverse effects of this medication.

A client who has been diagnosed with breast cancer is to receive chemotherapy with both cisplatin and vincristine. The client asks the nurse why both medications must be given together. The nurse should explain to the client that the combination of 2 chemotherapeutic medications is used for which reason? 1. Increase the destruction of tumor cells. 2. Prevent the destruction of normal cells. 3. Decrease the risk of the alopecia and stomatitis. 4. Increase the likelihood of erythrocyte and leukocyte recovery.

1. Increase the destruction of tumor cells. Cisplatin is an alkylatinglike medication, and vincristine is a vinca alkaloid. Alkylating medications are cell-cycle nonspecific. Vinca alkaloids are cell-cycle specific and act on the M phase. Single-agent medication therapy seldom is used. Combinations of medications are used to increase the destruction of tumor cells.

A client with a medical diagnosis of breast cancer is undergoing chemotherapy. The client complains to the nurse about losing her hair and severe fatigue from the treatment. Which interventions should the nurse implement for this client? Select all that apply. 1. Review side effects of chemotherapy and treatment with the client. 2. Teach the client how to resolve specific concerns of her personal life. 3. Teach the client to pace activities with rest so as to maintain strength. 4. Offer information on available counseling services and support groups. 5. Tell the client about some other clients who have had breast cancer treatment. 6. Inquire how the cancer diagnosis and treatment affect the client's normal routine.

1. Review side effects of chemotherapy and treatment with the client. 3. Teach the client to pace activities with rest so as to maintain strength. 4. Offer information on available counseling services and support groups. 6. Inquire how the cancer diagnosis and treatment affect the client's normal routine. It is not therapeutic nor is it the nurse's role to teach the client how to resolve specific concerns of her personal life. The nurse should determine how the cancer diagnosis and treatment are affecting the client's normal routine, and the client should be aware of potential side effects of treatment so as to cope with the events with medications or other measures. It is important for the nurse to inform clients about support groups available (e.g., Reach for Recovery) so the client does not feel isolated. Teaching clients to pace activities even when they feel well will conserve energy so they ultimately feel stronger and less fatigued. It is a breach of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA) laws for the nurse to discuss other clients and their medical problems.

The nurse is caring for a client on the oncology unit who has developed stomatitis during chemotherapy for treatment of breast cancer. The nurse should plan which measure to treat this complication? 1. Rinse the mouth with diluted baking soda or saline. 2. Use lemon and glycerin swabs liberally on painful oral lesions. 3. Brush the teeth and use non-waxed dental floss at least twice a day. 4. Place the client on NPO (nothing by mouth) status for 12 hours, and then resume liquids.

1. Rinse the mouth with diluted baking soda or saline. Stomatitis, or mouth ulcerations, occurs with the administration of many antineoplastic medications. The client's mouth should be examined daily for signs of ulceration. If stomatitis occurs, the client should be instructed to rinse the mouth with baking soda or saline. Lemon and glycerin swabs may cause pain and further irritation. The client should avoid brushing the teeth and flossing when stomatitis is severe. Food and fluids are important and should not be restricted. If chewing and swallowing are painful, the client may switch to a liquid diet. Instruct the client to avoid spicy foods and foods with hard crusts or edges.

The nurse is monitoring the intravenous (IV) infusion of an antineoplastic medication to treat breast cancer. During the infusion, the client complains of pain at the insertion site. On inspection of the site, the nurse notes redness and swelling and that the infusion of the medication has slowed in rate. The nurse suspects extravasation and should take which actions? Select all that apply. 1. Stop the infusion. 2. Prepare to apply ice or heat to the site. 3. Notify the primary health care provider (PHCP). 4. Restart the IV at a distal part of the same vein. 5. Prepare to administer a prescribed antidote into the site. 6. Increase the flow rate of the solution to flush the skin and subcutaneous tissue.

1. Stop the infusion. 2. Prepare to apply ice or heat to the site. 3. Notify the primary health care provider (PHCP). 5. Prepare to administer a prescribed antidote into the site. Redness and swelling and a slowed infusion indicate signs of extravasation. If the nurse suspects extravasation during the IV administration of an antineoplastic medication, the infusion is stopped and the PHCP is notified. Ice or heat may be prescribed for application to the site and an antidote may be prescribed to be administered into the site. Increasing the flow rate can increase damage to the tissues. Restarting an IV in the same vein can increase damage to the site and vein.

The home health care nurse is visiting a client who has undergone a mastectomy. The nurse determines that the client demonstrates greatest adjustment to the loss of the breast if which behavior is noted? 1. The client looks at the surgical site. 2. The client performs the prescribed arm exercises. 3. The client takes the pain medication as prescribed. 4. The client has read all of the postoperative materials provided by the hospital nurse.

1. The client looks at the surgical site. Of the options provided, the client behavior in the correct option demonstrates the greatest adaptation or adjustment (looking at the surgical site). This indicates that the client has acknowledged and is beginning to cope with the loss of the breast. Reading postoperative care booklets and performing prescribed exercises indicate an interest in self-care and are positive signs indicating adjustment. Taking pain medication is not related to adjustment to the loss of the breast.

The nurse is developing a plan of care for an older client that addresses interventions to prevent cold discomfort and the development of accidental hypothermia. The nurse should document which desired outcome in the plan of care? 1. The client's fingers and toes are warm to touch. 2.The client's body temperature is 98º F (36.7º C). 3. The client remains in a fetal position when in bed. 4. The client complains of coolness in the hands and feet only.

1. The client's fingers and toes are warm to touch. Desired outcomes for nursing interventions to prevent cold discomfort and the development of accidental hypothermia include the following: hands and limbs are warm; body is relaxed and not curled; body temperature is greater than 97º F (36.1º C); the client is not shivering; and the client has no complaints of feeling cold.

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. The passage of flatus 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 drainage is not expected from a colostomy.

Capecitabine has been prescribed for a client with breast cancer, and the nurse provides instructions to the client about the medication. Which statement by the client indicates the need for further instruction? 1. "I need to monitor my temperature." 2. "I need to be sure to go to the clinic to receive my yearly flu vaccine." 3. "I may have some diarrhea, but if it becomes severe, I will call my health care provider." 4. "It's important for me to contact my primary health care provider if I have any fever or other signs of infection."

2. "I need to be sure to go to the clinic to receive my yearly flu vaccine." Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. Adverse effects include bone marrow depression, cardiovascular toxicity, and respiratory toxicity. The client is instructed to obtain primary health care provider (PHCP) approval before receiving immunizations because the medication lowers the body's resistance to infection. Diarrhea is a frequent side effect of this medication, but the client should contact the PHCP if it becomes severe. The client should monitor his or her temperature and call the PHCP for severe diarrhea or for a fever or other sign of infection.

The nurse is reviewing the preoperative prescriptions for a client with a colon tumor who is scheduled for abdominal perineal resection and notes that the primary health care provider has prescribed neomycin for the client. After discussing a prescription for neomycin with the nursing student who is caring for the client, the nurse determines that the student understands the rationale for administration if which statement is made? 1. "The client is allergic to penicillin." 2. "It will help to decrease the bacteria in the bowel." 3. "It is given to prevent an immune dysfunction postoperatively." 4. "It is given because the client has an infection that must be treated prior to surgery."

2. "It will help to decrease the bacteria in the bowel." To reduce the risk of contamination at the time of surgery, the surgeon may prescribe that the bowel is emptied and cleansed. Laxatives and enemas may be prescribed to empty the bowel. An intestinal anti-infective such as neomycin may also be prescribed to decrease the bacteria in the bowel. There are no data in the question that indicate that the client has an infection or is allergic to penicillin. The medication does not prevent immune dysfunction.

The nurse is caring for a client with leukemia. In assessing the client for signs of leukemia, the nurse determines that what should be monitored? 1. Platelet count 2. Bone marrow biopsy 3. White blood cell count 4. Complete blood cell count

2. Bone marrow biopsy Bone marrow aspiration or biopsy allows examination of blast cells and other hypercellular activity. Blood studies will not provide a definitive diagnosis of leukemia.

A client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which laboratory value while the client is taking this medication? 1. Glucose level 2. Calcium level 3. Potassium level 4. Prothrombin time

2. Calcium level Tamoxifen may increase calcium, cholesterol, and triglyceride levels. Before the initiation of therapy, a complete blood count, platelet count, and serum calcium level should be assessed. These blood levels, along with cholesterol and triglyceride levels, should be monitored periodically during therapy. The nurse should assess for hypercalcemia while the client is taking this medication. Signs of hypercalcemia include increased urine volume, excessive thirst, nausea, vomiting, constipation, hypotonicity of muscles, and deep bone and flank pain.

A client arrives at the postpartum unit after delivery of her infant. On performing an assessment, the nurse notes that the client is shaking uncontrollably. Which nursing action is appropriate? 1. Massage the fundus. 2. Cover the client with a warm blanket. 3. Place the client in Trendelenburg's position. 4. Contact the primary health care provider (PHCP).

2. Cover the client with a warm blanket. In the postpartum period, a woman may experience a shaking, uncontrollable chill immediately after birth. The exact cause of this fairly common event is not known; however, it is thought to be associated with a nervous system reaction such as a vasovagal response. If the chill is not associated with an elevated temperature, it is of no clinical significance. The appropriate nursing action is to provide a warm blanket to the client and a warm drink if oral intake is not contraindicated.

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. Elevating the affected arm on a pillow above heart level 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.

The client with breast cancer has been given a prescription for cyclophosphamide. The nurse determines that the client understands the proper use of the medication if the client states to take which measure? 1. Increase dietary intake of potassium. 2. Increase fluid intake to 2 to 3 L/day. 3. Take the medication with large meals. 4. Decrease dietary intake of magnesium.

2. Increase fluid intake to 2 to 3 L/day. An adverse effect of cyclophosphamide is hemorrhagic cystitis. The client should drink large amounts of fluid during the administration of this medication. Clients also should observe for hematuria. The medication should be taken on an empty stomach, unless gastrointestinal upset occurs. Hyperkalemia can result from the use of the medication; therefore, the client would not be encouraged to increase potassium intake. The client would not be instructed to alter magnesium intake.

The nurse is providing medication instructions to a client with breast cancer who is receiving cyclophosphamide. The nurse should tell the client to take which action? 1. Take the medication with food. 2. Increase fluid intake to 2000 to 3000 mL daily. 3. Decrease sodium intake while taking the medication. 4.Increase potassium intake while taking the medication.

2. Increase fluid intake to 2000 to 3000 mL daily. Hemorrhagic cystitis is an adverse effect that can occur with the use of cyclophosphamide. The client needs to be instructed to drink copious amounts of fluid during the administration of this medication. Clients also should monitor urine output for hematuria. The medication should be taken on an empty stomach, unless gastrointestinal upset occurs. Hyperkalemia can result from the use of the medication; therefore, the client would not be told to increase potassium intake. The client would not be interm-15structed to alter sodium intake.

The nurse is reviewing the laboratory test results for a client with a diagnosis of leukemia. The nurse notes that the granulocyte count is decreased. The nurse interprets that the client is at risk for which condition? 1. Anemia 2. Infection 3. Bleeding 4. Dehydration

2. Infection Granulocytes are blood cells that destroy bacteria. When granulocytes are decreased from normal, the risk of infection increases significantly. A decreased granulocyte count is not associated with anemia, bleeding, or dehydration.

The nurse is caring for a client with leukemia who is receiving intravenous chemotherapy. The nurse reviews the laboratory results and notes that the white blood cell count is 2000 mm3 (2 × 109/L), the platelet count is 150,000 mm3 (150 × 109/L), the clotting time is 10 minutes, and the ammonia level is 20 mcg/dL (12 mcmol/L). Which nursing action would be appropriate? 1. Place the client on bleeding precautions. 2. Place the client on neutropenic precautions. 3. Remove the rectal thermometer from the client's room. 4. Instruct the dietary department to eliminate all proteins from the client's diet.

2. Place the client on neutropenic precautions. The normal white blood cell count is 5000 to 10,000 mm3 (5 to 10 × 109/L). When the white blood cell count drops, neutropenic precautions need to be implemented. This includes protective isolation techniques to protect the client from infection. Bleeding precautions need to be initiated when the platelet count drops below 90,000 to 100,000 mm3 (90 to 100 × 109/L) or per primary health care provider prescription or agency policy. The normal platelet count is 150,000 to 400,000 mm3 (150 to 400 × 109/L). The normal clotting time is 8 to 15 minutes, and the normal ammonia level is 10 to 80 mcg/dL (6 to 47 mcmol/L). Removing the rectal thermometer from the client's room would be done if bleeding precautions were initiated. There is no useful reason to eliminate all protein from the diet.

The nurse is reviewing the laboratory test results for a client with a diagnosis of leukemia who is receiving chemotherapy. The nurse notes that the client's platelet count is 20,000 mm3 (200 × 109/L). The nurse should prepare to implement which action based on this finding? 1. Remove the fresh flowers from the client's room. 2. Remove the rectal thermometer from the client's room. 3. Instruct family members to wear a mask when entering the client's room. 4. Call the dietary department to report that the client will be on a low-bacteria diet.

2. Remove the rectal thermometer from the client's room. When the client's platelet count is low, the client is at risk for bleeding. Options 1, 3, and 4 relate to the risk for infection. Rectal temperatures should not be taken on a client who is at risk for bleeding because the thermometer could cause an alteration in the delicate rectal membranes and lead to bleeding.

Tamoxifen citrate is prescribed for a client with metastatic breast carcinoma. The client asks the nurse if her family member with bladder cancer can also take this medication. The nurse most appropriately responds by making which statement? 1. "This medication can be used only to treat breast cancer." 2. "Yes, your family member can take this medication for bladder cancer as well." 3. "This medication can be taken to prevent and treat clients with breast cancer." 4. "This medication can be taken by anyone with cancer as long as their health care provider approves it."

3. "This medication can be taken to prevent and treat clients with breast cancer." Tamoxifen is an antineoplastic medication that competes with estradiol for binding to estrogen in tissues containing high concentrations of receptors. Tamoxifen is used to treat metastatic breast carcinoma in women and men. Tamoxifen is also effective in delaying the recurrence of cancer following mastectomy and for preventing breast cancer in those that are at high risk.

A clinic nurse prepares a teaching plan for a client receiving an antineoplastic medication to treat breast cancer. When implementing the plan, the nurse should make which statement to the client? 1. "You can take aspirin as needed for headache." 2. "You can drink beverages containing alcohol in moderate amounts each evening." 3. "You need to consult with the primary health care provider (PHCP) before receiving immunizations." 4. "It is fine to receive a flu vaccine at the local health fair without PHCP approval because the flu is so contagious."

3. "You need to consult with the primary health care provider (PHCP) before receiving immunizations." Because antineoplastic medications lower the resistance of the body, clients must be informed not to receive immunizations without the PHCP's approval. Clients also need to avoid contact with individuals who have recently received a live virus vaccine. Clients need to avoid aspirin and aspirin-containing products to minimize the risk of bleeding, and they need to avoid alcohol to minimize the risk of toxicity and side/adverse effects.

The nurse is monitoring a client with leukemia who is receiving doxorubicin by intravenous infusion. The nurse should monitor for which finding that would indicate doxorubicin toxicity? 1. Elevated creatinine 2. Red coloration in the urine 3. Electrocardiogram (ECG) changes 4. Elevated blood urea nitrogen (BUN)

3. Electrocardiogram (ECG) changes Cardiotoxicity can occur with the use of doxorubicin. The medication can produce irreversible toxicity to the heart, including ECG changes and heart failure. Elevated values on renal function tests are not associated with the use of this medication. A red coloration of the urine may occur with the use of this medication, but this effect is harmless.

The nurse is reviewing the laboratory results for a client with a diagnosis of leukemia and notes that the absolute neutrophil count is decreased. The nurse interprets this to mean that the client is at risk for which problem? 1. Anemia 2. Bleeding 3. Infection 4. Dehydration

3. Infection Neutrophils arise from stem cells and complete the maturation process in the bone marrow. They belong to a class of leukocytes known as granulocytes because of the large number of granules present inside each cell. Neutrophils provide the first internal line of defense, via phagocytosis, against foreign invaders (especially bacteria) in blood and extracellular fluid. If the neutrophil count is low, the client is at risk for infection. The remaining options are not associated with the function of neutrophils.

The nurse is monitoring a client with acute lymphocytic leukemia for toxic effects of asparaginase. The nurse should notify the primary health care provider if monitoring reveals which finding? 1. Alopecia 2. Oral ulcerations 3. Prolonged blood clotting times 4. Decreased white blood cell count

3. Prolonged blood clotting times Asparaginase can cause severe adverse effects; however, they often are different from those of other antineoplastic medications. By inhibiting protein synthesis, the medication can cause coagulation deficiencies and injury to the liver, pancreas, and kidneys. Signs and symptoms of central nervous system depression ranging from confusion to coma can occur. Nausea and vomiting can be intense and may limit the dose that can be tolerated. In contrast with most antineoplastic medications, asparaginase does not depress the bone marrow, nor does it cause alopecia, oral ulceration, or intestinal ulceration.

The clinic nurse prepares instructions for a client diagnosed with leukemia who developed stomatitis after the administration of a course of antineoplastic medications. The nurse should provide the client with which instruction? 1. Avoid foods and fluids for the next 12 to 24 hours. 2. Swab the mouth with lemon and glycerin 4 times a day. 3. Rinse the mouth with a diluted solution of baking soda or saline. 4. Brush the teeth with a stiff-bristled toothbrush, and use dental floss 3 times a day.

3. Rinse the mouth with a diluted solution of baking soda or saline. Stomatitis (ulceration in the mouth) can result from the administration of antineoplastic medications. The client should be instructed to examine the mouth daily and report any signs of ulceration. If stomatitis occurs, the client should be instructed to rinse the mouth with a diluted solution of baking soda or saline. Food and fluid are important and should not be restricted. If chewing and swallowing are painful, the client may switch to a liquid diet that includes milkshakes and ice cream. Instruct the client to avoid spicy foods and foods with hard crusts or edges. Lemon and glycerin swabs may cause pain and further irritation. The client should avoid brushing the teeth, particularly with a stiff-bristled toothbrush, and flossing when stomatitis is severe.

The nurse in the primary health care provider's office is performing a postoperative assessment of a client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. The nurse should provide which information to the client about her complaint? 1. These sensations are signs of a complication. 2.These sensations probably will be permanent. 3. These sensations dissipate over several months and usually resolve after 1 year. 4. It is nothing to worry about because most women who have this type of surgery experience this problem.

3. These sensations dissipate over several months and usually resolve after 1 year. Numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow occurs in most women after mastectomy. It is a result of injury to the nerves that provide sensation to the skin in those areas. These sensations may be described as heaviness, pain, tingling, burning, or "pins and needles." These sensations dissipate over several months and usually resolve by 1 year after surgery. These sensations are not a sign of a complication and are not permanent. The nurse would not tell the client that a complaint is nothing to worry about because this is nontherapeutic and avoids the client's concern.

The nurse is giving client instructions over the telephone about preparing for a mammography. The nurse should make which statement to the client? 1. "Wear metal jewelry as desired." 2. "Consume clear liquids only on the day of the test." 3. "Use only lanolin-based skin lotions on the day of the test." 4. "If possible, avoid using underarm deodorant on the day of the test."

4. "If possible, avoid using underarm deodorant on the day of the test." The client should avoid the use of lotions or underarm deodorant on the day of mammography because this can affect breast and axilla positioning and obtaining clear mammography pictures. At the mammography suite, the client may also be asked to clean the underarms with the provided wipes. Mammography is a type of radiographic procedure. Therefore, the client is advised not to wear jewelry or metal objects on the day of the test. No special dietary preparation is needed.

A new registered nurse (RN) is assisting the RN in admitting a client who has a diagnosis of hypothermia. The RN provides education to the new RN on anticipated vital signs in the client with hypothermia. Which statement by the new RN indicates that the teaching has been effective? 1. "The client will likely exhibit increased heart rate and increased blood pressure." 2. "The client will likely exhibit increased heart rate and decreased blood pressure." 3. "The client will likely exhibit decreased heart rate and increased blood pressure." 4. "The client will likely exhibit decreased heart rate and decreased blood pressure."

4. "The client will likely exhibit decreased heart rate and decreased blood pressure." The heart rate and blood pressure are decreased because the metabolic needs of the body are reduced with hypothermia. With fewer metabolic needs, the workload of the heart decreases. Therefore, the vital sign changes in the remaining options are incorrect.

The primary health care provider (PHCP) writes a prescription for capecitabine for a client with breast cancer who was admitted to the hospital. The nurse should contact the PHCP to verify the prescription if which condition is noted in the assessment data? 1. Myalgia 2. Psoriasis 3. Rheumatoid arthritis 4. Chronic kidney disease

4. Chronic kidney disease Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. A contraindication to the use of this medication is severe renal impairment such as that which occurs in chronic kidney disease. Myalgia, psoriasis, and rheumatoid arthritis are not contraindications to this medication.

A new registered nurse (RN) is assigned to the care of a client hospitalized with a diagnosis of hypothermia. After consulting with an experienced RN, which statement by the new RN indicates understanding of likely assessment findings for this client? 1. Increased heart rate and increased blood pressure 2. Increased heart rate and decreased blood pressure 3. Decreased heart rate and increased blood pressure 4. Decreased heart rate and decreased blood pressure

4. Decreased heart rate and decreased blood pressure Hypothermia decreases the heart rate and the blood pressure because the metabolic needs of the body are reduced in this condition. With fewer metabolic needs, the workload of the heart decreases, resulting in decreased heart rate and blood pressure. Therefore, the remaining options are incorrect.

The nurse is performing an admission assessment of a client with a possible right colon tumor. Which sign or symptom should the nurse anticipate the client may report? 1. Frequent diarrhea 2. Crampy gas pains 3. Flat, ribbon-like stools 4. Dull abdominal pain exacerbated by walking

4. Dull abdominal pain exacerbated by walking Characteristic symptoms of right colon tumors include vague, dull, abdominal pain exacerbated by walking and dark red- or mahogany-colored blood mixed in the stool. The symptoms described in the other options are associated with left colon tumors.

A just-delivered newborn is dried immediately by the nurse in the delivery area. The nurse thoroughly dries the newborn to prevent heat loss by which mechanism? 1. Radiation 2. Convection 3. Conduction 4. Evaporation

4. Evaporation The newborn can lose heat through radiation, convection, conduction, and evaporation. Heat is lost through the process of evaporation when the newborn is not dried thoroughly. Drying the infant's head assists with heat retention by preventing the mechanism of evaporation. Heat loss from radiation occurs when heat from the body surface radiates to the surrounding environment. In convection, air moving across the infant's skin transfers heat to the air. In conduction, heat loss occurs when the infant is on a cold surface, such as a table. Placing a warm blanket on the table assists with preserving body temperature. Warming room air relates to the heat loss mechanism of conduction.

The nurse tells a client with leukemia who is receiving chemotherapy that allopurinol has been added to the medication list. When the client asks the purpose of the new medication, the nurse responds that the allopurinol is intended to prevent which problem? 1. Nausea 2. Diarrhea 3. Muscle spasms 4. Hyperuricemia

4. Hyperuricemia Chemotherapy destroys cells, leading to the release of uric acid into the bloodstream. The client is then at risk of experiencing uric acid nephropathy, renal stones, and acute kidney injury. Allopurinol, an antigout medication, is used with chemotherapy to prevent or treat this complication of therapy. It also may be used in mouthwash following fluorouracil therapy to prevent stomatitis. Allopurinol is not used to treat nausea, diarrhea, or muscle spasms.

The nurse is caring for an unconscious client who is experiencing persistent hyperthermia with no signs of infection. On the basis of these findings the nurse suspects dysfunction in which area of the brain? 1. Cerebrum 2. Cerebellum 3. Hippocampus 4. Hypothalamus

4. Hypothalamus Hypothalamic damage causes persistent hyperthermia, which also may be called central fever. It is characterized by a persistent high fever with no diurnal variation. Another characteristic feature is absence of sweating. Hyperthermia would not result from damage to the cerebrum, cerebellum, or hippocampus.

The nurse is monitoring a client with chronic lymphocytic leukemia (CLL). Which sign should the nurse specifically monitor for and report to the primary health care provider? 1. Anemia 2. Bleeding 3. Pancytopenia 4. Lymphadenopathy

4. Lymphadenopathy CLL causes a slow increase in immature B cells. These cells infiltrate the bone marrow, lymph nodes, spleen, and liver. CLL eventually causes bone marrow failure; therefore, the client will have enlarged and swollen lymph nodes. Options 1 and 2 are clinical manifestations of acute leukemias. Option 3 is a clinical manifestation of hairy cell leukemia.

The nurse is caring for a client with metastatic breast cancer. The client describes a new and sudden sharp pain in the back. Based on this assessment finding, which is the priority nursing intervention? 1. Document the findings. 2. Administer pain medication. 3. Place a heating pad on the client's back. 4. Notify the primary health care provider (PHCP).

4. Notify the primary health care provider (PHCP). Spinal cord compression should be suspected in a client with metastatic disease, particularly with sudden onset of new back pain. Spinal cord compression causes back pain before neurological changes occur. Spinal cord compression constitutes an oncological emergency, so the PHCP should be notified. Although the nurse would document this finding, this is not the priority action. The nurse would not administer pain medication or place a heating pad on the client unless the cause of the new pain has been determined. In addition, a prescription from the PHCP is needed for the use of a heating pad.

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. One week after menstruation begins

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

The client has undergone mastectomy. The nurse determines that the client is making the best adjustment to the loss of the breast if which behavior is observed? 1. Refusing to look at the wound 2. Reading the postoperative care booklet 3. Asking for pain medication when needed 4. Participating in the care of the surgical drain

4. Participating in the care of the surgical drain The client demonstrates the best adaptation by participating in her own care. This would include care of surgical drains that are in place for a short time after discharge. Refusing to look at the wound indicates no adaptation to the loss. Reading the postoperative care booklet is useful but is not the best of the options presented here. Asking for pain medication is an action-oriented option, but it does not relate to acceptance of the loss of the breast.

The home care nurse visits a client who has just returned home from the hospital after a mastectomy with a suction drain in place. Which observed client behavior requires a need for further teaching? 1. Empties the drain to prevent infection 2. Elevates the arm when lying and sitting 3. Applies lotion to the area after the incision heals 4. Performs full range-of-motion exercises to the upper arm

4. Performs full range-of-motion exercises to the upper arm The client should be instructed to limit upper arm range-of-motion exercises to the level of the shoulder only. Once the suction drain has been removed, the client can begin full range-of-motion exercises to the upper arm as prescribed. The client should elevate the arm while sitting down or lying, and the client will be able to apply lotion to the incision once it has healed. The drain is emptied as needed.

The nurse is participating in a health screening clinic and is preparing teaching materials about colorectal cancer. Which risk factor for colorectal cancer should the nurse include? 1. High-fiber, low-fat diet 2.Age older than 30 years 3. Distant relative with colorectal cancer 4. Personal history of ulcerative colitis or gastrointestinal polyps

4. Personal history of ulcerative colitis or gastrointestinal polyps Common risk factors for colorectal cancer include age older than 40 years; first-degree relative with colorectal cancer; high-fat, low-fiber diet; and history of bowel problems, such as ulcerative colitis or familial polyposis.

To prevent heat loss by conduction during physical examination of a newborn infant, which action should the nurse implement? 1. Dry the newborn's head thoroughly. 2. Turn the thermostat in the room to 70º F. 3. Place the newborn near the nursery window. 4. Place a warm blanket on the examining table before placing the newborn on the table.

4. Place a warm blanket on the examining table before placing the newborn on the table. Heat loss occurs by four different mechanisms. In conduction, heat loss occurs when the infant is on a cold surface, such as a table. Placing a warm blanket on the table assists with preserving body temperature. Drying the infant's head assists with heat retention by preventing the mechanism of evaporation. Warming room air relates to the heat loss mechanism of conduction. Heat loss from radiation occurs when heat from the body surface radiates to the surrounding environment. In convection, air moving across the infant's skin transfers heat to the air.