Lacharity Chapter 2: Cancer

8. For a patient who is experiencing side effects of radiation therapy, which task would be the most appropriate to delegate to the UAP? 1. Helping the patient to identify patterns of fatigue 2. Recommending participation in a walking program 3. Reporting the amount and type of food consumed from the tray 4. Checking the skin for redness and irritation after the treatment

3. The UAP can observe the amount that the patient eats (or what is gone from the tray) and report to the nurse. Assessing patterns of fatigue and skin reaction is the responsibility of the RN. The initial recommendation for exercise should come from the physician.

16. Which members of the health care team (advanced practice nurse, MD, RN, LPN/LVN) should perform the tasks related to care of patients who are at risk for breast cancer? (There may be more than one professional who could complete the task.) 1. Perform the clinical breast examination. _________________________________________ 2. Teach about breast self-examination. _________________________________________ 3. Make a nursing diagnosis based on the assessment data. _________________________________________ 4. Assess the patient's belief about and use of complementary and alternative therapies. _________________________________________ 5. Reinforce the importance of a baseline screening mammogram starting at age 40. _________________________________________ 6. Explain the results of the mammogram to the patient. _________________________________________

1. Advanced practice nurse, MD, 2. Advanced practice nurse, MD, RN, 3. Advanced practice nurse, RN, 4. Advanced practice nurse, MD, RN, 5. Advanced practice nurse, MD, RN, LPN/LVN, 6. MD Advanced practice nurses could do any of the tasks; however, explaining results of a mammogram may be handled by the supervising physician, especially if complex follow-up is needed (e.g., surgery). Physicians could do any of the tasks except they do not make nursing diagnoses. RNs could do tasks 2, 3, 4, and 5 but usually do not do clinical breast examination, unless specially trained, and do not interpret results of diagnostic tests for patients. LPNs/LVNs could reinforce standard information about screening recommendations. The RN should make the nursing diagnoses, and the LPN/LVN assists in planning and implementing the interventions.

14. You are monitoring your patient who is at risk for spinal cord compression related to tumor growth. Which patient statement is most likely to suggest an early manifestation? 1. "Last night my back really hurt, and I had trouble sleeping." 2. "My leg has been giving out when I try to stand." 3. "My bowels are just not moving like they usually do." 4. "When I try to pass urine, I have difficulty starting the stream."

1. Back pain is an early sign of spinal cord compression occurring in 95% of patients. The other symptoms are later signs.

12. When staff assignments are made for the care of patients who are receiving chemotherapy, what is the major consideration regarding chemotherapeutic drugs? 1. During preparation, drugs may be absorbed through the skin or inhaled. 2. Many chemotherapeutic drugs are vesicants. 3. Chemotherapeutic drugs are frequently given through central venous access devices. 4. Oral and venous routes of administration are the most common.

1. Chemotherapy drugs should be given by nurses who have received additional training in how to safely prepare and deliver the drugs and protect themselves and others from exposure. The other options express concerns, but the general principles of drug administration apply.

25. You are providing end-of-life-care for a patient with terminal liver cancer. The patient is weak and restless. Her skin is cool and mottled. Dyspnea develops and the patient appears anxious and frightened. What should you do? 1. Obtain an order for morphine elixir. 2. Alert the rapid response team and call the physician for orders. 3. Deliver breaths at 20/min with a bag-valve mask and prepare for intubation. 4. Sit quietly with the patient and offer emotional support and comfort.

1. Morphine elixir is the therapy of choice because it is thought to reduce anxiety and the subjective sensation of air hunger. It also increases venous capacitance.End-of-life-care should not include aggressive measures such as intubation or resuscitation. Support and comfort are always welcome, but in this case you should not sit quietly because there is an option that would offer some physical relief for the patient.

6. A community health center is preparing a presentation on the prevention and detection of cancer. Which health care professional (RN, LPN/LVN, nurse practitioner,nutritionist) should be assigned responsibility for the following tasks? 1. Explain screening examinations and diagnostic testing for common cancers. ___________________________ 2. Discuss how to plan a balanced diet and reduce fats and preservatives. ___________________________ 3. Prepare a poster on the seven warning signs of cancer. ___________________________ 4. Discuss how to perform breast or testicular self-examinations. ___________________________ 5. Describe strategies for reducing risk factors such as smoking and obesity. ___________________________

1. Nurse practitioner, 2. Nutritionist, 3. LPN/LVN, 4. Nurse practitioner, 5. RN The nurse practitioner is often the provider who performs the physical examinations and recommends diagnostic testing. The nutritionist can give information about diet. The LPN/LVN will know the standard seven warning signs and can educate through standard teaching programs. The RN has primary responsibility for educating people about risk factors.

1. You are caring for a patient with esophageal cancer. Which task could be delegated to a UAP? 1. Assisting the patient with oral hygiene 2. Observing the patient's response to feedings 3. Facilitating expression of grief or anxiety 4. Initiating daily weighings

1. Oral hygiene is within the scope of duties of the UAP. It is the responsibility of the nurse to observe response to treatments and to help the patient deal with loss or anxiety. The UAP can be directed to weigh the patient but should not be expected to know when to initiate that measurement.

3. Which patient is at greatest risk for pancreatic cancer? 1. An elderly African-American man who smokes 2. A young white obese woman with gallbladder disease 3. A young African-American man with type 1 diabetes 4. An elderly white woman who has pancreatitis

1. Pancreatic cancer is more common in African-Americans, males, and smokers. Other associated factors include alcohol use, diabetes, obesity, history of pancreatitis, exposure to organic chemicals, consumption of a high-fat diet, and previous abdominal irradiation.

10. For a patient who is receiving chemotherapy, which laboratory result is of particular importance? 1. White blood cell (WBC) count 2. Prothrombin time and partial thromboplastin time 3. Electrolyte levels 4. Blood urea nitrogen level

1. WBC count is especially important, because chemotherapy can cause decreases in WBCs, particularly neutrophils (known as neutropenia), which leave the patient vulnerable to infection. The other tests are important in the total management but are less directly specific to chemotherapy in general.

5. When care assignments are being made for patients with alterations related to gastrointestinal (GI) cancer, which patient would be the most appropriate to assign to an LPN/LVN under the supervision of a team leader RN? 1. A patient with severe anemia secondary to GI bleeding 2. A patient who needs enemas and antibiotics to control GI bacteria 3. A patient who needs preoperative teaching for bowel resection surgery 4. A patient who needs central line insertion for chemotherapy

2. Administering enemas and antibiotics is within the scope of practice of LPNs/LVNs. Although some states an facilities may allow the LPN/LVN to administer blood, in general, administering blood, providing preoperative teaching, and assisting with central line insertion are the responsibilities of the RN.

24. A primary nursing responsibility is the prevention of lung cancer by assisting patients in cessation of smoking or other tobacco use. Which task would be appropriate to delegate to an LPN/LVN? 1. Development of a "quit plan" 2. Explanation of how to apply a nicotine patch 3. Discussion of strategies to avoid relapse 4. Suggestion of ways to deal with urges for tobacco

2. An LPN/LVN is versed in medication administration and able to teach patients standardized information. The other options require more in-depth assessment, planning, and teaching, which should be performed by the RN. Helping patients with smoking cessation is a Core Measure.

22. A patient with lung cancer develops syndrome of inappropriate antidiuretic hormone secretion (SIADH). After reporting symptoms of weight gain, weakness, and nausea and vomiting to the physician, you would anticipate which initial order for the treatment of this patient? 1. A fluid bolus 2. Fluid restrictions 3. Urinalysis 4. Sodium-restricted diet

2. Hyponatremia is a concern; therefore, fluid restrictions would be ordered. Urinalysis is less pertinent; however, the nurse should monitor for changes in urine specific gravity. The diet may need to include sodium supplements. Fluid bolus is unlikely to be ordered for patients with SIADH; however, IV normal saline or hypertonic saline solutions may be given very cautiously.

27. You are caring for a patient with uterine cancer who is being treated with intracavitary radiation therapy. The UAP reports that the patient insisted on ambulating to the bathroom and now "something feels like it is coming out." What is the priority action? 1. Assess the UAP's knowledge; explain the rationale for strict bed rest. 2. Assess for dislodgment; use forceps to retrieve and a lead container to store as needed. 3. Assess the patient's knowledge of the treatment plan and her willingness to participate. 4. Notify the physician about the potential or confirmed dislodgment of the radiation implant.

2. If the radiation implant has obviously been expelled (i.e., is on the bed linens), use a pair of forceps to place the radiation source in a lead container. The other options would be appropriate after safety of the patient and personnel are ensured.

17. For a patient with osteogenic sarcoma, which laboratory value causes you the most concern? 1. Sodium level of 135 mEq/L 2. Calcium level of 13 mg/dL 3. Potassium level of 4.9 mEq/L 4. Hematocrit of 40%

2. Potentially life-threatening hypercalcemia can occur in cancers with destruction of bone. Other laboratory values are pertinent for overall patient management but are less specific to bone cancers.

20. Following chemotherapy, a patient is being closely monitored for tumor lysis syndrome. Which laboratory value requires particular attention? 1. Platelet count 2. Electrolyte levels 3. Hemoglobin level 4. Hematocrit

2. Tumor lysis syndrome can result in severe electrolyte imbalances and potential kidney failure. The other laboratory values are important to monitor to identify general chemotherapy side effects but are less pertinent to tumor lysis syndrome.

26. You are asked to float to a different nursing unit. During report, you are told that the patient is receiving IV administration of vincristine (Oncovin) that should be completed within the next 15 minutes. The IV site is intact, and the patient is not having any problems with the infusion. You are not certified in chemotherapy administration. What is your priority action? 1. Ask the nurse to stay until the infusion is finished, because you are not certified. 2. Assess the IV site; check the progress of the infusion and the patient's condition. 3. Contact the charge nurse and explain that you are not chemotherapy certified. 4. Look up drug side effects and monitor, because the infusion is almost complete.

3. Explain that you are not chemotherapy certified so that the charge nurse can quickly rearrange the patient assignments. You can assess the patient, site, and infusion; however, you do not have the expertise to recognize the side effects of the medication or to give specialized care that may be needed. Asking the nurse to stay is not the best solution, because the care of the patient and the effects of the medication continue after the infusion has been completed. Looking up the side effects of the drug is okay for your own information, but you are still not qualified to deal with this situation. In addition, knowing how to properly discontinue the infusion and dispose of the equipment are essential for your own safety and the safety of others.

7. The physician tells the patient with cancer that there will be an initial course of treatment with continued maintenance treatments and ongoing observation for signs and symptoms over a prolonged period of time. Which patient statement would concern you the most? 1. "My symptoms will eventually be cured; I'm so happy that I don't have to worry any longer." 2. "My doctor is trying to help me control the symptoms; I am grateful for the extension of time with my family." 3. "My pain will be relieved, but I am going to die soon; I would like to have control over my own life and death." 4. "Initially, I may have to take some time off of work for my treatments; I can probably work full time in the future."

3. Further assess what the patient means by having "control over my own life and death." This could be an indirect statement of suicidal intent. A patient who believes he will be cured should also be assessed for misunderstanding what the physician said; however, the patient may need to use denial as a temporary defense mechanism. The patient's acknowledgment that the treatments are for control of symptoms or plans for the immediate future suggest an understanding of what the physician said.

11. For care of a patient who has oral cancer, which task would be appropriate to delegate to an LPN/LVN? 1. Assisting the patient to brush and floss 2. Explaining when brushing and flossing are contraindicated 3. Giving antacids and sucralfate suspension as ordered 4. Recommending saliva substitutes

3. Giving medications is within the scope of practice of the LPN/LVN. Assisting the patient in brushing and flossing should be delegated to the UAP. Explaining contraindications is the responsibility of the RN. Recommendations for saliva substitutes should come from the physician or pharmacist.

9. For a patient receiving the chemotherapeutic drug vincristine (Oncovin), which side effects should be reported to the physician? 1. Fatigue 2. Nausea and vomiting 3. Paresthesia 4. Anorexia

3. Paresthesia is a side effect associated with some chemotherapy drugs such as vincristine. The physician can modify the dosage or discontinue the drug. Fatigue, nausea, vomiting, and anorexia are common side effects of many chemotherapy medications. The nurse can assist the patient by planning for rest periods, giving antiemetics as ordered, and encouraging small meals containing high-protein and highcalorie foods.

19. An athletic young man was recently diagnosed with Ewing sarcoma. He has pain, lowgrade fever, and anemia. The surgeon recommends amputation of the right lower leg for an operable tumor. The patient tells you he is leaving the hospital to go on a long hiking trip. What is the priority nursing diagnosis? 1. Acute Pain related to tumor invasion of soft tissue 2. Fatigue related to anemia 3. Ineffective Coping related to loss of body image 4. Noncompliance related to personal values

3. The patient is not coping with the recent diagnosis of cancer and prospect of losing his leg. His decision to go hiking may be a form of denial, or possibly a veiled suicide threat. It is also possible that he has decided not to have any treatment; however, you need to make additional assessment about his decision and actions and help him to discuss alternatives and consequences. The other diagnoses may also apply, but if he leaves the hospital there will be no chance to address any other issues.

28. You are the charge nurse. Two hours into the shift you discover that two nurses have switched patients because Nurse A does "not like to take care of patients with prostate cancer." Which action should you take first? 1. Insist that they switch back to the original patient assignments and talk to each of them at the end of the shift. 2. Allow them this flexibility; as long as the patients are well cared for it doesn't matter if the assignments are changed. 3. Ask Nurse A to explain her position regarding prostate cancer patients and seek alternatives to prevent future issues. 4. Explain to Nurse A and B that all patients deserve kindness and care regardless of their condition or the nurses' personal feelings.

3. You must try to find out what Nurse A is thinking and feeling. If you can discover the underlying issue, there is a better chance that you can help her (e.g., referral to counseling or in-service training). You should try to avoid being too draconian with your staff by insisting that they switch back to the original assignments, or too condescending by lecturing them about patients' rights. Nurses frequently can and do switch patients to help each other out, but the charge nurse should always be informed prior to making the switch.

2. A 56-year-old patient comes to the walk-in clinic reporting scant rectal bleeding and intermittent diarrhea and constipation for the past several months. There is a history of polyps and a family history of colorectal cancer. While you are trying to teach about colonoscopy, the patient becomes angry and threatens to leave. What is the priority diagnosis? 1. Diarrhea/Constipation related to altered bowel patterns 2. Deficient Knowledge related to the disease process and diagnostic procedure 3. Risk for Deficient Fluid Volume related to rectal bleeding and diarrhea 4. Anxiety related to unknown outcomes and perceived threats to body integrity

4. The patient's physical condition is currently stable, but emotional needs are affecting his or her ability to receive the information required to make an informed decision. The other diagnoses are relevant, but if the patient leaves the clinic the interventions may be delayed or ignored.

23. In the care of a patient with neutropenia, what tasks can be delegated to a UAP? (Select all that apply.) 1. Taking vital signs every 4 hours 2. Reporting temperature of more than 100.4° F (38° C) 3. Assessing for sore throat, cough, or burning with urination 4. Gathering the supplies to prepare the room for protective isolation 5. Reporting superinfections, such as candidiasis 6. Practicing good hand-washing technique

Ans: 1, 2, 4, 6 Measuring vital signs and reporting on specific parameters, practicing good hand washing, and gathering equipment are within the scope of duties for a UAP. Assessing for symptoms of infections and superinfections is the responsibility of the RN.

13. You have just received the morning report from the night shift nurse. List the order of priority for assessing and caring for the following patients. 1. A patient who developed tumor lysis syndrome around 5:00 AM 2. A patient with frequent reports of breakthrough pain over the past 24 hours 3. A patient scheduled for exploratory laparotomy this morning 4. A patient with anticipatory nausea and vomiting for the past 24 hours _______,_______, _______, _______

Ans: 1, 3, 2, 4 Tumor lysis syndrome is an emergency involving electrolyte imbalances and potential renal failure. A patient scheduled for surgery should be assessed and prepared for surgery. A patient with breakthrough pain needs assessment, and the physician may need to be contacted for a change of dosage or medication. Anticipatory nausea and vomiting has a psychogenic component that requires assessment, teaching, reassurance, and administration of antiemetics.

21. People at risk are the target populations for cancer screening programs. Which of these asymptomatic patients need extra encouragement to participate in cancer screening? (Select all that apply.) 1. A 21-year-old white American woman who is sexually inactive, for a Pap test 2. A 30-year-old Asian-American woman, for an annual mammogram 3. A 45-year-old African-American man, for a prostate-specific antigen test 4. A 50-year-old African-American man, for a fecal occult blood test 5. A 50-year-old white American woman, for a colonoscopy 6. A 70-year-old Asian-American woman with normal results on three previous Pap tests, for a Pap test

Ans: 1, 3, 4, 5 Women age 21 or over should have annual Pap smears, regardless of sexual activity. African-American men should begin prostate-specific antigen testing at age 45. Colonoscopy and annual fecal occult blood testing are recommended for those with average risk starting at age 50. Annual mammograms are recommended for women over the age of 40. Women age 65 or older who have normal results on previous Pap tests may forego additional screenings for cervical cancer.

4. Patients receiving chemotherapy are at risk for thrombocytopenia related to chemotherapy or disease processes. Which actions are needed for patients who must be placed on bleeding precautions? (Select all that apply.) 1. Provide mouthwash with alcohol for oral rinsing. 2. Use paper tape on fragile skin. 3. Provide a soft toothbrush or oral sponge. 4. Gently insert rectal suppositories. 5. Avoid aspirin or aspirin-containing products. 6. Avoid overinflation of blood pressure cuffs. 7. Pad sharp corners of furniture.

Ans: 2, 3, 5, 6, 7 Mouthwash should not include alcohol, because it has a drying action that leaves mucous membranes more vulnerable. Insertion of suppositories, probes, or tampons into the rectal or vaginal cavity is not recommended. All other options are appropriate.

18. Which two cancer patients could potentially be placed together as roommates? 1. A patient with a neutrophil count of 1000/mm3 2. A patient who underwent debulking of a tumor to relieve pressure 3. A patient who just underwent a bone marrow transplantation 4. A patient who has undergone laminectomy for spinal cord compression _______,_______

Ans: 2, 4 Debulking of tumor and laminectomy are palliative procedures. These patients can be placed in the same room. The patient with a low neutrophil count and the patient who has had a bone marrow transplantation need protective isolation.

15. You are caring for an older woman with hepatic cancer. The UAP informs you that the patient's level of consciousness is diminished compared to earlier in the shift. Prioritize the steps of assessment and intervention related to this patient's change of mental status. 1. Take vital signs, including pulse, respirations, blood pressure, and temperature. 2. Check responsiveness and level of consciousness. 3. Obtain a blood glucose reading. 4. Check electrolyte values. 5. Check ammonia level. 6. Check the patency of existing IV lines. 7. Administer oxygen if needed and check pulse oximeter readings. _______, _______,_______, _______, _______, _______, _______

Ans: 2, 7, 1, 3, 6, 4, 5 Determine level of consciousness and responsiveness, and changes from baseline. Oxygen should be administered immediately in the presence of respiratory distress or risk for decreased oxygenation and perfusion. Pulse oximetry can be used for continuous monitoring. Adequate pulse, blood pressure, and respirations are required for cerebral perfusion. Increased temperature may signal infection or sepsis. Blood glucose levels should be checked even if the patient is not diabetic. Severe hypoglycemia should be immediately treated per protocol. A patent IV line may be needed for delivery of emergency drugs. Electrolyte and ammonia levels are relevant data for this patient, and abnormalities in these parameters may be contributing to change in mental status. (Note: Laboratory results [i.e., electrolytes and ammonia levels] may be concurrently available; however, you should train yourself to systematically look at data. Look at electrolytes first because these are more commonly ordered. In some cases, you may actually have to remind the physician to order the ammonia level if the patient with a hepatic disorder is having a change in mental status.)