201-Chapter 22: Care of Patients with Cancer

18. A client with prostate cancer is taking estrogen daily to control tumor growth. He reports that his left calf is swollen and painful. Which is the nurse's best action? a. Instruct the client to keep the leg elevated. b. Measure and compare calf circumferences. c. Apply ice to the calf after massaging it. d. Document this expected response.

ANS: B An adverse reaction to hormonal manipulation therapy is the development of thrombus formation. The nurse should measure both calf circumferences and compare them; the side with a thromboembolism will be larger. Elevation may be helpful, but first the nurse needs to assess the situation. Massaging a calf that is swollen and painful is never correct, because this action might break a clot to form an embolus, which could then travel to the lungs.

13. A client is on chemotherapy and has a platelet count of 25,000. Which intervention is most important to teach this client? a. "Eat a low-bacteria diet." b. "Take your temperature daily." c. "Use a soft-bristled toothbrush." d. "Avoid alcohol-based mouthwashes."

ANS: C This client has thrombocytopenia, which is a common side effect of chemotherapy. This increases the client's risk for prolonged bleeding in response to even minor injury, especially from highly vascular areas such as the gums. The client should be taught to use a soft toothbrush. A low-bacteria diet and daily temperature monitoring would be used in a client who is neutropenic. Alcohol-based mouthwashes will dry mucous membranes.

1. What statement indicates that the client understands teaching about neutropenia? a. "I need to use a soft toothbrush." b. "I have to wear a mask at all times." c. "My grandchildren may get an infection from me." d. "I will call my doctor if I have an increase in temperature."

ANS: D Bone marrow suppression leads to neutropenia and increases the client's risk for infection. Decreased numbers of neutrophils and other white blood cells can minimize the clinical manifestations of infection. For this reason, the client may not develop a high temperature, even with severe infection, and any elevation of temperature should be reported immediately to the health care provider. The client does not need to wear a mask or use a soft toothbrush (although if the client has low platelets, he or she should use a soft toothbrush to avoid causing trauma). The client is not contagious.

4. In evaluating dietary teaching for a client with chemotherapy-induced neutropenia, the nurse becomes concerned when the client makes which food choice? a. Fruit salad b. Applesauce c. Steamed broccoli d. Baked potato

ANS: A The client who is neutropenic should be taught to eat a low-bacteria diet. This includes avoiding raw fruits or vegetables and undercooked meat, eggs, or fish.

6. A client has bone cancer. What intervention does the nurse implement as a priority for this client? a. Using a lift sheet when repositioning the client b. Positioning the client's heels to keep them from touching the mattress c. Providing small, frequent meals rich in calcium and phosphorus d. Applying pressure for 5 minutes after intramuscular injections

ANS: A Bone metastasis of cancer can cause such bone destruction that grasping or pulling a client can result in a pathologic fracture. Using a lift sheet spreads the client's weight more evenly, preventing excessive force on any one body area. Preventing pressure on the heels will help prevent pressure ulcers; this is a good intervention for all clients but does not take priority over preventing fractures. Adding calcium and phosphorus to meals will not prevent fractures. Applying pressure after IM injections is not related to this client's condition.

28. The nurse questions which activity for the client with thrombocytopenia? a. Application of warm compresses to bruises b. Cleaning teeth with a soft-bristled brush c. Taking acetaminophen (Tylenol) for pain d. Using stool softeners daily for constipation

ANS: A Ice should be applied to areas of bruising or trauma to decrease bleeding. Warm compresses would lead to vasodilation and potentially to more bleeding. It is important to implement measures to decrease the risk of bleeding. A soft-bristled toothbrush decreases trauma to gums, which could cause bleeding. Straining at the stool could increase risk for rectal bleeding, so stool softeners may be prescribed. Acetaminophen does not affect platelet function and bleeding as do aspirin products.

22. A client with advanced cancer is being treated with intravenous mithramycin (Mithracin). Which clinical manifestation indicates that the treatment is effective? a. Bowel sounds are active in all four quadrants. b. The client's serum sodium level is 138 mEq/L. c. The pulse rate is 68 beats/min and bounding. d. Urine output has increased to 30 mL/hr.

ANS: A Mithramycin is used to treat hypercalcemia, which is seen most often in oncology clients who have bone metastases. Hypercalcemia reduces excitable membrane activity, causing decreased intestinal motility. Return of intestinal motility is an indication that serum calcium levels are decreasing. Mithramycin has no direct effect on serum sodium levels or urine output. The pulse rate most likely would be rapid and irregular with hypercalcemia and would normalize as calcium levels return to normal.

15. What is the priority problem for a client experiencing chemotherapy-induced anemia? a. Risk for injury related to fatigue b. Fatigue related to decreased oxygenation c. Body image problems related to skin color changes d. Inadequate nutrition related to anorexia

ANS: A Safety is always a client priority. The client who is anemic will be fatigued and may need assistance with activity to prevent injury. The other problems may apply; however, they do not take priority over safety.

16. A client is hospitalized for chemotherapy. The registered nurse intervenes when observing which action by the nursing assistant? a. Allowing the client to rest instead of making him or her perform oral hygiene b. Helping the client wash the groin and axillary areas every 12 hours c. Cutting food and opening food packages when the client's meal tray arrives d. Reminding the client to use the incentive spirometer every hour while awake

ANS: A The biggest dangers to clients on chemotherapy are neutropenia and the risk of serious infection or sepsis. Most infections arise from overgrowth of the client's own normal flora, so personal hygiene is critical. The client must perform hygiene measures on a schedule, even if he or she is very tired. Instead of allowing the client to rest, the nursing assistant should help the client perform oral hygiene and other measures. The other actions would be acceptable.

5. What teaching is essential for a client who has received an injection of iodine-131? a. "Do not share a toilet with anyone else or let anyone clean your toilet." b. "You need to save all your urine for the next week." c. "No special precautions are needed because this type of radiation is weak." d. "Avoid all contact with other people until the radiation device is removed."

ANS: A The radiation source is an unsealed isotope that is eliminated from the body in waste products, especially urine and feces. This material is radioactive for about 48 hours after instillation of the isotope. Having the client not share a toilet with other people or allowing anyone to clean the client's toilet for a specific period of time ensures that the isotope has been completely eliminated, and that the client's wastes are no longer radioactive.

24. A client is receiving high-dose chemotherapy for multiple myeloma. Which intervention is most important for the nurse to implement to prevent complications during chemotherapy? a. Ensure that the client's fluid intake is 3000 to 5000 mL/day. b. Monitor telemetry every hour during therapy. c. Apply pressure to all injection sites for 5 minutes. d. Assist the client in all ambulatory activities.

ANS: A This client is at high risk for tumor lysis syndrome. Tumor lysis syndrome is the precipitation of intracellular products released when tumor cells are destroyed rapidly. These products, particularly purines, can increase uric acid crystal precipitation in the kidney tubules and may cause acute tubular necrosis. In addition, serum potassium levels can become high. Maintaining adequate hydration and urine output is essential in preventing complications.

25. The nurse teaches a client with superior vena cava syndrome that improvement is characterized by which clinical manifestation? a. The client's hands are less swollen. b. Breath sounds are clear bilaterally. c. The client's back pain is relieved. d. Pedal edema is present.

ANS: A With superior vena cava syndrome, blood flow through the vena cava is compromised as a result of tumor growth. Blood backs up into the periphery, and the client experiences upper body swelling, including the hands and feet. Compression of the superior vena cava has no effect on breath sounds. This would occur when blood is impeded from leaving the lungs, and with disorders that affect the left side of the heart. Back pain is not associated with this disorder.

33. The nurse is caring for a client who has a sealed radiation implant for cervical cancer. Which activities by the nurse are appropriate? (Select all that apply.) a. Inform the supervisor of the nurse's positive pregnancy test. b. Obtain the dosimeter badge from the nurse going off shift. c. Keep the client's door open for frequent observation. d. Dispose of dirty linen in a red "biohazard" bag. e. Wear a lead apron while providing client care.

ANS: A, E Pregnant nurses should never care for clients with sealed implants of radioactive material, so if the nurse suspects she is pregnant, she should inform her supervisor and request a different assignment. Nurses should wear lead aprons while providing care, ensuring that the apron always faces the client. Each nurse should have his or her own dosimeter film badge. The client's door should be kept closed whenever possible and dirty linens kept in the client's room until the radiation source is removed.

32. The nurse is planning care for a client with hypercalcemia secondary to bone metastasis. Which interventions are included in the plan? (Select all that apply.) a. Increase oral fluids. b. Place an oral airway at the bedside. c. Monitor for Chvostek's sign. d. Implement seizure precautions. e. Assess for hyperactive reflexes. f. Observe for muscle weakness.

ANS: A, F Early manifestations of hypercalcemia include fatigue, loss of appetite, nausea, vomiting, constipation, and polyuria (increased urine output). More serious problems include severe muscle weakness, loss of deep tendon reflexes, paralytic ileus, dehydration, and electrocardiographic changes. An oral airway is not needed. Chvostek's sign is an assessment for hypocalcemia. Seizures and hyperactive reflexes do not occur with hypercalcemia.

2. A client is undergoing radiation therapy and asks the nurse about skin care for the exposed area. Which statement by the nurse is most accurate? a. "No products work well to reduce the skin reactions you get from radiation." b. "No one product works best, so you can choose what you would like to use." c. "The only medication that works well for skin reactions is very expensive." d. "No good studies on skin care with radiation have been conducted to date."

ANS: B A recent placebo-controlled study showed that none of three products used to manage radiation-related skin reactions was superior to the others. Researchers concluded that clients should use products that are easy to obtain and use and are within the client's budget. Simply stating that no one product works well does not give the client enough information to make an informed choice. Prescription medications for skin reactions can be expensive, but again this response does not help the client make a decision.

19. A client is receiving interleukin-2 (IL-2) for cancer. Which drug is the nurse prepared to administer if needed? a. Lorazepam (Ativan) b. Meperidine (Demerol) c. Furosemide (Lasix) d. Epoetin alfa (Epogen)

ANS: B Clients receiving IL-2 therapy usually experience chills, fever, and rigors during the infusion, especially the first time that they receive the drug. These reactions are a normal response to the administration of biological response modifiers such as IL-2. Clients are treated symptomatically for the discomfort. Demerol is used to treat the chills and rigor. The other medications would not treat a side effect of IL-2 therapy.

21. A client has small cell lung cancer. Which laboratory result requires immediate intervention by the nurse? a. Serum potassium of 5.1 mEq/L b. Serum sodium of 118 mEq/L c. Hematocrit of 45% d. Blood urea nitrogen (BUN) of 10 mg/dL

ANS: B In the syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH), secretion of antidiuretic hormone (ADH) from the posterior pituitary gland is increased, causing the client to reabsorb water from the distal convoluted tubule and collecting duct. As a result, weight increases, and serum sodium and hematocrit levels are diluted. Blood urea nitrogen (BUN) and hematocrit are normal. Potassium is slightly high, but very low sodium places the client at risk for seizures and even death.

12. A client's spouse reports that the last time the client received lorazepam (Ativan) before receiving chemotherapy, the client was extremely drowsy and didn't remember the trip home. Which is the nurse's best action? a. Hold the dose of lorazepam for this round of chemotherapy. b. Explain that this is a normal response to the drug. c. Perform a Mini-Mental State Examination. d. Document the response in the client's chart.

ANS: B Lorazepam, a benzodiazepine, induces sedation and amnesia, in addition to having antiemetic effects. Many clients have little if any memory about events occurring within a few hours after receiving lorazepam. This is an expected side effect and does not denote any permanent reduced cognition in the client. Both the client and the spouse should be aware of this effect so that the client is not at risk for injury. Driving, cooking, or operating mechanical equipment should not be performed until the drug's effects have worn off.

7. A client is undergoing radiation therapy and says, "I will be so glad when this is over and I don't have to worry about my skin." What response by the nurse is most appropriate? a. "Unfortunately, your skin will be permanently damaged from the radiation." b. "You need to protect your skin from the sun for at least a year afterward." c. "You can get a prescription for special lotions that reduce the effects of radiation." d. "You're having skin problems? That is unusual; let me take a look at your skin."

ANS: B Skin that has been in the path of external radiation is more susceptible to sun damage and must be protected from the sun for at least a year after completion of radiation therapy. Skin changes due to radiation are common but may not be permanent, depending on the amount of radiation absorbed. No one skin care product has been shown to significantly help radiation-related skin problems.

9. A client's radiation implant has become dislodged overnight, and the nurse finds it in the client's bed. What does the nurse do first? a. Assess the client's skin for radiation burns. b. Use tongs to put the implant into the radiation container. c. Notify the safety officer and move the client to a different room. d. Don gloves and attempt to replace the implant.

ANS: B The implant does emit radiation and should be placed into the secure, lead-lined container in the client's room. The nurse does not directly touch this implant but uses long-handled tongs for this purpose. The nurse does not need to assess the client's skin, nor should he or she attempt to replace the source. Moving the client is not necessary, although in keeping with facility policy, the radiation safety officer may need to be notified.

31. In planning a teaching session for a client undergoing photodynamic therapy for lung cancer, the nurse includes which statements? (Select all that apply.) a. "This is a palliative treatment that should decrease your pain." b. "Avoid exposure to the sun for 1 to 3 months after the treatment." c. "Do not eat or drink anything before your treatments." d. "Do not remove skin markings between treatments." e. "You need to wear sunglasses to protect your eyes after treatments." f. "Make sure you keep your curtains closed at home afterward."

ANS: B, E, F Phototherapy causes general sensitivity to light for up to 12 weeks. During this time, the client is at high risk for light sensitivity and eye pain. After the procedure, the client is taught to decrease exposure to sunlight (to the point of being homebound).

17. The student nurse overhears several staff members referring to a client who is receiving chemotherapy as having "chemo brain." The student asks the instructor what that means. Which response by the instructor is best? a. "That is an awful thing to say and the staff should not call a client by that name." b. "It refers to the client's brain as being irreversibly damaged by the chemotherapy." c. "The client has reduced cognitive function that may last for several years." d. "The client has delirium related to the toxic effects of the chemotherapy."

ANS: C "Chemo brain" refers to the changes in concentration, memory, and learning that sometimes accompany chemotherapy. It usually is not present at 3 years after chemotherapy has been completed, so clients should be reassured that this is a temporary condition. Although the staff should be more sensitive, simply criticizing them does not help the student understand the situation.

8. A client scheduled to undergo radiation therapy for breast cancer asks why 6 weeks of daily treatment is necessary. What is the nurse's best response? a. "Your cancer is widespread and requires more than the usual amount of radiation treatment." b. "Giving larger doses of radiation for a shorter period of time does not produce better effects and has worse side effects." c. "Research has shown that more cancer cells are killed if radiation is given in smaller doses over a longer time period." d. "It is less likely that your hair will fall out or that you will become anemic if radiation is given in this manner."

ANS: C Because of varying responses of all cancer cells within a given tumor, small doses of radiation are given on a daily basis for a set period of time. This method allows multiple opportunities to destroy cancer cells while minimizing damage to normal tissues.

10. A client is receiving a chemotherapeutic agent intravenously through a peripheral line. What is the nurse's first action when the client reports burning at the site? a. Check for a blood return. b. Slow the rate of infusion. c. Discontinue the infusion. d. Apply a cold compress.

ANS: C Both irritants and vesicants can cause tissue damage. If the nurse suspects extravasation, he or she should immediately stop the infusion. Even if the IV has a good blood return, some of the chemotherapeutic agent can still be leaking into the tissues. Slowing the rate of infusion is not sufficient to prevent further leakage and damage. Applying a cold compress may or may not be the correct action, depending on the specific agent. However, the compress would be applied only after the infusion has been discontinued.

29. The nurse prioritizes which intervention in a client with xerostomia secondary to radiation therapy to the neck area? a. Applying lotions and oils to affected areas b. Wearing a hat to decrease heat loss c. Providing oral care after meals and at bedtime d. Monitoring vital signs every 4 hours

ANS: C Head and neck radiation may damage the salivary glands, may cause dry mouth (xerostomia), and may increase the client's lifelong risk for tooth decay. Instruct clients to avoid using lotions or ointments in these areas unless the radiologist prescribes them. Xerostomia is not associated with hair loss, which might require a hat. Monitoring vital signs is important for any client receiving radiation therapy but is not a priority for the client with xerostomia.

30. Which statement indicates that the client needs more teaching about mucositis? a. "I will rinse my mouth with water after every meal." b. "I will use a soft-bristled toothbrush to prevent trauma." c. "I should use an alcohol-based mouth rinse to kill bacteria." d. "I cannot use floss because it may irritate my gums."

ANS: C Mouthwashes that contain alcohol are drying and can exacerbate mucosal irritation, leading to painful mouth sores. Rinsing the mouth with water or normal saline is indicated. Interventions aimed at decreasing risk for trauma or irritation are matters of priority because of inflammation associated with mucositis.

23. A nurse is reviewing the white blood cell count with differential for a client receiving chemotherapy for cancer. Which finding alerts the nurse to the possibility of sepsis? a. Total white blood cell count is 9000/mm3. b. Lymphocytes outnumber basophils. c. "Bands" outnumber "segs." d. Monocyte count is 1800/mm3.

ANS: C Normally, mature segmented neutrophils ("segs") are the major population of circulating leukocytes, constituting 55% to 70% of the total white blood cell count. Less than 3% to 5% of circulating white blood cells should be the less mature band neutrophils. A left shift occurs when the bone marrow releases more immature neutrophils than mature neutrophils. This condition indicates severe infection with possible sepsis and must be explored further.

27. After receiving change-of-shift report, which client does the nurse assess first? a. Client with leukemia who needs an antiemetic before chemotherapy b. Client with breast cancer scheduled for external beam radiation c. Client with xerostomia associated with laryngeal cancer d. Client with neutropenia who has just been admitted with a possible infection

ANS: D The most complex, potentially unstable client is the one with neutropenia with suspected infection. Because the onset of infection is insidious in clients with neutropenia, this client is at risk for sepsis. All other clients are stable.

3. A client who has just had a mastectomy is crying. When the nurse asks about her crying, the client responds, "I know I shouldn't cry because this surgery may well save my life." What is the nurse's best response? a. "It is all right to cry. Mourning this loss will help make you stronger." b. "I know this is hard, but your chances of survival are better now." c. "I can arrange for someone who had a mastectomy to come visit if you like." d. "How have you coped with difficult situations in the past?"

ANS: C Often, cancer surgery involves the loss of a body part or a decrease in function. Mourning or grieving for a body image alteration is a healthy part of adapting or adjusting to a new image. Visiting with someone who has experienced the same situation as the client is very helpful in showing the client that many aspects of life can be the same afterward. If the opportunity to arrange this type of visit is available, this would be the nurse's best response. The other options do not provide any assistance to the client in coping with her new body image and grieving for her loss.

20. A nurse manager on an oncology nursing unit notes an increased incidence of infection and serious consequences for clients on the unit. Which action by the nursing manager is most beneficial in this situation? a. Review asepsis policies at a mandatory in-service for staff. b. Spot-check all staff for good handwashing practices. c. Develop standard protocols to identify and treat clients with infection. d. Institute protective precautions for all clients receiving chemotherapy.

ANS: C Treatment delays have a serious negative impact on neutropenic clients with infection. Nursing units should have standardized protocols to obtain cultures and diagnostic tests, and to start antibiotics as soon as a client is suspected of having an infection. In-services and spot-checking for good handwashing practice are good ideas as part of a comprehensive infection control practice but are not as important as standard protocols that ensure rapid diagnosis and treatment. Not all clients on chemotherapy will need protective precautions.

26. A client has late-stage colon cancer with metastasis to the spine and bones. Which nursing intervention does the nurse add to the care plan to address a priority problem? a. Provide six small meals and snacks daily. b. Offer the client prune juice twice a day. c. Ensure that the client gets adequate rest. d. Give the client pain medications around the clock.

ANS: D Although all interventions might be appropriate, a client with late-stage cancer and bone metastases is at risk for severe pain. Giving the client pain medication around the clock is the best way to manage this type of pain.

14. A client with chemotherapy-induced bone marrow suppression has received filgrastim (Neupogen). Which laboratory finding indicates that this therapy is effective for the client? a. Hematocrit is 28%. b. Hematocrit is 38%. c. Segmented neutrophil count is 2500/mm3. d. Segmented neutrophil count is 3500/mm3.

ANS: D Filgrastim is a single-lineage growth factor that stimulates the maturation and release of only segmented neutrophils. This drug is not given unless the neutrophil count is dangerously low. The near-normal range of neutrophils indicates effective therapy.

11. A client receiving intravenous chemotherapy asks the nurse the reason for wearing a mask, gloves, and gown while administering drugs to the client. What is the nurse's best response? a. "These coverings protect you from getting an infection from me." b. "I am preventing the spread of infection from you to me or any other client here." c. "The policy is for any nurse giving these drugs to wear a gown, gloves, and mask." d. "The clothing protects me from accidentally absorbing these drugs."

ANS: D Most chemotherapy drugs are absorbed through the skin and mucous membranes. As a result, health care workers who prepare or give these drugs, especially nurses and pharmacists, are at risk for absorbing them. Even at low doses, chronic exposure to chemotherapy drugs can affect health. The Oncology Nursing Society and the Occupational Safety and Health Administration (OSHA) have specific guidelines for using caution and wearing protective clothing whenever preparing, giving, or disposing of chemotherapy drugs.