A client with cancer is admitted to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescriptions include radiation therapy. Which action should the nurse implement?
Notify the radiation department to withhold the treatments for now.
Ask the client about his expected goals for this hospitalization.
Determine if the client wishes to cancel further radiation treatments.
Explain that palliative care measures can be provided at home.
The Correct Answer is B
It is important for the nurse to clarify the client's goals for hospitalization, including the client's understanding of the role of radiation therapy in palliative care. The nurse should also assess the client's understanding of the potential benefits and risks of radiation therapy and communicate this information to the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Administering a large volume of medication in a single injection is not recommended for infants as it can lead to discomfort, tissue trauma, and potential complications such as muscle fibrosis or nerve injury. Dividing the medication into two injections with volumes under 1 mL is a common practice for infants and can help minimize discomfort and complications.
In addition, the nurse should select an appropriate needle size and injection site based on the infant's size and age. A 22 gauge 1 1/2 inch (3.8 cm) needle is too large for an infant and may cause discomfort and tissue damage. The nurse should use a smaller gauge needle and choose an appropriate injection site, such as the vastus lateralis muscle in the thigh or the dorsogluteal muscle in the buttocks, based on the infant's age and size.
Finally, administering an injection into the deltoid muscle is not recommended for infants as this muscle is not fully developed until later in childhood. Using a quick dart-like motion to inject into the dorsogluteal site is also not recommended as it can cause tissue damage and discomfort. Instead, the nurse should use a slow, steady technique to administer the injection while ensuring the infant is held securely by the parent or another caregiver.
Correct Answer is B
Explanation
After retinal detachment surgery, it is crucial to protect the eye and the surgical repair site from accidental trauma or pressure. Providing an eye shield helps to shield the eye during sleep when the client may not have conscious control over their movements.
This can help prevent inadvertent rubbing or bumping of the eye, which could potentially disrupt the surgical repair and hinder the healing process.
Obtaining vital signs every 2 hours during hospitalization is a routine nursing intervention for postoperative care in general but is not specific to retinal detachment surgery. The frequency of vital sign monitoring may vary depending on the client's overall condition and the healthcare provider's orders.
Teaching a family member to administer eye drops may be necessary for the client's ongoing care, but it is not specifically related to the immediate postoperative period. Eye drop administration instructions can be provided as part of the client's discharge teaching.
Encouraging deep breathing and coughing exercises is a general postoperative intervention that promotes respiratory function and helps prevent complications such as pneumonia. While important for overall postoperative care, it is not specific to retinal detachment surgery.

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