A nurse is caring for a client who is to start chemotherapy treatment advanced breast cancer. She tells the nurse she is worried about the adverse effects of the treatment. Which of the following responses should the nurse make?

I agree. Sometimes the adverse effect can be worse than the disease

"Someone from the American Cancer Society will be here soon to answer your questions

What is it about the adverse effects that concern you?

I will have your provider discuss the adverse effects with you before the treatment begins

Answer and Explanation

The Correct Answer is C

A) "I agree. Sometimes the adverse effects can be worse than the disease":
While it's important for the nurse to acknowledge the client's concerns, making this statement may not be helpful in this situation. It could unintentionally reinforce fear and anxiety, implying that the chemotherapy's side effects may be worse than the disease itself, which is not always the case. Instead, the nurse should engage the client in a discussion to explore the specific concerns, allowing for tailored support and information.

B) "Someone from the American Cancer Society will be here soon to answer your questions":
While the American Cancer Society can provide valuable support and resources, referring the client to someone else to answer their questions can feel dismissive. The nurse should take the opportunity to listen to the client’s concerns and provide immediate reassurance or information. Direct involvement in the discussion builds trust and allows for more immediate emotional and psychological support.

C) "What is it about the adverse effects that concern you?":
This response is the most appropriate as it encourages the client to express their specific concerns. By asking the client to clarify their worries, the nurse can provide more accurate information, address misunderstandings, and offer reassurance. This open-ended question helps the nurse understand the client's emotions and individual needs, which allows for a more personalized approach in managing anxiety and providing education about the chemotherapy treatment.
D) "I will have your provider discuss the adverse effects with you before the treatment begins":
While it is important for the healthcare provider to discuss the treatment plan and potential side effects, the nurse should not defer the conversation entirely. The nurse plays an essential role in providing ongoing support, educating the client, and answering questions. The nurse can start the conversation and provide information about the common side effects of chemotherapy, offering the opportunity for further discussion with the provider as needed. Deferring the conversation might leave the client feeling unsupported.

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Correct Answer is A

Explanation

A) Assess lung sounds and respiratory rate at least every 2 hours:
In a patient with Myasthenia Gravis (MG) who has undergone thymectomy, monitoring respiratory status is critical. MG is a neuromuscular disorder that can lead to respiratory muscle weakness, which may be exacerbated post-operatively. Assessing lung sounds and respiratory rate at least every 2 hours is crucial to detect early signs of respiratory compromise, including hypoventilation or atelectasis.

B) Assess and document pain level once every shift:
While pain assessment is important, especially after a thymectomy, this action alone does not directly address the immediate issue of ineffective breathing patterns. In patients with MG, respiratory complications are a priority concern. Pain management should be part of the overall plan of care, but it is secondary to monitoring respiratory function in the acute post-operative period. Pain can affect respiratory effort, but it should be managed in the context of more pressing issues like airway and breathing assessment.

C) Maintain sequential compression device (SCD's) while in bed:
While SCDs are important in preventing deep vein thrombosis (DVT) in patients who are immobile, they are not the most appropriate intervention for a client with ineffective breathing patterns. The primary concern in a post-thymectomy patient with MG is respiratory function.

D) Elevate the head of the bed ten degrees:
While elevating the head of the bed can help with comfort and potentially improve ventilation in some patients, it is not the most specific or effective intervention for managing ineffective breathing patterns in a patient with MG. For optimal respiratory function, it is typically more beneficial to elevate the head of the bed to a higher degree (e.g., 30-45 degrees) to enhance lung expansion, rather than just 10 degrees.

A. Description of injury, vital signs during surgery, and current vital signs B. Description of operative procedure and patient tolerance C. Total intake and output (IV fluids, blood products, urine/chest tube output, blood loss) D. Presence of the patients spiritual advisor and family E. Medications administered during surgery and IV access sites

Correct Answer is ["A","B","C","E"]

Explanation

A) Description of injury, vital signs during surgery, and current vital signs:
This information is crucial for the ICU nurse to understand the nature of the injury, how the patient responded during surgery, and their current hemodynamic status. Vital signs during surgery provide insight into the patient's cardiovascular stability and response to anesthesia, blood loss, and interventions. Current vital signs are important to monitor for any postoperative complications.

B) Description of operative procedure and patient tolerance:
The ICU nurse needs to know the details of the surgery performed, such as the type of trauma repair and any complications that may have occurred during the procedure. Understanding how the patient tolerated the surgery (e.g., any complications such as hypotension or arrhythmias) is important for planning post-operative care and anticipating potential issues in the ICU.

C) Total intake and output (IV fluids, blood products, urine/chest tube output, blood loss):
Tracking fluid balance is critical in trauma patients, especially those who have suffered significant blood loss. IV fluids, blood products, and other inputs (such as urine and chest tube output) provide vital information on the patient's circulatory status and renal function. Blood loss is also important to monitor, as it may need to be replaced, and fluid status affects the patient's recovery.

D) Presence of the patient's spiritual advisor and family:
Although family presence can be an important part of patient care, especially in a trauma situation, it is not essential information for the ICU nurse to receive during a report. While the ICU nurse may ask for family updates and visitor information, the focus of the report should be on the patient's clinical status and post-operative needs.

E) Medications administered during surgery and IV access sites:
The ICU nurse must know the medications administered during surgery, especially anesthesia agents, antibiotics, and analgesics, to understand their effects and anticipate any needed follow-up care, such as pain management or monitoring for adverse reactions. Knowing the IV access sites (e.g., central line, peripheral IV) is important for administering medications, fluids, and for monitoring potential complications related to vascular access.

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A nurse is caring for a client who is to start chemotherapy treatment advanced breast cancer. She tells the nurse she is worried about the adverse effects of the treatment. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with Myasthenia Gravis (MG) who is post op thymectomy. The client problem is Ineffective Breathing Pattern, Which action would the nurse include in the plan of care?

Correct Answer is A

Explanation

The Operating Room (OR) nurse is preparing to give report to the Intensive Care Unit (ICU) nurse on a patient who has had surgery after suffering penetrating chest and abdominal trauma. What should the nurse include in the report? (Select All that Apply.)

Correct Answer is ["A","B","C","E"]

Explanation

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