The nurse is caring for a client who had a bowel resection for colon cancer. The vital signs were stable during surgery. While in the post-anesthesia care unit (PACU) the client is sleepy but awakens easily. The pulse ox is 88%. What would be the priority action by the nurse?

Call a rapid response for more assistance

Administer naloxone 0.4 mg SQ and reassess

Check the temperature and apply warmed blankets

Encourage the client to take deep breaths

Answer and Explanation

The Correct Answer is D

A. Calling a rapid response may be necessary if the client's condition deteriorates, but it is not the immediate priority in this scenario where the client is still able to be aroused.
B. Administering naloxone is appropriate if there is suspicion of opioid overdose; however, the priority is to address the low oxygen saturation first with non-invasive measures.
C. Checking the temperature and applying warmed blankets may be important, but the immediate concern is the low oxygen saturation.
D. Encouraging the client to take deep breaths is the most appropriate immediate action to improve oxygen saturation levels and enhance ventilation, as the client is in a post-anesthesia state where respiratory depression can occur.

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Correct Answer is C

Explanation

A. This statement may not be ideal; smaller, more frequent meals can help manage appetite and energy levels better than three large meals, especially for cancer patients who may experience fatigue or nausea.
B. A flat lying position can hinder lung expansion; a more elevated position is generally recommended to facilitate breathing.
C. This statement shows understanding of the need to manage energy levels and not overexert oneself, which is crucial for maintaining stamina during treatment.
D. Pain management typically requires more frequent dosing rather than a once-a-day regimen, depending on the severity of the pain.

A. A profound feeling of tiredness B. Renal impairment C. Expectoration of frothy sputum D. Development of bone marrow suppression

Correct Answer is A

Explanation

A. A profound feeling of tiredness is a common side effect of radiation therapy due to fatigue caused by the treatment itself and the body's response to cancer.
B. Renal impairment is not a typical direct side effect of radiation therapy for esophageal cancer; it is more commonly associated with treatments targeting the kidneys or systemic therapies.
C. Expectoration of frothy sputum may indicate pulmonary issues or fluid overload but is not a common side effect specifically related to radiation therapy for esophageal cancer.
D. Development of bone marrow suppression is possible but less common specifically with radiation therapy compared to chemotherapy, which is more directly associated with this side effect.

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The nurse is caring for a client who had a bowel resection for colon cancer. The vital signs were stable during surgery. While in the post-anesthesia care unit (PACU) the client is sleepy but awakens easily. The pulse ox is 88%. What would be the priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client was recently diagnosed with lung cancer. The nurse is evaluating discharge teaching with the client. Which statement about lung cancer indicates that teaching was effective?

Correct Answer is C

Explanation

In assessing a client with esophageal cancer being treated with radiation therapy, which finding(s) would alert the nurse to a possible side effect of this treatment?

Correct Answer is A

Explanation

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