The nurse is assessing a patient who is
receiving chemotherapy with an alkylating drug. Which assessment findings would be considered indications of an oncologic emergency? (Select all that apply.)
a. Dry, "scratchy," or "swollen" throat
b. Loss of hair
c. Decreased red blood cell count
d. White patches in the mouth or throat
e. Temperature of 100.7° F (38.2° C)
f. Decreased urine output
ANS: A, D, E, F
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The nurse has palpated a lump in a female patient's right breast. The nurse documents this as a small, round, firm, distinct, lump located at 2 o'clock, 2 cm from the nipple. It is nontender and fixed
No associated retraction of the skin or nipple, no erythema, and no axillary lymphadenopathy are observed. What information is missing from the documentation? a. Shape of the lump b. Consistency of the lump c. Size of the lump d. Whether the lump is solitary or multiple
The first-semester nursing student expresses concern that staff actions in the clinical setting do not reflect the same standards being taught in nursing classes. Which stage of Davis's model does this represent?
1. Initial innocence 2. Labeled recognition of incongruity 3. Role simulation 4. Provisional internalization
What nursing action is indicated when a child receiving a unit of packed red blood cells complains of chills, headache, and nausea?
a. Continue the infusion and take the child's vital signs. b. Stop the infusion immediately and notify the physician. c. Slow the infusion and assess for cessation of symptoms. d. Start a dextrose solution and stay with the child.
A patient diagnosed with dementia is watching a crime story on television. Suddenly, the patient begins to yell, "Stop! He's got a gun." What is the nurse's best intervention?
a. Administer a PRN dose of an atypical antipsychotic medication. b. Turn off the television and tell the patient, "You are safe." c. Reassure the patient that there are no guns nearby. d. Provide a snack, and put the patient in bed.