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 ["2.5"]

Explanation

Ordered Dose: The doctor has prescribed Diltiazem at a rate of 2.5 mg per hour. This means the patient needs to receive 2.5 milligrams of Diltiazem every hour.

Medication Concentration: The medication is supplied as 125 mg of Diltiazem in 125 mL of fluid. This translates to a concentration of 1 mg of Diltiazem per 1 mL of solution.

Since the medication concentration is 1 mg/mL, delivering 2.5 mg of Diltiazem per hour requires infusing 2.5 mL of the solution per hour.

Therefore, the nurse should set the IV pump to deliver 2.5 mL/hr of the Diltiazem solution.

A. Maintaining strict bedrest for first 24 hours B. Measuring urine output hourly and performing daily weighs C. Keeping the environment quiet to decrease cardiac workload D. Reducing oxygen demand and providing pain control

Correct Answer is D

Explanation

A) Maintaining strict bedrest for first 24 hours:
While bedrest is often recommended in the early stages following a myocardial infarction (MI), the priority nursing intervention is to reduce oxygen demand on the heart, which can be achieved through pain management and controlling the workload on the heart, rather than solely relying on bedrest. Bedrest alone may not address the underlying physiological needs of the heart, such as reducing ischemia or controlling pain.

B) Measuring urine output hourly and performing daily weights:
Monitoring urine output and performing daily weights are important in managing fluid balance, especially for those with heart failure or volume overload. However, in the acute phase of an anterior wall myocardial infarction, the priority intervention is addressing the oxygen demand on the heart and providing pain relief, which is more immediate in stabilizing the client and reducing myocardial injury.

C) Keeping the environment quiet to decrease cardiac workload:
While creating a calm and quiet environment helps in reducing stress and decreasing cardiac workload, it is still secondary to actively managing the oxygen demand of the heart. Decreasing the workload of the heart is essential, but this is done more effectively through interventions such as pain management, oxygen therapy, and medications that reduce myocardial oxygen demand (e.g., nitroglycerin, beta-blockers).

D) Reducing oxygen demand and providing pain control:
This is the highest priority intervention for a client who has suffered an acute anterior wall myocardial infarction (MI). Pain from an MI increases the heart's oxygen demand and can exacerbate ischemia. Pain relief, often with morphine, not only reduces pain but also helps in vasodilation, reducing the heart's workload. Additionally, oxygen therapy should be given to ensure adequate oxygenation, and medications like beta-blockers, nitroglycerin, and ACE inhibitors are used to reduce the workload of the heart.

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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

A patient is to receive a continuous infusion of Diltiazem at 2.5 mg hr for Atrial fibrillation, The medication is supplied 125 mg of Diltlazem in 125 mL of IV fluid. At what rate should the nurse set the IV pump? (round to the nearest tenth)

Correct Answer is ["2.5"]

Explanation

Which nursing intervention is highest priority for the client who has suffered an acute anterior wall mycordial infarction?

Correct Answer is D

Explanation

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