A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following actions should the nurse plan to take?

Tell the client to expect dark stools following chemotherapy.

Have the client swish with commercial mouthwash before therapy.

Administer an antiemetic prior to the procedure.

Have the client floss 4 times daily.

Answer and Explanation

The Correct Answer is C

Choice A reason: Tell the client to expect dark stools following chemotherapy

Dark stools are not a common side effect of chemotherapy. This symptom is more often associated with gastrointestinal bleeding or the use of certain medications, such as iron supplements or bismuth-containing compounds. Chemotherapy can cause a range of side effects, but dark stools are not typically one of them. Therefore, it is not necessary to inform the client to expect this symptom.

Choice B reason: Have the client swish with commercial mouthwash before therapy

While maintaining oral hygiene is important during chemotherapy, using a commercial mouthwash before therapy is not specifically recommended. Some commercial mouthwashes contain alcohol or other irritants that can exacerbate oral mucositis, a common side effect of chemotherapy. Instead, clients are often advised to use a gentle, alcohol-free mouthwash or a saline rinse to maintain oral hygiene and prevent infections.

Choice C reason: Administer an antiemetic prior to the procedure

Administering an antiemetic prior to chemotherapy is a standard practice to prevent nausea and vomiting, which are common side effects of many chemotherapeutic agents. Antiemetics help to improve the client’s comfort and adherence to the treatment regimen by reducing these distressing symptoms. This proactive approach is crucial in managing the side effects of chemotherapy and ensuring that the client can tolerate the treatment.

Choice D reason: Have the client floss 4 times daily

Flossing is an important part of oral hygiene, but flossing 4 times daily is excessive and can cause irritation or damage to the gums, especially in clients undergoing chemotherapy who may have a higher risk of oral mucositis and bleeding. It is generally recommended to floss once daily and to use a soft-bristled toothbrush to maintain oral health without causing additional trauma.

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Correct Answer is A

Explanation

Choice A reason: Hemorrhage

Hemorrhage is a significant and immediate postoperative complication following a transurethral resection of the prostate (TURP). This procedure involves removing part of the prostate gland, which can lead to bleeding. Monitoring for signs of hemorrhage, such as a significant drop in blood pressure, increased heart rate, and visible blood in the urine, is crucial. Early detection and intervention are essential to manage bleeding and prevent severe complications. Hemorrhage can lead to hypovolemic shock if not addressed promptly, making it the priority complication to monitor for.

Choice B reason: Infection

Infection is a common postoperative complication, but it typically develops a few days after surgery rather than immediately. Signs of infection include fever, chills, and increased white blood cell count. While it is important to monitor for infection, it is not the immediate priority compared to hemorrhage. Preventive measures, such as maintaining sterile techniques and administering prophylactic antibiotics, can help reduce the risk of infection.

Choice C reason: Urinary retention

Urinary retention can occur after TURP due to swelling or blood clots obstructing the urethra. This condition can cause discomfort and increase the risk of bladder damage. Monitoring for urinary retention involves assessing the client’s ability to void and checking for bladder distention. While it is an important complication to monitor, it is not as immediately life-threatening as hemorrhage.

Choice D reason: Pain

Pain is a common postoperative symptom and should be managed effectively to ensure the client’s comfort and recovery. However, pain management is typically addressed through prescribed analgesics and is not considered a life-threatening complication. Monitoring for pain and providing appropriate pain relief are essential aspects of postoperative care, but they do not take precedence over monitoring for hemorrhage.

A. Obtain a 12-lead ECG. B. Suggest that the client use a salt substitute. C. Advise the client to add citrus juices and bananas to her diet. D. Obtain a blood sample for a serum sodium level.

Correct Answer is A

Explanation

Choice A reason: Obtain a 12-lead ECG

Obtaining a 12-lead ECG is a critical action when a client has a potassium level of 6.8 mEq/L, which indicates hyperkalemia. Hyperkalemia can cause serious cardiac dysrhythmias, including life-threatening arrhythmias such as ventricular fibrillation or asystole. An ECG can help detect these abnormalities early, allowing for prompt intervention to prevent cardiac complications. The ECG may show characteristic changes such as peaked T waves, widened QRS complexes, and prolonged PR intervals, which are indicative of hyperkalemia.

Choice B reason: Suggest that the client use a salt substitute

Suggesting that the client use a salt substitute is not appropriate in this situation. Many salt substitutes contain potassium chloride, which can further increase the potassium level in the blood. For a client with hyperkalemia, it is crucial to avoid additional sources of potassium to prevent exacerbating the condition. Therefore, recommending a salt substitute could be harmful.

Choice C reason: Advise the client to add citrus juices and bananas to her diet

Advising the client to add citrus juices and bananas to her diet is also inappropriate. Both citrus juices and bananas are high in potassium and can contribute to an increase in serum potassium levels. For a client with hyperkalemia, it is essential to limit dietary potassium intake to help lower the potassium levels in the blood. Encouraging the consumption of high-potassium foods would be counterproductive and potentially dangerous.

Choice D reason: Obtain a blood sample for a serum sodium level

While obtaining a blood sample for a serum sodium level can be part of a comprehensive assessment, it is not the immediate priority in managing hyperkalemia. The primary concern with a potassium level of 6.8 mEq/L is the risk of cardiac dysrhythmias. Therefore, obtaining an ECG to monitor the heart’s electrical activity is the most urgent and appropriate action. Once the immediate risk is addressed, further laboratory tests, including serum sodium levels, can be conducted as part of the overall assessment and management plan.

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A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. Which of the following complications is the priority for the nurse to monitor for?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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