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: Decrease the Infusion Rate on the IV

Decreasing the infusion rate on the IV is the appropriate action to take when a client experiences flushing of the neck and tachycardia while receiving vancomycin. These symptoms are indicative of vancomycin flushing syndrome (VFS), also known as “red man syndrome,” which is a reaction caused by the rapid infusion of vancomycin. Slowing the infusion rate allows the body more time to metabolize the drug and can help alleviate the symptoms.

Choice B reason: Document that the Client Experienced an Anaphylactic Reaction to the Medication

Documenting that the client experienced an anaphylactic reaction is not accurate in this scenario. Vancomycin flushing syndrome is an anaphylactoid reaction, not an anaphylactic one. Anaphylactoid reactions are not mediated by IgE antibodies and do not require prior sensitization to the drug. Therefore, it is important to distinguish between the two and document the reaction correctly.

Choice C reason: Change the IV Infusion Site

Changing the IV infusion site is not necessary in this case. The symptoms of flushing and tachycardia are related to the rate of vancomycin infusion, not the site of infusion. Therefore, changing the site would not address the underlying issue.

Choice D reason: Apply Cold Compresses to the Neck Area

Applying cold compresses to the neck area may provide some symptomatic relief, but it does not address the root cause of the reaction. The primary intervention should be to slow the infusion rate to prevent further release of histamine and alleviate the symptoms.

A. Wrap the stump with an elastic bandage in a figure-eight configuration. B. Remove the elastic bandage and re-wrap the stump once per day. C. Perform passive range of motion exercises once daily. D. Secure the elastic bandage to the lowest joint.

Correct Answer is A

Explanation

Choice A reason: Wrap the stump with an elastic bandage in a figure-eight configuration

Wrapping the stump with an elastic bandage in a figure-eight configuration is a standard practice in postoperative care for below-the-knee amputations. This method helps to shape and shrink the residual limb, preparing it for a prosthesis fitting. The figure-eight wrap provides even compression, which helps to reduce swelling and promote proper healing. It also helps to prevent the formation of edema and ensures that the residual limb maintains a conical shape, which is ideal for fitting a prosthetic socket.

Choice B reason: Remove the elastic bandage and re-wrap the stump once per day

While it is important to regularly check and adjust the bandage, removing and re-wrapping the stump only once per day may not be sufficient. The bandage should be checked more frequently to ensure it remains properly positioned and provides consistent compression. In some cases, it may need to be adjusted multiple times a day to maintain the desired level of compression and to prevent any issues such as slippage or uneven pressure.

Choice C reason: Perform passive range of motion exercises once daily

Performing passive range of motion exercises is beneficial for maintaining joint flexibility and preventing contractures. However, these exercises should be performed more frequently than once daily, especially in the early postoperative period. Regular exercises help to maintain muscle strength, improve circulation, and promote overall mobility. The frequency and type of exercises should be tailored to the individual needs of the client and guided by a physical therapist.

Choice D reason: Secure the elastic bandage to the lowest joint

Securing the elastic bandage to the lowest joint is not recommended. The bandage should be wrapped in a way that provides even compression without restricting movement or circulation. The figure-eight configuration is preferred because it allows for better control of the compression and helps to shape the residual limb effectively. Securing the bandage to a joint can lead to discomfort and may impede proper blood flow.

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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 assessing a client who is receiving vancomycin. The nurse notes a flushing of the neck and tachycardia. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is preparing a client who is postoperative following a below-the-knee amputation for a leg prosthesis fitting. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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