The nurse is caring for a client with a history of breast cancer who is receiving chemotherapy. Which side effect should the nurse monitor for?

Neutropenia

Hypertension

Hyperkalemia

Weight gain

Answer and Explanation

The Correct Answer is A

Choice A reason: Neutropenia, a low neutrophil count, is a common chemotherapy side effect due to bone marrow suppression, increasing infection risk. Monitoring neutrophil counts is critical, as infections in breast cancer patients can be life-threatening, making it the priority side effect to assess.

Choice B reason: Hypertension is not a typical chemotherapy side effect, though some agents cause cardiovascular effects. Neutropenia is more common, compromising immunity, making it the priority to monitor, as infections pose an immediate threat in breast cancer patients on chemotherapy.

Choice C reason: Hyperkalemia is rare with chemotherapy, except in tumor lysis syndrome. Neutropenia is a frequent side effect, increasing infection risk due to marrow suppression, making it the priority to monitor, as it directly impacts patient safety during breast cancer treatment.

Choice D reason: Weight gain is not a primary chemotherapy side effect; weight loss is more common due to nausea. Neutropenia is critical to monitor, as low neutrophils increase infection risk, requiring urgent intervention in breast cancer patients undergoing chemotherapy.

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Correct Answer is B

Explanation

Choice A reason: Delegating oral care to UAP is appropriate for routine hygiene in AIDS patients with candidiasis. Leaving oral care solely to the nurse is unnecessary unless complex treatments are required. A soft-bristled toothbrush ensures safe, effective cleaning, supporting UAP involvement in standard oral hygiene.

Choice B reason: A soft-bristled toothbrush is ideal for oral care in candidiasis, as it gently cleans without traumatizing painful ulcers. In AIDS, oral hygiene reduces fungal load and discomfort. This instruction ensures safe, effective care by UAP, aligning with standard hygiene practices for mucosal infections.

Choice C reason: Sterile gloves are unnecessary for routine oral care, as candidiasis is not highly contagious in this context. Standard precautions, including clean gloves, suffice for UAP performing hygiene. Requiring sterile gloves is excessive, complicating care without added benefit compared to using a soft toothbrush.

Choice D reason: Mouthwash may irritate candidiasis ulcers, especially if alcohol-based, and is not the priority. Brushing with a soft-bristled toothbrush effectively cleans the mouth without causing trauma. Mouthwash is secondary and requires nurse oversight to ensure compatibility with the client’s condition, unlike brushing.

A. Replace the gauze with a transparent dressing B. Apply a hydrocolloid gel dressing C. Leave the dressing off until consulting with the healthcare provider D. Increase the frequency of the dressing changes

Correct Answer is B

Explanation

Choice A reason: Transparent dressings are semi-permeable, suitable for superficial wounds with minimal exudate. Stage 3 pressure injuries, with deeper tissue damage and granulation, require moisture-retentive dressings to support healing. Transparent dressings may not provide the moist environment needed for optimal granulation tissue formation and epithelialization in deeper wounds.

Choice B reason: Hydrocolloid gel dressings maintain a moist wound environment, ideal for stage 3 pressure injuries with granulation tissue. They promote autolytic debridement, support epithelialization, and protect the wound. This is the best choice, as gauze may adhere to granulation tissue, causing trauma during removal, unlike hydrocolloids, which foster healing.

Choice C reason: Leaving the dressing off exposes the wound to infection and drying, which impairs granulation tissue and delays healing. Stage 3 pressure injuries require a moist, protected environment. Consulting the provider may be appropriate for complex cases, but immediate dressing application is standard to maintain optimal wound conditions.

Choice D reason: Increasing dressing change frequency may disrupt granulation tissue and delay healing, especially with gauze, which can adhere to the wound bed. Stage 3 pressure injuries benefit from stable, moist environments provided by advanced dressings like hydrocolloids, not frequent changes that risk trauma and infection.

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The nurse is caring for a client with a history of breast cancer who is receiving chemotherapy. Which side effect should the nurse monitor for?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult client is admitted with AIDS and oral candidiasis manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide the UAP?

Correct Answer is B

Explanation

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

Correct Answer is B

Explanation

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