A client who is receiving a blood transfusion begins to experience chills, shortness of breath, nausea, excessive perspiration, and a vague sense of uneasiness. What is the nurse’s first best action?

Questions 68

ATI RN

ATI RN Test Bank

Pharmacology and the Nursing Process 10th Edition Test Bank Questions

Question 1 of 5

A client who is receiving a blood transfusion begins to experience chills, shortness of breath, nausea, excessive perspiration, and a vague sense of uneasiness. What is the nurse’s first best action?

Correct Answer: D

Rationale: The correct answer is D: Stop the infusion. This is the best action because the client is likely experiencing a transfusion reaction. Stopping the infusion immediately is crucial to prevent further complications. Reporting the signs and symptoms to the healthcare provider (A) can cause a delay in addressing the reaction. While monitoring vital signs (B) and assessing respiratory status (C) are important, stopping the infusion takes precedence to ensure the client's safety and prevent a severe reaction.

Question 2 of 5

On a visit to the gynecologist, a client complains of urinary frequency, pelvic discomfort, and weight loss. After a complete physical examination, blood studies, and a pelvic examination with a Papanicolaou test, the physician diagnoses stage IV ovarian cancer. The nurse expects to prepare the client for which initial treatment?

Correct Answer: C

Rationale: The correct initial treatment for stage IV ovarian cancer is major surgery (Choice C). This is because at this advanced stage, surgery is typically performed to debulk the tumor and remove as much cancerous tissue as possible, followed by chemotherapy to target any remaining cancer cells. Radiation therapy (Choice A) is not typically the initial treatment for ovarian cancer. Chemotherapy (Choice B) is often used in combination with surgery, but surgery is usually the first line of treatment for stage IV disease. Choosing no treatment (Choice D) would be detrimental as the cancer is advanced and requires immediate intervention.

Question 3 of 5

A client with cancer is scheduled for radiation therapy. The nurse knows that radiation at any treatment site may cause a certain adverse effect. Therefore, the nurse should prepare the client to expect:

Correct Answer: A

Rationale: The correct answer is A: Hair loss. Radiation therapy targets fast-growing cancer cells, which can also affect healthy cells such as those in hair follicles, leading to hair loss. This adverse effect occurs commonly with radiation therapy due to its impact on rapidly dividing cells. Hair loss is a well-known side effect that clients undergoing radiation therapy are often prepared for. The other choices, B: Fatigue, C: Stomatitis, and D: Vomiting, are also potential side effects of radiation therapy, but hair loss is specifically associated with radiation treatment due to its effect on hair follicles. Fatigue is a common side effect of cancer treatment in general, stomatitis is more commonly associated with chemotherapy, and vomiting can be a side effect of radiation but is not as directly linked as hair loss.

Question 4 of 5

A client is undergoing a diagnostic work-up for suspected testicular cancer. When obtaining the client’s history, the nurse checks for known risk factors for this type of cancer. Testicular cancer has been linked to:

Correct Answer: D

Rationale: The correct answer is D: Cryptorchidism. Cryptorchidism, or undescended testicle, is a known risk factor for testicular cancer as the undescended testicle is more prone to developing cancerous changes. This condition increases the risk of testicular cancer even if the testicle is surgically corrected later in life. Other choices like A (Testosterone therapy during childhood) and B (Sexually transmitted disease) are not linked to testicular cancer. Choice C (Early onset of puberty) is not a direct risk factor for testicular cancer.

Question 5 of 5

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client’s plan of care?

Correct Answer: A

Rationale: The correct answer is A: Avoiding using soap on the irradiated areas. Soap can irritate the skin and exacerbate the risk for impaired skin integrity in a client receiving radiation therapy. By avoiding soap, we minimize the risk of skin breakdown and promote skin healing. B: Applying talcum powder can actually worsen skin irritation and should be avoided. C: Wearing a lead apron is not relevant to the nursing diagnosis of risk for impaired skin integrity. D: Removing thoracic skin markings is not necessary for skin integrity and may disrupt the treatment plan.

Access More Questions!

ATI RN Basic


$89/ 30 days

ATI RN Premium


$150/ 90 days

Similar Questions