A client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis site for cancer cells?

Correct Answer: A

Rationale: The liver is one of the most common sites for metastasis of cancer cells. This is because the liver receives a high volume of blood flow, making it a common site for cancer cells to spread through the bloodstream. Additionally, the liver's function in filtering toxins and foreign substances from the blood makes it a favorable environment for cancer cells to establish secondary tumors. Monitoring the liver for metastasis is crucial in cancer diagnosis and management.

Correct Answer: C

Rationale: Maintaining a neutral thermal environment is an appropriate nursing intervention to promote adequate oxygenation in a low birth weight newborn. Newborns, especially those with low birth weight, have limited capacity to regulate their body temperature. Keeping the baby warm helps prevent cold stress, which can lead to increased metabolic demands and oxygen consumption. By maintaining a neutral thermal environment, the newborn's energy can be directed towards growth and development, rather than compensating for temperature fluctuations. This intervention helps optimize oxygenation and overall well-being of the low birth weight newborn. The other options (A, B, D) do not directly address the need for adequate oxygenation in a low birth weight newborn.

Correct Answer: A

Rationale: The circulating nurse is responsible for ensuring the cleanliness, proper temperature, humidity, and lighting in the operating room. The circulating nurse plays a crucial role in maintaining the overall environment and ensuring that it meets the necessary standards for the safety and well-being of the patient and the surgical team. They are in charge of coordinating and overseeing all aspects of the operating room environment, including maintaining a sterile field, assisting with instrument setup, and ensuring that all equipment is functioning properly. Additionally, the circulating nurse manages communication within the operating room and ensures that all necessary supplies are available during the surgical procedure. It is within the circulating nurse's scope of practice to take charge of these responsibilities to create an optimal operating room environment.

Correct Answer: D

Rationale: The nurse should inform the mother that the baby can be discharged once the Plastibell rim falls off. The Plastibell method involves placing a small plastic ring over the foreskin, which cuts off circulation and causes the foreskin to fall off on its own within a week to 10 days after the procedure. Once the Plastibell rim has fallen off, it indicates that the circumcision site has healed, and the baby is ready to be discharged. The other options, such as the newborn voiding, receiving vitamin K, or yellow exudate forming over the glans, are important aspects of post-circumcision care but are not indicative of the baby being ready for discharge.

Correct Answer: C

Rationale: Cisplatin is a cornerstone in the treatment of germ cell tumors.