Ramona Gunther, 18, was diagnosed with Stage II Hodgkins disease and is preparing to receive external radiation therapy. She tells the nurse she is scared 'about having to get radiation treatments all over my body.' Which of the following is the most appropriate response?

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Question 1 of 5

Ramona Gunther, 18, was diagnosed with Stage II Hodgkins disease and is preparing to receive external radiation therapy. She tells the nurse she is scared 'about having to get radiation treatments all over my body.' Which of the following is the most appropriate response?

Correct Answer: B

Rationale: The dose of radiation is not based on the staging of the disease alone, and there is not enough information to know that the dose will be low. With Stage II, the involved lymph nodes are all on the same side of the diaphragm, so the radiation will be given on that part of the body. The potential of fractures occurs because of the cancer, but the radiation is not given for that reason. She has not stated that she's afraid of being radioactive, so this answer does not address her concern.

Question 2 of 5

A very obese female client returns to her room after abdominal surgery. The client is drowsy, but oriented; her abdominal dressing is dry and intact; and her vital signs are T 98.4, P 87, R 18, and BP 146/72. An appropriate postoperative nursing diagnosis would be:

Correct Answer: D

Rationale: The assessment information provided does not suggest a postoperative airway problem or a problem with compliance. The assessment information provided does not suggest a problem with compliance or a postoperative airway problem. While the client is obese and has altered nutrition, the nutritional problem is more than her body requirements, not less. Pain is a common phenomenon in clients who have had surgery. Postoperative pain is related to the manipulation of and the injury to tissues during the surgical procedure.

Question 3 of 5

The nurse documents a client's surgical incision as having red granulated tissue. This indicates that the wound is:

Correct Answer: D

Rationale: The wound is not infected. An infected wound would contain pus, debris, and exudate. A necrotic wound would appear black or brown. The wound is healing properly. It is filled with red granulated tissue and fragile capillaries. A necrotic wound would appear black or brown. The wound is healing properly. It is filled with red granulated tissue and fragile capillaries.

Question 4 of 5

A client is having a left pneumonectomy. In planning this client's postoperative care, nursing interventions for a postoperative left pneumonectomy would include:

Correct Answer: D

Rationale: Chest tubes are not usually necessary in a pneumonectomy, because there is no lung to re-expand on the operative side. The pneumonectomy client should be positioned on the back or operated side, because the sutured bronchial stump may open, which would allow fluid to drain into the unoperated side and drown the client. The client should not have a pillow under the shoulder and back, because of the subscapular incision. Rales are commonly heard over the base of the remaining lung. An increase could indicate circulatory overload. Rales should be closely monitored.

Question 5 of 5

A 29-year-old client is scheduled for an arthrotomy of the right knee following a football injury. The client describes his state of health as excellent and states that he does not use any medication. In providing psychological support for the client during the preoperative period, the nurse should:

Correct Answer: B

Rationale: Teaching coughing and deep breathing is a component of preoperative teaching, but it does not necessarily provide psychological support. Spiritual care, a component of psychological support, can reduce the client's fears and anxieties related to the surgical experience. Performing a physical assessment is part of the physical preparation for surgery, not the psychological preparation. Providing the preoperative medication is a part of the preparation immediately before surgery. While the medication will sedate and relax the client, it is not considered to be psychological support.

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