The clinic nurse is caring for a 42-year-old male oncology patient. He complains of extreme fatigue and weakness after his first week of radiation therapy. Which response by the nurse would best reassure this patient?

Correct Answer: A

Rationale: The correct answer is A because it acknowledges the patient's symptoms, reassures monitoring, and addresses the cause. It validates his experience while offering a proactive approach. Choice B is incorrect as it dismisses the patient's symptoms and can cause distress. Choice C is incorrect because it generalizes the patient's experience and lacks individualized care. Choice D is incorrect as it may give false hope and oversimplifies the situation. A provides the best balance of empathy and information for the patient's well-being.

Correct Answer: C

Rationale: The correct answer is C: Sudden cessation of output from the drainage device. This is crucial because it can indicate a potential complication like a blocked drain or infection, requiring immediate medical attention to prevent further issues. Other choices like fatigue (A) are common after surgery but not urgent. Temperature elevation (B) may indicate infection but is not as critical as sudden cessation of drainage. Gradual decline in output (D) is expected as the drainage decreases over time, so it doesn't require immediate reporting.

Correct Answer: B

Rationale: Correct Answer: B - Eat fish at least 5 times per week. Rationale: 1. Fish is rich in omega-3 fatty acids, which are beneficial for heart health. 2. Eating fish frequently can help reduce the risk of cardiovascular diseases. 3. Consuming fish aligns with dietary recommendations for cardiovascular health. Summary of Incorrect Choices: A: Maintaining carbohydrate intake is important, but it may not specifically indicate success in cardiovascular disease management. C: Limiting trans fats is crucial, but it alone may not indicate overall success in dietary management for cardiovascular disease. D: Avoiding high-fiber foods is not recommended, as fiber is beneficial for heart health and overall well-being.

Correct Answer: C

Rationale: The correct answer is C: Monitoring the integrity of the surgical site. This is the priority intervention as it ensures early detection of any complications like infection or bleeding. The nurse should assess for signs of infection, such as redness, swelling, or drainage, and monitor for any changes in the wound appearance. Placing the patient in high Fowler's position (A) may be beneficial for comfort but is not the priority. Administering sitz baths (B) may be helpful for comfort but should not be the priority over monitoring the surgical site. Avoiding analgesics (D) unless the pain is unbearable is not appropriate as pain management is essential for the patient's comfort and recovery.

Correct Answer: A

Rationale: The correct answer is A: Obtaining a midstream urine specimen. This task is within the scope of practice for nursing assistive personnel as it involves collecting a specimen, which is a routine and non-invasive procedure. Nursing assistive personnel are trained to perform basic tasks like specimen collection. Choices B, C, and D involve more complex skills and procedures that require specialized training and knowledge, which are typically performed by licensed nurses. Interpreting bladder scan results (B), inserting a straight catheter (C), and irrigating a catheter (D) all require a higher level of expertise and assessment that nursing assistive personnel are not qualified to do.

Correct Answer: B

Rationale: The correct initial intervention for a chemical burn to the eye is to generously flush the affected eye with normal saline or water. Flushing helps to remove the chemical from the eye, preventing further damage. Antibiotic solution (choice A) is not the first intervention as the priority is to remove the chemical. Applying a patch (choice C) can trap the chemical against the eye, worsening the injury. Applying direct pressure (choice D) is not appropriate and can cause additional harm. Flushing with normal saline or water is the most effective and safest initial intervention to minimize damage from a chemical burn to the eye.

Correct Answer: B

Rationale: The correct answer is B: Decreased skin turgor. Diarrhea leads to fluid loss, causing dehydration and decreased skin turgor. This indicates the patient's hydration status. A: Distended abdomen is more common in conditions like bowel obstruction, not necessarily in diarrhea. C: Increased energy levels are unlikely due to the patient's weakened state from dehydration. D: Elevated blood pressure is not typically associated with dehydration.

Correct Answer: D

Rationale: The correct answer is D: Sentinel node biopsy. This procedure involves identifying and removing the sentinel lymph node(s) which is the first lymph node(s) that cancer cells are likely to spread to from the primary tumor. This method helps determine if cancer has spread beyond the primary site without the need for a full axillary lymph node dissection. It is less invasive, has fewer side effects, and provides accurate staging information. Lymphadenectomy (A) refers to the removal of multiple lymph nodes, which is more extensive than necessary in this case. Needle biopsy (B) and open biopsy (C) are not specific to lymph node evaluation and do not provide accurate staging information for breast cancer.

Correct Answer: D

Rationale: The correct answer is D: MRI. MRI is the most appropriate test for diagnosing spinal cord compression from a tumor as it provides detailed images of soft tissues, including the spinal cord and surrounding structures. It can accurately identify the location, size, and extent of the tumor. Anterior-posterior x-ray (A) is not as detailed and may not clearly show soft tissue abnormalities. Ultrasound (B) is not typically used for imaging the spinal cord and may not provide sufficient information. Lumbar puncture (C) is used to collect cerebrospinal fluid and is not helpful for diagnosing spinal cord compression from a tumor.