The nurse is developing a plan of care for marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable?

Correct Answer: C

Rationale: Marrow suppression is the major dose-limiting adverse reaction to floxuridine (FUDR). It typically becomes noticeable 2 to 4 days after drug administration. Floxuridine acts by interfering with DNA replication and is most toxic to rapidly dividing cells, such as those in the bone marrow. As a result, bone marrow suppression leading to decreased production of blood cells can occur relatively quickly after the administration of floxuridine. Monitoring for bone marrow suppression is essential in patients receiving this medication to ensure timely intervention and prevention of complications such as anemia, thrombocytopenia, and leukopenia.

Correct Answer: C

Rationale: The most appropriate expected outcome for a client experiencing anxiety related to a cancer diagnosis would be "Client uses any effective method to reduce tension." This outcome focuses on the client actively managing their anxiety by utilizing various strategies to decrease tension and promote feelings of calmness. It empowers the client to take control of their anxiety and seeks to foster a sense of well-being during a difficult time. The other options do not directly address the active management of anxiety as effectively as option C.

Correct Answer: D

Rationale: Breast self-examination (BSE) is a very popular means of early detection of breast cancer as it involves women being aware of how their breasts look and feel to detect any changes such as lumps, swelling, or other abnormalities. By performing regular self-examinations, women can identify any potential issues early on and seek medical advice promptly. While mammograms (X-ray) and clinical breast exams by healthcare providers are also important screening methods for detecting breast cancer, BSE is particularly valuable as women can perform it on a regular basis at home, thus increasing the chances of identifying any concerning changes promptly. It is recommended that women perform BSE monthly to become familiar with their breast tissue and notice any changes over time.

Correct Answer: C

Rationale: Early postoperative ambulation is important for preventing complications such as pneumonia. When a patient remains immobile for an extended period after surgery, they are at an increased risk of developing pneumonia due to decreased lung expansion and secretions pooling in the lungs. Ambulation helps improve lung function, promote better oxygenation, and prevent respiratory complications like pneumonia. In contrast, increased peristalsis helps prevent constipation, coughing helps prevent respiratory complications as well, and wound healing is not directly related to the need for early postoperative ambulation.

Correct Answer: B

Rationale: Fatigue in a patient with heart failure is commonly caused by decreased cardiac output. In heart failure, the heart is unable to pump enough blood to meet the body's demands, resulting in reduced delivery of oxygen and nutrients to the tissues. This can lead to generalized weakness and fatigue. Dyspnea (choice A) is commonly associated with heart failure but is more specific to difficulty breathing, while a dry cough (choice C) is a symptom that can be present but is not typically the primary cause of fatigue. Orthopnea (choice D) is a symptom of heart failure characterized by difficulty breathing when lying flat but is not directly related to the patient's increasing fatigue in this scenario.