Nursing Care of Adults II Final Exam Study
Guide ,Complete Questions with 100% Correct Answers
What are the side effects of Chemotherapy?
-Most common side effect- Nausea and vomiting
-Most serious side effect- Suppressing Bone Marrow (Anemia, Neutropenia, Thrombocytopenia)
-Other side effects include:
Alopecia (temporary)
Mucositis
Skin changes
Anxiety, sleep disturbance
Altered bowel elimination
Nephrotoxic, hemorrhagic cystitis
Cardiopulmonary toxicity
Possible sterility, teratogenic effect
Peripheral neuropathy
Changes in cognitive function: "Chemo brain"
Fatigue
What are the side effects of Radiation Therapy?
-Vary according to the site
-Local altered skin integrity : radiation dermatitis
-Alopecia (permanent) associated with whole brain radiation. Radiation of other body parts does not
lead to hair loss.
-Stomatitis, xerostomia, mucositis , altered taste sensations
-Fatigue, malaise, anorexia
-Inflammatory responses leading tissue fibrosis and scarring
What are the nursing interventions implemented to prevent injury in patients with
thrombocytopenia?
-Gentle handling; use a lift sheet when moving and positioning pt in bed
-Avoid IM injections & venipunctures; use the smallest-gauge needle when injections are necessary and
apply firm pressure for 10 minutes to the needle stick site;
-Apply ice to areas of trauma;
-Observe IV site q4h for bleeding; test all urine & stool for occult blood;
-Avoid trauma to rectal tissues (No enemas, suppositories administered with caution);
-Measure abdominal girth daily;
-Use electric shave, soft-bristled toothbrush or tooth sponges;
-Avoid blowing nose or inserting objects into the nose;
-Avoid contact sports.
,-Wear shoes with firm soles whenever ambulating;
-Keep pathways and walkways clear and uncluttered.
What are the nursing interventions associated with care of patients with chemotherapy induced
peripheral neuropathy?
-Do not walk around in bare feet. Always wear shoes with a protective sole.
-Be sure shoes are long & wide enough to prevent creating sores or blisters. Do not wear new shoes for
longer than 2 hrs at a time.
-Avoid pointed-toe shoes and shoes with heels higher than 2 inches.
-Avoid extremes of temperature. Use warm water rather than hot water.
-Pts receiving oxaliplatin must avoid drinking cold fluids or going outside with extremities exposed to
cold temperatures
-Use potholders when cooking.
-Use gloves when washing dishes or gardening.
-Eat foods high in fiber. Drink 2-3 liters of fluid daily unless contraindicated.
-Avoid using area rugs, especially those that slide easily.
-Use handrails when going up or down steps.
-Get up from a lying or sitting position slowly.
What are the nursing interventions associated with care of patients with Sealed Implants?
-Assign the patient in a private room with private bath. Place a caution sign on the door of the pt's room.
Keep door closed.
-Wear a dosimeter badge when caring for the patient.
-Wear a lead apron while providing care.
-Limit time to 30 minutes per care provider per shift.
-Do not allow pregnant women or children < 16 yoa to visit.
-Visitor should stay at least 6 feet distance from the source. Limit visitors to 30 minutes per day.
-Save all dressings and bed linens in the patient's room until the radioactive source is removed. After the
source is removed, dispose of dressings & linens in the usual manner.
-If dislodged, use a long-handled forceps to retrieve the source and deposit it in the lead container in the
pt's room immediately.
-Never touch the radioactive source with bare hands.
What are the nursing interventions associated with Sepsis and Disseminated Intravascular
Coagulation?
The best management is prevention:
-Identify patients at risk
-Aseptic technique during invasive procedures
-Teach patients and families to seek assistance with early signs of infection
-IV antibiotics
-Anticoagulants (heparin) during early stage
-Cryoprecipitated clotting factors when hemorrhage is the primary problem.
,What are the clinical manifestations associated with Syndrome of Inappropriate Antidiuretic Hormone
(SIADH) - hyponatremia?
Mild manifestations include weakness, muscle cramps, loss of appetite, fatigue. As sodium level drops to
110 mEq/L, seizures, coma and death may occur.
What are the nursing interventions associated with Syndrome of Inappropriate Antidiuretic Hormone
(SIADH) - hyponatremia?
Priority is on patient safety:
-Fluid restriction
-Increased sodium intake
-Drug therapy - demeclocycline (Declomycin)
-Immediate radiation or chemotherapy
What are the clinical manifestations of Spinal Cord Compression (SCC)?
Back pain, sensation of heaviness in the arms or legs, numbness or tingling in the hands or feet, inability
to distinguish hot and cold, unsteady gait, bladder and/ or bowel dysfunction depending on level of
compression.
What are the nursing interventions associated with Spinal Cord Compression (SCC)?
-Perform ongoing neurological assessment
-Pharmacological & nonpharmacological pain management (high doses of corticosteroids, radiation or
surgery. External back or neck braces)
-Assist with ROM exercises
-Intermittent urinary catheterization and bowel training program
What are the clinical manifestations associated with Hypercalcemia?
Early manifestations include fatigue, loss of appetite, N & V, constipation, increased urine output
Serious manifestations include muscle weakness, loss of DTR, paralytic ileus, dehydration, ECG changes
What are the nursing interventions associated with Hypercalcemia?
-Need to consume 2-4 L of fluid daily unless contraindicated
-Maintenance of nutritional intake without restricting normal calcium intake
-Use of dietary and pharmacological interventions for constipation
-Drug therapy - oral glucocorticoids, calcitonin, diphosphonate, gallium nitrate, mithramycin
-Antiemetic therapy for N & V
-Promotion of mobility & safety precaution
What are the clinical manifestations associated with Superior Vena Cava (SVC) Syndrome?
-Early manifestations include facial edema especially around eyes (early sign), tightness of the shirt and
blouse collar (Stoke's sign).
-As compression worsens, the pt develops engorged blood vessels, distended jugular veins and
, erythema of the upper body, edema of arms and hands, dyspnea, erythema, epistaxis.
-Late manifestations include hemorrhage, cyanosis, mental status changes, decreased cardiac output,
hypotension.
What are the nursing interventions associated with Superior Vena Cava (SVC) Syndrome?
-Avoid upper extremity venipuncture and blood pressure measurement; instruct pt to avoid tight
clothing and jewelry on fingers, wrist, neck
-Place the pt in semi-Fowler's position. Avoid supine or prone position.
-Monitor the pt's fluid volume status, administer IVF cautiously
What are the clinical manifestations associated with Tumor Lysis Syndrome (TLS)?
A positive sign that cancer treatment is effective. However Hyperkalemia and hyperuricemia can have
life-threatening end-organ effects on the myocardium, kidneys & CNS.
-Nausea, vomiting, diarrhea, muscle cramps or twitches, weakness, numbess or tingling, fatigue,
decreased urination, irregular heart rate, confusion, restlessness, irritability, delirium, hallucinations,
seizures
What are the nursing interventions associated with Tumor Lysis Syndrome (TLS)?
-Identify at-risk pts
-Assess S & S of electrolyte imbalances, assess urine pH to confirm alkalization
-Close monitoring serum electrolyte and uric acid levels
-Drink at least 3 L of fluid daily
-Drug therapy - diuretics, allopurinol, sodium polystyrene sulfonate PO or IV, glucose and insulin IV
-Dialysis
What is the normal range for RBC?
Males: 4.7-6.1 million/uL
Females: 4.2-5.4 million/uL
What is the normal range for hemoglobin?
Males: 14-18 g/dL
Females: 12-16 g/dL
What is the normal range for hematocrit?
Males: 42%-52%
Females: 37%-47%
What is the normal range for WBC?
4,000-11,000 cell/mm^3
What is the normal range for platelets?
Guide ,Complete Questions with 100% Correct Answers
What are the side effects of Chemotherapy?
-Most common side effect- Nausea and vomiting
-Most serious side effect- Suppressing Bone Marrow (Anemia, Neutropenia, Thrombocytopenia)
-Other side effects include:
Alopecia (temporary)
Mucositis
Skin changes
Anxiety, sleep disturbance
Altered bowel elimination
Nephrotoxic, hemorrhagic cystitis
Cardiopulmonary toxicity
Possible sterility, teratogenic effect
Peripheral neuropathy
Changes in cognitive function: "Chemo brain"
Fatigue
What are the side effects of Radiation Therapy?
-Vary according to the site
-Local altered skin integrity : radiation dermatitis
-Alopecia (permanent) associated with whole brain radiation. Radiation of other body parts does not
lead to hair loss.
-Stomatitis, xerostomia, mucositis , altered taste sensations
-Fatigue, malaise, anorexia
-Inflammatory responses leading tissue fibrosis and scarring
What are the nursing interventions implemented to prevent injury in patients with
thrombocytopenia?
-Gentle handling; use a lift sheet when moving and positioning pt in bed
-Avoid IM injections & venipunctures; use the smallest-gauge needle when injections are necessary and
apply firm pressure for 10 minutes to the needle stick site;
-Apply ice to areas of trauma;
-Observe IV site q4h for bleeding; test all urine & stool for occult blood;
-Avoid trauma to rectal tissues (No enemas, suppositories administered with caution);
-Measure abdominal girth daily;
-Use electric shave, soft-bristled toothbrush or tooth sponges;
-Avoid blowing nose or inserting objects into the nose;
-Avoid contact sports.
,-Wear shoes with firm soles whenever ambulating;
-Keep pathways and walkways clear and uncluttered.
What are the nursing interventions associated with care of patients with chemotherapy induced
peripheral neuropathy?
-Do not walk around in bare feet. Always wear shoes with a protective sole.
-Be sure shoes are long & wide enough to prevent creating sores or blisters. Do not wear new shoes for
longer than 2 hrs at a time.
-Avoid pointed-toe shoes and shoes with heels higher than 2 inches.
-Avoid extremes of temperature. Use warm water rather than hot water.
-Pts receiving oxaliplatin must avoid drinking cold fluids or going outside with extremities exposed to
cold temperatures
-Use potholders when cooking.
-Use gloves when washing dishes or gardening.
-Eat foods high in fiber. Drink 2-3 liters of fluid daily unless contraindicated.
-Avoid using area rugs, especially those that slide easily.
-Use handrails when going up or down steps.
-Get up from a lying or sitting position slowly.
What are the nursing interventions associated with care of patients with Sealed Implants?
-Assign the patient in a private room with private bath. Place a caution sign on the door of the pt's room.
Keep door closed.
-Wear a dosimeter badge when caring for the patient.
-Wear a lead apron while providing care.
-Limit time to 30 minutes per care provider per shift.
-Do not allow pregnant women or children < 16 yoa to visit.
-Visitor should stay at least 6 feet distance from the source. Limit visitors to 30 minutes per day.
-Save all dressings and bed linens in the patient's room until the radioactive source is removed. After the
source is removed, dispose of dressings & linens in the usual manner.
-If dislodged, use a long-handled forceps to retrieve the source and deposit it in the lead container in the
pt's room immediately.
-Never touch the radioactive source with bare hands.
What are the nursing interventions associated with Sepsis and Disseminated Intravascular
Coagulation?
The best management is prevention:
-Identify patients at risk
-Aseptic technique during invasive procedures
-Teach patients and families to seek assistance with early signs of infection
-IV antibiotics
-Anticoagulants (heparin) during early stage
-Cryoprecipitated clotting factors when hemorrhage is the primary problem.
,What are the clinical manifestations associated with Syndrome of Inappropriate Antidiuretic Hormone
(SIADH) - hyponatremia?
Mild manifestations include weakness, muscle cramps, loss of appetite, fatigue. As sodium level drops to
110 mEq/L, seizures, coma and death may occur.
What are the nursing interventions associated with Syndrome of Inappropriate Antidiuretic Hormone
(SIADH) - hyponatremia?
Priority is on patient safety:
-Fluid restriction
-Increased sodium intake
-Drug therapy - demeclocycline (Declomycin)
-Immediate radiation or chemotherapy
What are the clinical manifestations of Spinal Cord Compression (SCC)?
Back pain, sensation of heaviness in the arms or legs, numbness or tingling in the hands or feet, inability
to distinguish hot and cold, unsteady gait, bladder and/ or bowel dysfunction depending on level of
compression.
What are the nursing interventions associated with Spinal Cord Compression (SCC)?
-Perform ongoing neurological assessment
-Pharmacological & nonpharmacological pain management (high doses of corticosteroids, radiation or
surgery. External back or neck braces)
-Assist with ROM exercises
-Intermittent urinary catheterization and bowel training program
What are the clinical manifestations associated with Hypercalcemia?
Early manifestations include fatigue, loss of appetite, N & V, constipation, increased urine output
Serious manifestations include muscle weakness, loss of DTR, paralytic ileus, dehydration, ECG changes
What are the nursing interventions associated with Hypercalcemia?
-Need to consume 2-4 L of fluid daily unless contraindicated
-Maintenance of nutritional intake without restricting normal calcium intake
-Use of dietary and pharmacological interventions for constipation
-Drug therapy - oral glucocorticoids, calcitonin, diphosphonate, gallium nitrate, mithramycin
-Antiemetic therapy for N & V
-Promotion of mobility & safety precaution
What are the clinical manifestations associated with Superior Vena Cava (SVC) Syndrome?
-Early manifestations include facial edema especially around eyes (early sign), tightness of the shirt and
blouse collar (Stoke's sign).
-As compression worsens, the pt develops engorged blood vessels, distended jugular veins and
, erythema of the upper body, edema of arms and hands, dyspnea, erythema, epistaxis.
-Late manifestations include hemorrhage, cyanosis, mental status changes, decreased cardiac output,
hypotension.
What are the nursing interventions associated with Superior Vena Cava (SVC) Syndrome?
-Avoid upper extremity venipuncture and blood pressure measurement; instruct pt to avoid tight
clothing and jewelry on fingers, wrist, neck
-Place the pt in semi-Fowler's position. Avoid supine or prone position.
-Monitor the pt's fluid volume status, administer IVF cautiously
What are the clinical manifestations associated with Tumor Lysis Syndrome (TLS)?
A positive sign that cancer treatment is effective. However Hyperkalemia and hyperuricemia can have
life-threatening end-organ effects on the myocardium, kidneys & CNS.
-Nausea, vomiting, diarrhea, muscle cramps or twitches, weakness, numbess or tingling, fatigue,
decreased urination, irregular heart rate, confusion, restlessness, irritability, delirium, hallucinations,
seizures
What are the nursing interventions associated with Tumor Lysis Syndrome (TLS)?
-Identify at-risk pts
-Assess S & S of electrolyte imbalances, assess urine pH to confirm alkalization
-Close monitoring serum electrolyte and uric acid levels
-Drink at least 3 L of fluid daily
-Drug therapy - diuretics, allopurinol, sodium polystyrene sulfonate PO or IV, glucose and insulin IV
-Dialysis
What is the normal range for RBC?
Males: 4.7-6.1 million/uL
Females: 4.2-5.4 million/uL
What is the normal range for hemoglobin?
Males: 14-18 g/dL
Females: 12-16 g/dL
What is the normal range for hematocrit?
Males: 42%-52%
Females: 37%-47%
What is the normal range for WBC?
4,000-11,000 cell/mm^3
What is the normal range for platelets?
