Nursing 211

N211: Health Differences Across the Lifespan I a. Rationale: Cancer cells traveling in the bloodstream is one of the primary mechanisms of metastasis. 14. Administer prescribed antiemetics prior to chemotherapy 15. Stop the infusion 16. “I’ll watch her caloric intake, since she has gained so much weight” a. Rationale: The parent should understand that the weight gain is a temporary side effect of the medications, not the result of overeating. 17. Excessive bleeding a. Rationale: Excessive bleeding is an emergency in the patient with thrombocytopenia 18. Cucumbers a. Rationale: Cucumbers cause the formation of gas and associated odors in the pouch. 19. Decreased serum sodium (this is the clearest indicator) 20. Risk for infection a. Rationale: Neutrophils (white blood cells) are an important defense against infection, and addressing a decrease should be the nurse’s first priority 21. Promote optimal ventilation a. Rationale: Because the lobectomy has removed a section of the lung, respiratory complications are the most likely to occur. Nursing measures to promote optimal ventilation, including positioning, breathing exercises, and removal of excess secretions may be used to achieve this goal. 22. Low bulk foods like bananas are indicated for treatment of diarrhea. There is a risk for hypokalemia in patients with diarrhea. 23. 10-20% of these lesions transform into skin cancer. a. Rationale: Some actinic keratosis lesions do eventually transform into squamous cell carcinoma. 24. Sodium a. Rationale: Fluid retention is often a problem for patients receiving steroid hormones for chemotherapy. Restricting sodium intake helps prevent this problem 25. Provide a low-residue diet a. Rationale: A low-residue diet limits bowel movements and decreases the risk of dislodgement. 26. Platelets 100,000/mm³ a. Rationale: This value is too low, placing the patient at risk for bleeding and infection 27. Denying a visit by the child’s classmate who has a cold 28. Rinse mouth with baking soda in water 29. Constipation and leucopenia 30. Monitor neurological status a. Rationale: The patient’s neurological status can be compromised by increased intracranial pressure and lack of oxygen as a result of superior vena cava syndrome. 31. Seizures a. Rationale: Glioma, a common type of brain tumor, is very likely to cause seizures. 32. Irrigation may not be necessary to establish regularity.

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