A client with breast cancer is receiving 5-Fluorouracil (5-FU). ...

[APUS57]

A client with breast cancer is receiving 5-Fluorouracil (5-FU). Based on knowledge of this medication and its anticipated adverse effects or side effects, which nursing action should the nurse perform?
 
  1. Monitor ECG
   2. Assess lung sounds
   3. Test stool for occult blood
   4. Encourage daily fluid intake of 23 liters

Question 2

A nurse assesses a client with cirrhosis who is experiencing hypertension, edema, and shortness of breath. For which diagnosis should the nurse develop a plan of care?
 
  1. Deficient Fluid Volume
   2. Ineffective Tissue Perfusion
   3. Excess Fluid Volume
   4. Impaired Skin Integrity

[dudman123]

Answer to Question 1

3. Test stool for occult blood

Rationale:
The possible adverse effects or side effects associated with 5-FU are stomatitis, alopecia, nausea and vomiting, gastritis, enteritis, diarrhea, anemia, leucopenia, and thrombocytopenia. Assessing for bleeding by checking stool for occult blood is recommended in this client. Monitoring the ECG is recommended in clients receiving antitumor antibiotics. Assessing lung sounds is recommended in clients receiving alkylating agents, due to the potential for developing pulmonary fibrosis. Encouraging a daily fluid intake of 23 liters is recommended also for clients receiving alkylating agents because they could potentially develop renal failure.

Answer to Question 2

3. Excess Fluid Volume

Rationale:
The client experiencing shortness of breath, edema, and hypertension should have a care plan for fluid volume excess. Hypertension, shortness of breath, and edema are manifestations of fluid excess. Hypotension and dry mucous membranes are associated with deficient fluid volume. Ineffective tissue perfusion would be the appropriate diagnosis for a client experiencing cyanosis or tissue necrosis. Edema can cause an alteration in skin integrity, but there is no evidence of such problems with this client.

[APUS57]

Excellent

[scikid]

Gracias!