Breast
A patient is 1 day post–lumpectomy. The nurse is planning care. What is the priority nursing intervention?
Assess surgical site for bleeding/hematoma
A patient with lung cancer is experiencing increasing shortness of breath and decreased oxygen saturation. What is the priority nursing intervention?
Apply oxygen and assess airway/breathing
A patient is immediately post–TURP. The nurse notes continuous bladder irrigation (CBI) is running. What is the priority nursing assessment?
Ensure catheter patency and urine flow
A patient is 1 day post–colectomy with new colostomy. What is the priority nursing assessment?
Assess stoma color and perfusion
A patient with leukemia has a WBC of 1,000 and is starting chemotherapy. What is the priority nursing intervention?
Initiate neutropenic precautions
A patient is post–modified radical mastectomy with lymph node removal. Which action by a new nurse requires correction?
Taking BP on the affected arm
A patient with lung cancer develops:
What is the priority intervention?
Initiate fluid restriction
A patient post-TURP has urine that is dark red with clots. What is the priority nursing action?
Increase irrigation rate
A patient’s stoma appears:
What is the priority nursing action?
Notify provider immediately
A patient with leukemia has platelets of 20,000. What is the priority nursing intervention?
Initiate bleeding precautions
A patient post-mastectomy reports tightness and decreased movement in the affected arm. What is the priority nursing intervention?
Encourage gentle range-of-motion exercises
A patient with lung cancer and severe hyponatremia begins having seizures. What is the priority nursing intervention?
Administer hypertonic saline (as ordered) and protect airway
A patient post-TURP reports bladder spasms and leakage around the catheter. What is the priority nursing action?
Assess for obstruction or clots
A patient with a new colostomy has not had any output for 24 hours and reports abdominal cramping. What is the priority nursing action?
Assess for obstruction and notify provider
A patient with leukemia develops a fever of 101°F with an ANC of 400. What is the priority nursing action?
Notify provider immediately (neutropenic fever)
A patient on tamoxifen reports:
What is the priority nursing action?
Activate emergency response (suspected PE)
A patient is post–lung resection (lobectomy). The chest tube suddenly stops draining and the patient becomes increasingly dyspneic. What is the priority nursing action?
Assess for obstruction/kink and ensure chest tube patency
A patient with prostate cancer is receiving androgen deprivation therapy. What is the priority long-term nursing consideration?
Monitor for osteoporosis and bone loss
A patient post-colectomy is advancing diet. What is the priority nursing teaching regarding nutrition?
Start with low-fiber foods and gradually increase
A patient starting chemotherapy for leukemia is at risk for tumor lysis syndrome. What is the priority preventative intervention?
Aggressive IV hydration
A patient post-mastectomy has a surgical drain. The nurse notes:
What is the priority nursing action?
Notify provider immediately (possible hemorrhage)
A patient with lung cancer develops:
What complication is occurring and what is the priority intervention?
Superior vena cava (SVC) syndrome → elevate HOB and notify provider
A patient post-TURP suddenly has:
CBI is still running. What is the priority nursing action?
Check for catheter obstruction and manually irrigate if needed
A patient post-colorectal surgery develops:
What is the priority concern and nursing action?
Suspected anastomotic leak → notify provider immediately
A patient with leukemia develops:
What is the priority concern and nursing action?
Tumor lysis syndrome → notify provider and prepare for rapid intervention