5040 Final (questions)

Which action will the admitting nurse include in the care plan for a 30-year old woman who is neutropenic? a. Avoid any injections. b. Check temperature every 4 hours. c. Omit fruits or vegetables from the diet. d. Place a "No Visitors" sign on the door.

B

Which information in the preoperative patient's medication history is most important to communicate to the health care provider? A. The patient uses acetaminophen (Tylenol) occasionally for aches and pains. B. The patient takes garlic capsules daily but did not take any on the surgical day. C. The patient has a history of cocaine use but quit using the drug over 10 years ago D. The patient took a sedative medication the previous night to assist in falling asleep

B

Which information obtained by the nurse caring for patient with thrombocytopenia should be immediately communication to the health care provider? A. The platelet count is 52,000 B. The patient is difficult to arouse C. There are purpura on the oral mucosa D. There are large bruises on the patient's back

B

Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura (ITP) A. Assign the patient to a private room B. Avoid intramuscular(IM) injection C. Use rinses rather than a soft toothbrush for oral care D. Restrict activity to passive and active range of motion

B

The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect? A. Yellow-tinged sclerae B. Shiny, smooth tongue C. Numbness of the extremities D. Gum bleeding and tenderness

C

A patient arrives in the ambulatory surgery center for a scheduled laparacopy procedure in outpatient surgery. Which information is of most concern to the nurse? A. The patient is planning to drive home after surgery B. The patient had a sip of water 4 hours before arriving C. The patient's insurance does not cover outpatient surgery D. The patient has not had surgery suing general anesthesia before

A

A patient scheduled for an elective hysterectomy tells the nurse, "I am afraid that I will die in surgery like my mother did!" Which response by the nurse is the most appropriate? A. "Tell me more about what happened to your mother" B. "You will receive medications to reduce your anxiety" C. You should talk to the doctor again about the surgery" D. "Surgical techniques have improved a lot in recent years"

A

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of A. Iron B. Folic acid C. Vitamin B12 D. Vitamin C

B

A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first? a. Assess the patient's pain. b. Orient the patient to the unit. c. Take the patient's vital signs. d. Read the postoperative orders.

C

A widowed mother of four school-age children is hospitalized with metastatic ovarian cancer. The patient is crying and tells the nurse that she does not know what will happen to her children when she dies. Which response by the nurse is the most appropriate? A. "Why don't we talk about the options you have for the care of your children?" B. "I'm sure you have friends that will take the children when you can't care for them" C. "For now you need to concentrate on getting well and not worrying about your children" D. "Many patients with cancer live for a long time, so there is still time to plan for your children"

A

The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care? A. Avoid intramuscular injections B. Encourage increased oral fluids C. Check temperature every 4 hours D. Increase intake of iron-rich foods

A

A patient who has ovarian cancer is crying and tells the nurse, ""my husband rarely visits. He just doesn't care." The husband indicates to the nurse that he never knows what to say to help his wife. Which nursing diagnosis is most appropriate for the nurse to add to the plan of care? A. Compromised family coping related to disruption in lifestyle B. Impaired home maintenance related to perceived role changes C. Risk for caregiver role strain related to burdens of caregiving responsibilities D. Dysfunctional family processes related to effect of illness on family members

D

When caring for a preoperative patient on the day of surgery, which actions included in the plan of care can the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply. A. Teach incentive spirometer use B. Explain preoperative routine care C. Obtain and document baseline vitals signs D. Remove nail polish and apply pulse oximeter E. Transport the patient by stretcher to the operating room

C, D, E

A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitation at rest. The nurse would expect the patient's laboratory findings to include A. A hematocrit of 38% B. an RBC count of 4,500,000 C. Normal red blood cell indices D. A hemoglobin of 8.6

D

A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding? A. Hematocrit 35% B. Hemoglobin of 11.8 C. Platelet count of 400,000 D. White blood cell (WBC) count of 2800

D

The nurse is caring for a patient with left-sided lung cancer. Which finding would be most important for the nurse to report to the health care provider? A. Hematocrit 32% B. Pain with deep inspiration C. Serum Sodium 126 mEq/L D. Decreased breath sounds on left side

C

After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first? A. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating B. Patient who has 30mL of sanguineous drainage in the wound drain 10 hours after hip replacement sugery C. Patient who has bibasilar crackles and a temperature of 100 degrees F on the first postoperative day after chest surgery D. Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) administration

A

The nurse caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee will a. immobilize the joint. b. apply heat to the knee. c. assist the patient with light weight bearing. d. perform passive range of motion to the knee.

A

When caring for patient who is pancytopenic, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene? A. The UAP assists the patient to use dental floss after eating B. The UAP adds baking soda to the patinet's saline oral rinses C. The UAP puts fluoride toothpaste on the patient's toothbrush D. The UAP has the patient rinse after meals with a saline solution

A

Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the physician? a. Leg bruises b. Tarry stools c. Skin abrasions d. Bleeding gums

B

A 38-year-old female is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery? A. The patient's lack of knowledge about postoperative pain control measures B. The patient's statement that her last menstrual period was 8 weeks previously C. The patient's history of a postoperative infection following a prior cholecystectomy The patient's concern that she will be unable to care for her children postoperatively

B

An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hour in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider? a. Patient complains of severe fatigue. b. Patient needs to void every hour during the day. c. Patient takes only 50% of meals and refuses snacks. d. Patient has audible crackles to the midline posterior chest.

D

Which action will the nurse include in the plan of care for a 72-year-old woman admitted with multiple myeloma? a. Monitor fluid intake and output. b. Administer calcium supplements. c. Assess lymph nodes for enlargement. d. Limit weight bearing and ambulation.

A

Which statement by a patient schedule for surgery is most important to report to the health care provider? A. "I had a heart valve replacement last year" B. "I had bacterial pneumonia 3 months ago" C. "I have knee pain whenever I walk or jog" D. "I have a strong family history of breast cancer"

A

While ambulating in the room, a patient complains of feeling dizzy. In what order will the nurse accomplish the following activities? a. Have the patient sit down in a chair. b. Give the patient something to drink. c. Take the patient's blood pressure (BP). d. Notify the patient's health care provider

A, C, B, D

The nurse at the clinic is interviewing a 64-year-old woman who is 5 feet, 3 inches tall and weight 125 pound. The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk? Select all that apply. A. Pap testing B. Tobacco use C. Sunscreen use D.Mammography E. Colorectal screening

A, C, D, E

A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan? Select all that apply A. Cook food thoroughly before eating B. Choose low fiber, low residue foods C. Avoid public transportation such as buses D. Use rectal suppositories if needed for consitipation E. Talk to the oncologist before having any dental work done

A, C, E

On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate? a. Increase the IV fluid rate. b. Continue to take vital signs every 15 minutes. c. Administer oxygen therapy at 100% per mask. d. Notify the anesthesia care provider (ACP) immediately.

B

A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to maintain the patient's self-esteem? a. Tell the patient to limit social contacts until regrowth of the hair occurs. b. Encourage the patient to purchase a wig or hat and wear it once hair loss begins. c. Teach the patient to gently wash hair with a mild shampoo to minimize hair loss. d. Inform the patient that hair usually grows back once the chemotherapy is complete.

B

A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching? a. The patient ambulates several times a day in the room. b. The patient's visitors bring in some fresh peaches from home. c. The patient cleans with a warm washcloth after having a stool. d. The patient uses soap and shampoo to shower every other day.

B

A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action should the nurse take? A. Withhold the usual scheduled insulin dose because the patient is NPO. B. Obtain a blood glucose measurement before any insulin administration C. Give the patient the usual insulin dose because stress will increase the blood glucose D. Administer a lower dose of insulin because there will be no oral intake before surgery

B

A patient who has never had any prior surgeries tells the nurse doing the preoperative assessment about an allergy to bananas and avocados. Which action is most important for the nurse to take? A.Notify the dietitian about the food allergies B. Alert the surgery center about a possible latex allergy C. Reassure the patient that all allergies are noted on the medical record D. Ask whether the patient uses antihistamines to reduce allergic reactions

B

A patient with Hodgkin's lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." Which intervention should the nurse add to the plan of care? a. Minimize activity until the treatment is completed. b. Establish time to take a short walk almost every day. c. Consult with a psychiatrist for treatment of depression. d. Arrange for delivery of a hospital bed to the patient's home.

B

An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to a. provide a diet high in vitamin K. b. alternate periods of rest and activity. c. teach the patient how to avoid injury. d. place the patient on protective isolation.

B

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient? A. Potential complication: hypovolemic shock B. Potential complication: venous thromboembolism C. Potential complication: fluid and electrolyte imbalance D. Potential complication: impaired surgical wound healing

B

In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72, pulse 74, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take? A. Place the patient in a side-lying position B. Encourage the patient to take deep breaths C. Prepare to transfer the patient to a clinical unit D. Increase the rate of the postoperative IV fluid

B

The health care provider's progress note for a patient states that the complete blood count (CBC) shows "shift to the left." Which assessment finding will the nurse expect? A. Cool extremities B. Pallor and weakness C. Elevated temperature D. Low oxygen saturation

C

Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first? a. 44-year-old with sickle cell anemia who says "my eyes always look sort of yellow" b. 23-year-old with no previous health problems who has a nontender lump in the axilla c. 50-year-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue d. 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement

B

The home health nurse cares for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment? a. "I have frequent muscle aches and pains." b. "I rarely have the energy to get out of bed." c. "I experience chills after I inject the interferon." d. "I take acetaminophen (Tylenol) every 4 hours."

B

The nurse is planning to administer a transfusion of packed red blood cells to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to UAP A. Verify the patient indentification according to hospital policy B. Obtain the temperature, blood pressure, and pulse before the transfusion C. Double-check the product numbers on the pRBCs with the patient ID band D. Monitor the patient for shortness of breath or chest pain during the transfusion

B

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I do not really understand what the doctor said." Which action is best for the nurse to take? A. Provide an explanation of the planned surgical procedure B. Notify the surgeon that the informed consent process is not complete C. Administer the prescribed preoperative antibiotics and withhold any ordered sedative medications D. Notify the operating room staff that the surgeon needs to give a more complete explanation of the procedure

B

The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the A. Schilling test B. Bilirubin level C. Stool occult blood test D. Gastric analysis testing

B

Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help with the transfer of a patient to the clinical unit? a. Clarify the postoperative orders with the surgeon. b. Help with the transfer of the patient onto a stretcher. c. Document the appearance of the patient's incision in the chart. d. Provide hand off communication to the surgical unit charge nurse.

B

Which patient requires the most rapid assessment and care by the emergency department nurse? a. The patient with hemochromatosis who reports abdominal pain b. The patient with neutropenia who has a temperature of 101.8° F c. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours d. The patient with thrombocytopenia who has oozing after having a tooth extracted

B

A 52-year-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states, "I A. need to start eating more red meat and liver" B. will stop having a glass of wine with dinner" C. could choose nasal spray rather than injection of vitamin B12 D. will need to take a proton pump inhibitor like omeprazole"

C

A patient who has severe pain associated with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective? A. The patient uses the ordered opioid pain medication whenever the pain is greater than 5 (0 to 10 scale) B. The patient agrees to take the medications by the IV route in order to improve analgesic effectiveness C. The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs. D. The patient states that nonopioid analgesics may be used when the maximal dose of the opioid is reached without adequate pain relief

C

A patient who is scheduled for a right breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct? A. Benign tumors do not cause damage to other tissues B. Benign tumors are likely to recur in the same location C. Malignant tumors may spread to other tissues or organs D. Malignant cells reproduce more rapidly than normal cells

C

A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action is most appropriate? A. Add strained baby meats to foods such as casseroles B. Teach the patient about foods that are high in nutrition. C. Avoid giving the patient foods that are strongly disliked D. Add extra spice to enhance the flavor of foods that are served

C

After change-of-shift report on the oncology unit, which patient should the nurse assess first? a. Patient who has a platelet count of 82,000/µL after chemotherapy b. Patient who has xerostomia after receiving head and neck radiation c. Patient who is neutropenic and has a temperature of 100.5° F (38.1° C) d. Patient who is worried about getting the prescribed long-acting opioid on time

C

During a routine health examination, a 40-year-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next? a. Teach the patient about the need for a colonoscopy at age 50. b. Teach the patient how to do home testing for fecal occult blood. c. Obtain more information from the patient about the family history. d. Schedule a sigmoidoscopy to provide baseline data about the patient.

C

During the teaching session for a patient who has a new diagnosis of acute leukemia the patient is restless and is looking away, never making eye contact. After teaching about the complications associated with chemotherapy, the patient asks the nurse to repeat all of the information. Based on this assessment, which nursing diagnosis is most appropriate for the patient? a. Risk for ineffective adherence to treatment related to denial of need for chemotherapy b. Acute confusion related to infiltration of leukemia cells into the central nervous system c. Risk for ineffective health maintenance related to anxiety about new leukemia diagnosis d. Deficient knowledge: chemotherapy related to a lack of interest in learning about treatment

C

The nurse is caring for a patient who has been diagnosed with stage 1 cancer of the colon . When assessing the need for psychologic support, which question by the nurse will provide the most information? A. "How long ago where you diagnosed with this cancer? B. "Do you have any concerns about body images changes?" C. "Can you tell me what has been helpful to you in the past when coping with stressful events?" D. "Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon?"

C

The nurse is caring for a patient who smokes 2 packs/day. To reduce the patient's risk of lung cancer, which action by the nurse is the best? A. Teach the patient about the seven warning signs of cancer B. Plan to monitor the patient's carcinoembryonic antigen (CEA) level C. Discuss the risks associated with cigarettes during every patient encounter D. Teach the patient about the use of annual chest x-rays for lung cancer screening

C

The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first? a. 35-year-old patient who has wet desquamation associated with abdominal radiation b. 42-year-old patient who is sobbing after receiving a new diagnosis of ovarian cancer c. 24-year-old patient who received neck radiation and has blood oozing from the neck d. 56-year-old patient who developed a new pericardial friction rub after chest radiation

C

Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assessing the patient for signs and symptoms of infection b. Teaching the patient the purpose of neutropenic precautions c. Administering subcutaneous filgrastim (Neupogen) injection d. Developing a discharge teaching plan for the patient and family

C

A patient who has been receiving a heparin infusion and warfarin (Coumadin) for deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when her platelet level drops to 110,000. Which action will the nurse include in the plan of care? A. Use low-molecular-weight heparin only B. Administer the warfarin at the scheduled time C. Teach the patient about the purpose of platelet tranfusions D. Discontinue heparin and flush intermittent IV lines using normal saline

D

A patient who takes a diuretic and a beta-blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the health care provider before surgery? A. Hematocrit 36% B. Blood pressure 144/82 C. Pulse 58 beats per min D. Serum potassium 3.2

D

The nurse reviews the complete blood count (CBC) and white blood cell (WBC) differential of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider? a. Monocytes 4% b. Hemoglobin 13.6 g/dL c. Platelet count 168,000/µL d. White blood cells (WBCs) 15,500/µL

D

The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider? A. Hematocrit of 30% B. Platelets of 95,000 C. Hemoglobin of 10 D. White blood cell (WBC) count of 2700

D

The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective? a. "After cancer has not recurred for 5 years, it is considered cured." b. "The cancer will be cured if the entire tumor is surgically removed." c. "Cancer is never considered cured, but the tumor can be controlled with surgery, chemotherapy, and radiation." d. "I will need to have follow-up examinations for many years after I have treatment before I can be considered cured."

D

The outpatient surgery nurse reviews the complete (CBC) count results for a patient who is scheduled for surgery in a few days. The results are white blood cell (WBC) count 10.2 x 10^3, hemoglobin 15g/dL; hematocrit 45%; platelets 150 x 10^3. Which action should the nurse take? A. Call the surgeon and anesthesiologist immediately B. Ask the patient about any symptoms of a recent infection C. Discuss the possibility of blood transfusion with the patient. D. Send the patient to the holding area when the operating room calls.

D

When assessing a newly admitted patient, the nurse notes pallor of the skin and nail beds. The nurse should ensure that which laboratory test has been ordered? A. Platelet count B. Neutrophil count C. White blood cell count D. Hemoglobin count

D

Which action should the nurse take when caring for a patient who is receiving chemotherapy and complains of problems with concentration? A. Teach the patient to rest the brain by avoiding new activities B. Teach that "chemo-brain" is a short-term effect of chemotherapy C. Report patient symptoms immediately to the health care provider D. Suggest use of a daily planner and encourage adequate rest and sleep

D