AH 2 EXAM 1
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.
Which patient statement indicates that the nurses teaching about tamoxifen (Nolvadex) has been effective? a. I can expect to have leg cramps. b. I will call if I have any eye problems. c. I should contact you if I have hot flashes. d. I will be taking the medication for 6 to 12 months
B.
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 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. cobalamin (vitamin B12). d. ascorbic acid (vitamin C).
b. folic acid.
The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider? a. Generalized muscle aches b. Complaints of nausea and anorexia c. Oral temperature of 100.6 F (38.1 C) d. Crackles heard at the lower scapular border
d. Crackles heard at the lower scapular border
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. Dysfunctional family processes related to effect of illness on family members
The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect? a. Nausea b. Alopecia c. Mucositis d. Hematuria
d. Hematuria
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 constipation. e. Talk to the oncologist before having any dental work done.
A, C, E
The nurse at the clinic is interviewing a 64-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg). 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 19-year-old woman with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets? a. The platelet count is 42,000/mL. b. Petechiae are present on the chest. c. Blood pressure (BP) is 94/56 mm Hg. d. Blood is oozing from the venipuncture site.
A.
A 51-year-old patient with a small immobile breast lump is considering having a fine-needle aspiration (FNA) biopsy. The nurse explains that an advantage to this procedure is that a. FNA is done in the outpatient clinic and results are available in 1 to 2 days. b. only a small incision is needed, resulting in minimal breast pain and scarring. c. if the biopsy results are negative, no further diagnostic testing will be needed. d. FNA is guided by a mammogram, ensuring that cells are taken from the lesion.
A.
A patient who is scheduled for a lumpectomy and axillary lymph node dissection tells the nurse, I would rather not know much about the surgery. Which response by the nurse is best? a. Tell me what you think is important to know about the surgery. b. It is essential that you know enough to provide informed consent. c. Many patients do better after surgery if they have more information. d. You can wait until after surgery for teaching about pain management.
A.
A student nurse prepares a list of teaching topics for a patient with a new diagnosis of breast cancer. Which item should the charge nurse suggest that the student nurse omit from the teaching topic list about breast cancer diagnostic testing? a. CA 15-3 level testing b. HER-2 receptor testing c. Estrogen receptor testing d. Oncotype DX assay testing
A.
An appropriate nursing intervention for a patient with non-Hodgkins lymphoma whose platelet count drops to 18,000/L during chemotherapy is to a. check all stools for occult blood. b. encourage fluids to 3000 mL/day. c. provide oral hygiene every 2 hours. d. check the temperature every 4 hours.
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 using the accompanying illustration to teach a patient about breast self-examination, the nurse will include the information that most breast cancers are located in which part of the breast? a. 1 b. 2 c. 3 d. 4 e. 5
A.
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 information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider? a. Serum calcium level is 15 mg/dL. b. Patient reports no stool for 5 days. c. Urine sample has Bence-Jones protein. d. Patient is complaining of severe back pain
A.
Which information will the nurse include in patient teaching for a 36-year-old patient who is scheduled for stereotactic core biopsy of the breast? a. A local anesthetic will be given before the biopsy specimen is obtained. b. You will need to lie flat on your back and lie very still during the biopsy. c. A thin needle will be inserted into the lump and aspirated to remove tissue. d. You should not have anything to eat or drink for 6 hours before the procedure.
A.
Which patient should the nurse assign as the roommate for a patient who has aplastic anemia? a. A patient with chronic heart failure b. A patient who has viral pneumonia c. A patient who has right leg cellulitis d. A patient with multiple abdominal drains
A.
A 30-year-old man with acute myelogenous leukemia develops an absolute neutrophil count of 850/L while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate? a. Discuss the need for hospital admission to treat the neutropenia. b. Teach the patient to administer filgrastim (Neupogen) injections. c. Plan to discontinue the chemotherapy until the neutropenia resolves. d. Order a high-efficiency particulate air (HEPA) filter for the patients home.
B.
. A 33-year-old patient has a saline breast implant inserted in the outpatient surgery area. Which instruction will the nurse include in the discharge teaching? a. Take aspirin every 4 hours to reduce inflammation. b. Check wound drains for excessive blood or a foul odor. c. Wear a loose-fitting bra to decrease irritation of the sutures. d. Resume normal activities 2 to 3 days after the mammoplasty.
B.
. The nurse notes bilateral enlargement of the breasts during examination of a 62-year-old man. Which action should the nurse take first? a. Teach the patient how to palpate the breast tissue for lumps. b. Question the patient about medications being currently used. c. Refer the patient for mammography and biopsy of the breast tissue. d. Explain that this is a temporary condition due to hormonal changes.
B.
A 28-year-old man with von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the a. platelet count. b. bleeding time. c. thrombin time. d. prothrombin time
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) injections. c. Use rinses rather than a soft toothbrush for oral care. d. Restrict activity to passive and active range of motion
B.
A 36-year-old who has a diagnosis of fibrocystic breast changes calls the nurse in the clinic with symptoms. Which is most important to report to the health care provider? a. There is yellow-green discharge from the patients right nipple. b. There is an area on the breast that is hot, pink, and tender to touch. c. The lumps are firm and most are in the upper outer breast quadrants. d. The lumps are larger and painful before the patients menstrual period.
B.
A 58-year-old woman tells the nurse, I understand that I have stage II breast cancer and I need to decide on a surgery, but I feel overwhelmed. What do you think I should do? Which response by the nurse is best? a. I would have a lumpectomy, but you need to decide what is best for you. b. Tell me what you understand about the surgical options that are available. c. It would not be appropriate for me to make a decision about your health. d. There is no need to make a decision rapidly; you have time to think about this.
B.
A 68-year-old woman with acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate? a. If you do not want to have chemotherapy, other treatment options include stem cell transplantation. b. The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy. c. The decision about treatment is one that you and the doctor need to make rather than asking what I would do. d. You dont need to make a decision about treatment right now because leukemias in adults tend to progress quite slowly.
B.
A patient with a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient? a. Infuse the PRBCs slowly over 4 hours. b. Transfuse only leukocyte-reduced PRBCs. c. Administer the scheduled diuretic before the transfusion. d. Give the PRN dose of antihistamine before the transfusion.
B.
A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? a. Avoid venipunctures. b. Notify the patients physician. c. Apply sterile dressings to the sites. d. Give prescribed proton-pump inhibitors
B.
A routine complete blood count indicates that an active 80-year-old man may have myelodysplastic syndrome. The nurse will plan to teach the patient about a. blood transfusion b. bone marrow biopsy. c. filgrastim (Neupogen) administration. d. erythropoietin (Epogen) administration.
B.
After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first? a. 56-year-old with frequent explosive diarrhea b. 33-year-old with a fever of 100.8 F (38.2 C) c. 66-year-old who has white pharyngeal lesions d. 23-year old who is complaining of severe fatigue
B.
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 replacemen
B.
The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Verify the patient identification (ID) 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 providing preoperative teaching about the transverse rectus abdominis musculocutaneous (TRAM) procedure to a patient. Which information will the nurse include? a. Saline-filled implants are placed under the pectoral muscles. b. Recovery from the TRAM surgery takes at least 6 to 8 weeks. c. Muscle tissue removed from the back is used to form a breast. d. TRAM flap procedures may be done in outpatient surgery centers.
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.
The nurse provides discharge teaching for a 61-year-old patient who has had a left modified radical mastectomy and lymph node dissection. Which statement by the patient indicates that teaching has been successful? a. I will need to use my right arm and to rest the left one. b. I will avoid reaching over the stove with my left hand. c. I will keep my left arm in a sling until the incision is healed. d. I will stop the left arm exercises if moving the arm is painful.
B.
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 assessment finding in a 36-year-old patient is most indicative of a need for further evaluation? a. Bilateral breast nodules that are tender with palpation b. A breast nodule that is 1 cm in size, nontender, and fixed c. A breast lump that increases in size before the menstrual period d. A breast lump that is small, mobile, with a rubbery consistency
B.
Which information obtained by the nurse caring for a patient with thrombocytopenia should be immediately communicated to the health care provider? a. The platelet count is 52,000/L. b. The patient is difficult to arouse. c. There are purpura on the oral mucosa. d. There are large bruises on the patients back.
B.
Which information should the nurse include in teaching a patient who is scheduled for external beam radiation to the breast? a. The radiation therapy will take a week to complete. b. Careful skin care in the radiated area will be necessary. c. Visitors are restricted until the radiation therapy is completed. d. Wigs may be used until the hair regrows after radiation therapy.
B.
Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? a. Hematocrit 55% b. Presence of plethora c. Calf swelling and pain d. Platelet count 450,000/mL
C
A 53-year-old woman at menopause is discussing the use of hormone therapy (HT) with the nurse. Which information about the risk of breast cancer will the nurse provide? a. HT is a safe therapy for menopausal symptoms if there is no family history ofBRCA genes. b. HT does not appear to increase the risk for breast cancer unless there are other risk factors. c. The patient and her health care provider must weigh the benefits of HT against the risks of breast cancer. d. Natural herbs are as effective as estrogen in relieving symptoms without increasing the risk of breast cancer.
C.
A 54-year-old woman with acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to a. emphasize the positive outcomes of a bone marrow transplant. b. discuss the need for adequate insurance to cover post-HSCT care. c. ask the patient whether there are any questions or concerns about HSCT. d. explain that a cure is not possible with any other treatment except HSCT.
C.
A patient newly diagnosed with stage I breast cancer is discussing treatment options with the nurse. Which statement by the patient indicates that additional teaching may be needed? a. There are several options that I can consider for treating the cancer. b. I will probably need radiation to the breast after having the surgery. c. Mastectomy is the best choice to decrease the chance of cancer recurrence. d. I can probably have reconstructive surgery at the same time as a mastectomy.
C.
A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102 F (38.9 C), and severe back pain. Which physician order will the nurse implement first? a. Administer morphine sulfate 4 mg IV. b. Give acetaminophen (Tylenol) 650 mg. c. Infuse normal saline 500 mL over 30 minutes. d. Schedule complete blood count and coagulation studies.
C.
A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take? a. Draw blood for a new crossmatch. Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 343 b. Send a urine specimen to the laboratory. c. Administer PRN acetaminophen (Tylenol). d. Give the PRN diphenhydramine (Benadryl)
C.
After a 48-year-old patient has had a modified radical mastectomy, the pathology report identifies the tumor as an estrogen-receptor positive adenocarcinoma. The nurse will plan to teach the patient about a. estradiol (Estrace). b. raloxifene (Evista). c. tamoxifen (Nolvadex). d. trastuzumab (Herceptin).
C.
During a well woman physical exam, a 43-year-old patient asks about her risk for breast cancer. Which question is most pertinent for the nurse to ask? a. Do you currently smoke tobacco? b. Have you ever had a breast injury? c. At what age did you start having menstrual periods? d. Is there a family history of fibrocystic breast changes?
C.
The nurse is caring for a 52-year-old patient with breast cancer who is receiving chemotherapy with doxorubicin (Adriamycin) and cyclophosphamide (Cytoxan). Which assessment finding is most important to communicate to the health care provider? a. The patient complains of fatigue. b. The patient eats only 25% of meals. c. The patients apical pulse is irregular. d. The patients white blood cell (WBC) count is 5000/L.
C.
When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care? a. Discourage deep breathing to reduce risk for splenic rupture. b. Teach the patient to use ibuprofen (Advil) for left upper quadrant pain. c. Schedule immunization with the pneumococcal vaccine (Pneumovax). d. Avoid the use of acetaminophen (Tylenol) for 2 weeks prior to surgery.
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.
Which action will the nurse include in the plan of care for a patient who has thalassemia major? a. Teach the patient to use iron supplements. b. Avoid the use of intramuscular injections. c. Administer iron chelation therapy as needed. d. Notify health care provider of hemoglobin 11g/dL.
C.
Which action will the nurse include in the plan of care for a patient with right arm lymphedema? a. Check blood pressure (BP) on both right and left arms. b. Avoid isometric exercise on the right arm. c. Assist with application of a compression sleeve. d. Keep the right arm at or below the level of the heart.
C.
Which instruction will the nurse plan to include in discharge teaching for the patient admitted with a sickle cell crisis? a. Take a daily multivitamin with iron. b. Limit fluids to 2 to 3 quarts per day. c. Avoid exposure to crowds when possible. d. Drink only two caffeinated beverages daily
C.
Which nursing action should be included in the plan of care for a patient returning to the surgical unit following a left modified radical mastectomy with dissection of axillary lymph nodes? a. Obtain a permanent breast prosthesis before the patient is discharged from the hospital. b. Teach the patient to use the ordered patient-controlled analgesia (PCA) every 10 minutes. c. Post a sign at the bedside warning against venipunctures or blood pressures in the left arm. d. Insist that the patient examine the surgical incision when the initial dressings are removed.
C.
. A patient who has non-Hodgkins lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse? a. Anorexia b. Vomiting c. Oral ulcers d. Lip swelling
D.
A critical action by the nurse caring for a patient with an acute exacerbation of polycythemia vera is to a. place the patient on bed rest. b. administer iron supplements. c. avoid use of aspirin products. d. monitor fluid intake and output.
D.
A patient has had left-sided lumpectomy (breast-conservation surgery) and an axillary lymph node dissection. Which nursing intervention is appropriate to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Teaching the patient how to avoid injury to the left arm b. Assessing the patients range of motion for the left arm c. Evaluating the patients understanding of instructions about drain care d. Administering an analgesic 30 minutes before scheduled arm exercises
D.
A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurses first action should be to a. administer oxygen therapy at a high flow rate. b. obtain a urine specimen to send to the laboratory. c. notify the health care provider about the symptoms. d. disconnect the transfusion and infuse normal saline.
D.
A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when her platelet level drops to 110,000/L. Which action will the nurse include in the plan of care? a. Use low-molecular-weight heparin (LMWH) only. b. Administer the warfarin (Coumadin) at the scheduled time. c. Teach the patient about the purpose of platelet transfusions. d. Discontinue heparin and flush intermittent IV lines using normal saline.
D.
Following successful treatment of Hodgkins lymphoma for a 55-year-old woman, which topic will the nurse include in patient teaching? a. Potential impact of chemotherapy treatment on fertility b. Application of soothing lotions to treat residual pruritus c. Use of maintenance chemotherapy to maintain remission d. Need for follow-up appointments to screen for malignancy
D.
The nurse is admitting a patient scheduled this morning for lumpectomy and axillary lymph node dissection. Which action should the nurse take first? a. Teach the patient how to deep breathe and cough. b. Discuss options for postoperative pain management. c. Explain the postdischarge care of the axillary drains. d. Ask the patient to describe what she knows about the surgery
D.
The nurse teaching a young womens community service group about breast self-examination (BSE) will include that a. BSE will reduce the risk of dying from breast cancer. b. BSE should be done daily while taking a bath or shower. c. annual mammograms should be scheduled in addition to BSE. d. performing BSE after the menstrual period is more comfortable
D.
The nurse will anticipate teaching a 56-year-old patient who is diagnosed with lobular carcinoma in situ (LCIS) about a. lumpectomy. b. lymphatic mapping. c. MammaPrint testing. d. tamoxifen (Nolvadex).
D.
The nurse will teach a patient with metastatic breast cancer who has a new prescription for trastuzumab (Herceptin) that a. hot flashes may occur with the medication. b. serum electrolyte levels will be drawn monthly. c. the patient will need frequent eye examinations. d. the patient should call if she notices ankle swelling
D.
The outpatient clinic receives telephone calls from four patients. Which patient should the nurse call back first? a. 57-year-old with ductal ectasia who has sticky multicolored nipple discharge and severe nipple itching b. 21-year-old with a family history of breast cancer who wants to discuss genetic testing for the BRCA gene c. 40-year-old who still has left side chest and arm pain 2 months after a left modified radical mastectomy d. 50-year-old with stage 2 breast cancer who is receiving doxorubicin (Adriamycin) and has ankle swelling and fatigue
D.
When the nurse is working in the womens health care clinic, which action is appropriate to take? a. Teach a healthy 30-year-old about the need for an annual mammogram. b. Discuss scheduling an annual clinical breast examination with a 22-year-old. c. Explain to a 60-year-old that mammography frequency can be reduced to every 3 years. d. Teach a 28-year-old with a BRCA-1 mutation about magnetic resonance imaging (MRI).
D.
Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin induced thrombocytopenia (HIT)?\ a. Prothrombin time b. Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time
D.
Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy? a. Platelet count b. Reticulocyte count c. Total lymphocyte count d. Absolute neutrophil count
D.
Which patient information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis? a. Skin color b. Hematocrit c. Liver function d. Serum iron level
D.
Which statement by a patient indicates good understanding of the nurses teaching about prevention of sickle cell crisis? a. Home oxygen therapy is frequently used to decrease sickling. b. There are no effective medications that can help prevent sickling. c. Routine continuous dosage narcotics are prescribed to prevent a crisis. d. Risk for a crisis is decreased by having an annual influenza vaccination.
D.
A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective? a. I can buy some aloe vera gel to use on the area. b. I will expose the treatment area to a sun lamp daily. c. I can use ice packs to relieve itching in the treatment area. d. I will scrub the area with warm water to remove the scales.
a. I can buy some aloe vera gel to use on the area.
Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? a. I will call my health care provider if my stools turn black. b. I will take a stool softener if I feel constipated occasionally. c. I should take the iron with orange juice about an hour before eating. d. I should increase my fluid and fiber intake while I am taking iron tablets.
a. I will call my health care provider if my stools turn black.
Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient? a. IL-2 enhances the immunologic response to tumor cells. b. IL-2 stimulates malignant cells in the resting phase to enter mitosis. c. IL-2 prevents the bone marrow depression caused by chemotherapy. d. IL-2 protects normal cells from the harmful effects of chemotherapy
a. IL-2 enhances the immunologic response to tumor cells.
Which menu choice indicates that the patient understands the nurses teaching about best dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast b. Cantaloupe and cottage cheese c. Strawberry and banana fruit plate d. Cornmeal muffin and orange juice
a. Omelet and whole wheat toast
The nurse assesses a patient with non-Hodgkins lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse? a. Shortness of breath b. Temperature 100.2 F (37.9 C) c. Shivering and complaint of chills d. Generalized muscle aches and pains
a. Shortness of breath
When caring for a 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 patients saline oral rinses. c. The UAP puts fluoride toothpaste on the patients toothbrush. d. The UAP has the patient rinse after meals with a saline solution
a. The UAP assists the patient to use dental floss after eating.
A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is most appropriate? a. The cancer involves only the cervix. b. The cancer cells look almost like normal cells. c. Further testing is needed to determine the spread of the cancer. d. It is difficult to determine the original site of the cervical cancer
a. The cancer involves only the cervix.
The nurse is caring for a patient with colon cancer who is scheduled for external radiation therapy to the abdomen. Which information obtained by the nurse would indicate a need for patient teaching? a. The patient swims a mile 3 days a week. b. The patient snacks frequently during the day. c. The patient showers everyday with a mild soap. d. The patient has a history of dental caries with amalgam fillings.
a. The patient swims a mile 3 days a week.
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 most appropriate? a. Why dont we talk about the options you have for the care of your children? b. Im sure you have friends that will take the children when you cant 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. Why dont we talk about the options you have for the care of your children?
A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first? a. Give the patient the prescribed PRN opioid. b. Assess for sensation and strength in the legs. c. Notify the health care provider about the symptoms. d. Teach the patient how to use relaxation to reduce pain
b. Assess for sensation and strength in the legs.
The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective? a. Lime sherbet b. Blueberry yogurt c. Cream cheese bagel d. Fresh strawberries and bananas
b. Blueberry yogurt
A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to maintain the patients 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. Encourage the patient to purchase a wig or hat and wear it once hair loss begins.
A patient with Hodgkins 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 patients home.
b. Establish time to take a short walk almost every day.
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. I rarely have the energy to get out of bed.
Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia? a. Potential complication: seizures b. Potential complication: infection c. Potential complication: neurogenic shock d. Potential complication: pulmonary edema
b. Potential complication: infection
The nurse should include which food choice when providing dietary teaching for a patient scheduled to receive external beam radiation for abdominal cancer? a. Fresh fruit salad b. Roasted chicken c. Whole wheat toast d. Cream of potato soup
b. Roasted chicken
The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? a. Infuse the medication over a short period of time. b. Stop the infusion if swelling is observed at the site. c. Administer the chemotherapy through a small-bore catheter. d. Hold the medication unless a central venous line is available.
b. Stop the infusion if swelling is observed at the site.
The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention? a. The UAP flushes the toilet once after emptying the patients bedpan. b. The UAP stands by the patients bed for 30 minutes talking with the patient. c. The UAP places the patients bedding in the laundry container in the hallway. d. The UAP gives the patient an alcohol-containing mouthwash to use for oral care.
b. The UAP stands by the patients bed for 30 minutes talking with the patient.
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 patients 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. The patients visitors bring in some fresh peaches from home.
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. alternate periods of rest and activity.
It is important for the nurse providing care for a patient with sickle cell crisis to a. limit the patients intake of oral and IV fluids. b. evaluate the effectiveness of opioid analgesics. c. encourage the patient to ambulate as much as tolerated. d. teach the patient about high-protein, high-calorie foods.
b. evaluate the effectiveness of opioid analgesics.
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. 24-year-old patient who received neck radiation and has blood oozing from the neck
A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. Which action, if taken by the nurse, is most appropriate? a. Have the patient eat large meals when nausea is not present. b. Offer dry crackers and carbonated fluids during chemotherapy. c. Administer prescribed antiemetics 1 hour before the treatments. d. Give the patient two ounces of a citrus fruit beverage during treatments.
c. Administer prescribed antiemetics 1 hour before the treatments.
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. Avoid giving the patient foods that are strongly disliked.
The nurse is caring for a patient who has been diagnosed with stage I 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 were you diagnosed with this cancer? b. Do you have any concerns about body image 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. Can you tell me what has been helpful to you in the past when coping with stressful events?
External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation? a. Test all stools for the presence of blood. b. Maintain a high-residue, high-fiber diet. c. Clean the perianal area carefully after every bowel movement. d. Inspect the mouth and throat daily for the appearance of thrush.
c. Clean the perianal area carefully after every bowel movement.
The nurse is caring for a patient who smokes 2 packs/day. To reduce the patients risk of lung cancer, which action by the nurse is best? a. Teach the patient about the seven warning signs of cancer. b. Plan to monitor the patients 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. Discuss the risks associated with cigarettes during every patient encounter.
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. Malignant tumors may spread to other tissues or organs.
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. Obtain more information from the patient about the family history.
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/L 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. Patient who is neutropenic and has a temperature of 100.5 F (38.1 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. Risk for ineffective health maintenance related to anxiety about new leukemia diagnosis
The nurse is caring for a patient with left-sided lung cancer. Which finding would bemost 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. Serum sodium 126 mEq/L
The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement, if made by the patient, indicates that teaching was effective? a. The biopsy will remove the cancer in my prostate gland. b. The biopsy will determine how much longer I have to live. c. The biopsy will help decide the treatment for my enlarged prostate. d. The biopsy will indicate whether the cancer has spread to other organs.
c. The biopsy will help decide the treatment for my enlarged prostate.
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. The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs.
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 injections of vitamin B12 d. will need to take a proton pump inhibitor like omeprazole (Prilosec).
c. could choose nasal spray rather than injections of vitamin B12
A patient has been assigned the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers. Which nursing action will be most effective in improving oral intake? a. Offer the patient frequent small snacks between meals. b. Assist the patient to choose favorite foods from the menu. c. Provide teaching about the importance of nutritional intake. d. Apply the ordered anesthetic gel to oral lesions before meals.
d. Apply the ordered anesthetic gel to oral lesions before meals.
A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). The nurse will include which information in the patients teaching plan? a. Transplant of the donated cells is painful because of the nerves in the tissue lining the bone. b. Donor bone marrow cells are transplanted through an incision into the sternum or hip bone. c. The transplant procedure takes place in a sterile operating room to minimize the risk for infection. d. Hospitalization will be required for several weeks after the stem cell transplant procedure is performed.
d. Hospitalization will be required for several weeks after the stem cell transplant procedure is performed.
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. I will need to have follow-up examinations for many years after I have treatment before I can be considered cured.
The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in therapy with the health care provider? a. Poor oral intake b. Frequent loose stools c. Complaints of nausea and vomiting d. Increase in carcinoembryonic antigen (CEA)
d. Increase in carcinoembryonic antigen (CEA)
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 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. Patient has audible crackles to the midline posterior chest.
A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient? a. Remove food debris from the teeth and oral mucosa with a stiff toothbrush. b. Use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth. c. Gargle and rinse the mouth several times a day with an antiseptic mouthwash. d. Rinse the mouth before and after each meal and at bedtime with a saline solution
d. Rinse the mouth before and after each meal and at bedtime with a saline solution
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. Suggest use of a daily planner and encourage adequate rest and sleep.
A patient with a large stomach tumor that is attached to the liver is scheduled to have a debulking procedure. Which information should the nurse teach the patient about the outcome of this procedure? a. Pain will be relieved by cutting sensory nerves in the stomach. b. Relief of pressure in the stomach will promote better nutrition. c. Tumor growth will be controlled by the removal of malignant tissue. d. Tumor size will decrease and this will improve the effects of other therapy.
d. Tumor size will decrease and this will improve the effects of other therapy.
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/L c. Hemoglobin of 10 g/L d. White blood cell (WBC) count of 2700/L
d. White blood cell (WBC) count of 2700/L The low WBC count places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that WBC growth factors such as filgrastim (Neupogen) are needed. Although the other laboratory data indicate decreased levels, they do not indicate any immediate life-threatening adverse effects of the chemotherapy.
A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patients laboratory findings to include a. a hematocrit (Hct) of 38%. b. an RBC count of 4,500,000/mL. c. normal red blood cell (RBC) indices. d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).
d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).
