ch 16,17,18
The client has finished the first round of chemotherapy. Which statement made by the client indicates a need for further teaching by the nurse?
"I can continue taking my vitamins and herbs because they make me feel better."
The nurse is caring for a client is scheduled for chemotherapy followed by autologous stem cell transplant. Which of the following statements by the client indicates a need for further teaching?
"I hope they find a bone marrow donor who matches."
The nurse is initiating intravenous therapy for a client who is in shock. Which ratio of fluid to fluid lost is anticipated?
3:01
The nurse is correct to state that a client's body needs to have adequate nutrition to maintain energy. Which type of transport of dissolved substances requires adenosine triphosphate (ATP)?
Active transport
The nurse is instructing on the body's negative feedback loop to ensure homeostasis to a class of sixth graders. Which action by bases keeps the blood pH nearly neutral?
Bases bind with hydrogen.
A cancer client makes the following statement to the nurse: "I guess I will tell my doctor to forego the chemotherapy. I do not want to be throwing up all the time. I would rather die." Which of the following facts supports the use of chemotherapy for this client?
Chemotherapy treatment can be adjusted to optimize effects while limiting adverse effects
The nurse receives report that a client's pH level is 7.4. Which nursing action would be most appropriate?
Complete a head-to-toe assessment.
The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration?
Dark, concentrated urine
The physician recommends that you have your daughter vaccinated with HPV vaccine. What is this vaccine for?
Help prevent cervical cancer
When providing care for a client with stage IV cancer, the nurse knows to include which intervention in the plan of care?
Incorporating touching and listening
The nurse is caring for a client with highly pigmented skin. Which assessment technique is used to evaluate cyanosis?
Inspect the conjunctiva.
When the client complains of increased fatigue following radiotherapy, the nurse knows this is most likely to be related to which factor?
Radiation can result in myelosuppression.
The nurse knows that interferon agents are used in association with chemotherapy to produce which effects in the client?
Shorten the period of neutropenia
The nurse is invited to present a teaching program to parents of school-age children. Which topic would be of greatest value for decreasing cancer risks?
Sun safety and use of sunscreen
A bowel resection is scheduled for a client with the diagnosis of colon cancer with metastasis to the liver and bone. Which statement by the nurse best explains the purpose of the surgery?
"Tumor removal will promote comfort."
The registered nurse is receiving a client from the emergency room on a dopamine drip. The registered nurse asks the nurse to prepare the room for the client. The practical nurse obtains an IV pump, sets the bed, arranges the furniture, and places towels and a gown in the bathroom. Which other piece of equipment is essential?
An automatic blood pressure monitoring machine
You are providing client teaching for a client undergoing chemotherapy. What dietary modifications should you advise?
Avoid spicy and fatty foods.
A client is scheduled for a nerve-sparing prostatectomy. The emotional spouse confides in the nurse that the client will not talk about the cancer and/or upcoming surgery. Which nursing diagnosis will the nurse choose as primary diagnosis for this client?
Fear
A newly diagnosed cancer client is crying and states the following to the nurse: "I promised God that I will be a better person if I can just get better." What is the appropriate assessment of this comment by the nurse?
The cancer is viewed as a punishment from past actions
A client with advanced cancer makes the following comment to the nurse: "Why are you bathing me? I am going to die no matter what." What is the most appropriate response of the nurse?
"Would you like to talk about what you are feeling?"
While doing a health history, a client tells you that her mother, grandmother, and sister died of cancer. The client wants to know what she can do to keep from getting cancer. What would be your best response?
"You can't prevent cancer, but you can have your blood analyzed for tumor markers to see what your risk level is."
The nurse is reporting the current nursing assessment to the physician. Vital signs: temperature, 97.2° F; pulse, 68 beats/minute, thready; respiration, 28 breaths/minute, blood pressure, 102/78 mm Hg; and pedal pulses, palpable. The physician asks for the pulse pressure. Which would the nurse report?
24
The nursing instructor is talking with her junior nursing class about fluid and electrolyte balance. What would the instructor tell her students that the average daily fluid intake for an adult is?
2500mL
You are the nurse caring for a client in septic shock. You know to closely monitor your client. What finding would you observe when the client's condition is in its initial stages?
A rapid, bounding pulse
The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply.
An elevated hematocrit level, electrolyte imbalance
The nurse is documenting assessment findings of a client diagnosed with anasarca. Which nursing documentation best shows improvement in disease progression?
Decreased abdominal girth
Which of the following laboratory findings, would be identified by the nurse as the greatest risk for a cancer client scheduled for implantable port?
Platelet count 98,000/mm3
Which of the following can be considered carcinogens?
Dietary substances
The client is receiving a vesicant antineoplastic for treatment of cancer. Which assessment finding would require the nurse to take immediate action?
Extravasation
You are caring for a client with severe hypokalemia. The physician has ordered IV potassium to be administered at10 mEq/hr. The client complains of burning along his vein. What should you do?
Seek a physician's order to dilute the infusion.
You are the nurse caring for a client with shock accompanied by lung congestion. How would you position this client?
Semi-Fowler's with lower extremities raised to approximately 15o
Chemotherapy has been used for the past 3 months to treat a client with pancreatic cancer. The CA 19-9 levels are rising. Which explanation would the nurse attribute as the most likely cause?
The cancer is growing despite the chemotherapy treatment.
The nurse recognizes which of the following alternative therapies as appropriate in the care of cancer clients? Select all that apply.
reminiscing, hot and cold therapy
The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?" Given the client's condition, which statement is most correct?
"The client is in shock because the blood volume has decreased in the system."
The emergency department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG?
Bicarbonate
The nurse is evaluating a client in the intensive care unit to identify improvement in the client's condition. Which outcome does the nurse note as the result of inadequate compensatory mechanisms?
Organ damage
The nurse is assisting the physician with placing a ventricular assist device (VAD). Which assessment finding would confirm the successful implementation?
Pedal pulse stronger
The nurse is providing afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in hypervolemia status?
Weight
Which nursing interventions are most important when implementing care for a client receiving temporary internal sealed radiation therapy? Select all that apply.
time, distance and shielding; count wires, threads or needles every shift; avoid standing in direct path of inplants.
The seasoned nurse is instructing the new graduate on information obtained from central venous pressure and pulmonary artery pressure. Which statement, made by the seasoned nurse, reflects the most pertinent information regarding circulation?
"A pulmonary artery pressure provides information about pressure on the left side of the heart"
A client is recovering from a craniotomy with tumor debulking. Which comment by the client indicates to the nurse a correct understanding of what the surgery entailed?
"I guess the doctor could not remove the entire tumor."
The nurse is caring for a client who does not accept blood or blood products. Which nursing actions conserve blood? Select all that apply.
administer medication to stimulate bone marrow, draw minimum volume of blood for diagnostic tests, reinfuse the client's own blood via closed circuit container, admnister factor viii to stimulate coagulation process
A client is in a driving accident creating a spinal cord injury. The nurse caring for a client realizes that the client is at risk for which type of shock?
Neurogenic
The nurse is assigned a client with calcium level of 4.0 mg/dL. Which system assessment would the nurse ask detailed questions?
Neurological system
A client is experiencing edema in the tissue. The nurse is correct in anticipating which tonicity of intravenous fluid?
No intravenous solution
A 64-year-old client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client?
No, sodium intake should be restricted.
A client with cancer stage T4, N3, M1 is ordered morphine sulfate 4 mg, subcutaneous every 3 to 4 hours. Two hours after the last injection, the client rings the call bell to report a pain scale of 9. Which is the appropriate action by the nurse?
Notify the physician of the breakthrough pain in an attempt to obtain additional orders
The nurse is adding the intake and output results for a client diagnosed with dehydration. The nurse notes a 24-hour intake of 1500 mL/day between oral fluids and intravenous solutions. The output total is calculated as 2800 mL/day from urine output, emesis, and Hemovac drainage. Which nursing action is best to maintain an acceptable fluid balance?
Offer a prescribed antiemetic medication.
The nurse is reviewing client lab work for a critical lab value. Which value is called to the physician for additional orders?
Potassium: 5.8 mEq/L
You are a student nurse being precepted in the ICU. You are caring for a client in the compensatory stage of shock who is hypovolemic. Which compensatory mechanism is most important in the reabsorption and retention of fluid in the body?
Production of antidiuretic hormone and corticosteroid hormones
The nurse is performing hourly assessments on a client in the compensation stage of shock. In documenting the hourly urine output of 40 mL from the Foley catheter, which nursing action is most appropriate?
Record 40 mL as the hourly output.
You are caring for a client in the compensation stage of shock. You know that one of the body's mechanisms of compensation in this stage of shock is the renin-angiotensin-aldosterone system. What does this system do?
Restores blood pressure
You are assessing a 6-year-old little girl in the emergency department (ED) who was brought in by her mother. She was stung by a bee and is allergic to bee venom. The child is now having trouble breathing. She is vasodilated, hypotensive, and has broken out in hives. What do you suspect is wrong with this child?
She is having an allergic reaction and going into anaphylactic shock.
You are a public health nurse giving a talk on the warning signals of cancer to a local community group. Which of the following are the warning signals of cancer? Select all that apply.
Sores that don't heal, unusual bleeding or discharge, persistent indigestion
You are an oncology nurse caring for a client who is taking antineoplastic agents. What adverse symptoms must you monitor for in this client?
Symptoms of gout
The nurse is obtaining physician orders which include a pulse pressure. The nurse is most correct to report which of the following?
The difference between the systolic and diastolic pressure
The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The client asks what is making the acidotic state. The nurse is most correct to identify which result of the disease process that causes the rise in pH?
The lungs are not able to blow off carbon dioxide.
The client is diagnosed with a benign brain tumor. Which of the following features of a benign tumor is of most concern to the nurse?
Tumor pressure against normal tissues
The nurse is caring for the client with massive blood loss from a gunshot wound. With little time to spare, which blood type is infused?
TypeO
The nurse is caring for a client diagnosed with shock. During report, the nurse reports the results of which assessments that signal early signs of the decompensation stage? Select all that apply.
Vital signs, skin color, urine output, peripheral pulses
The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock?
WBC: 42,000/mm3
An elderly client has been diagnosed with metastatic cancer and has a poor prognosis of survival. The family asks the nurse for advice on whether to tell the client of the diagnosis or to keep it quiet. Which is the best response from the nurse?
"In my experience, clients who know are more likely to be involved with their plan of care."
The nurse is caring for a client with the diagnosis of colon cancer with metastasis to the liver. Which statement made by the client indicates an understanding of the diagnosis?
"My cancer has now spread to my liver."
A client with a 4-cm breast mass is scheduled for biopsy with frozen section followed by lumpectomy and possible mastectomy. The client asks the nurse, "Why can't the doctor tell me specifically whether I will need to have my entire breast removed"? Which is the best response from the nurse?
"The frozen section will determine presence of cancer and type of surgery required."
The nurse is caring for a client who is scheduled for chemotherapy. Which is the best statement the nurse can make about the client experiencing chemotherapy-induced alopecia?
"The hair loss is temporary."
The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance?
A 52-year-old with diarrhea
The nurse is caring for a client with frequent dizziness. The nurse is evaluating the client for postural hypotension. Which of the following symptoms would indicate a potential diagnosis?
A drop in systolic blood pressure (15 mm Hg) upon rising
The nurse is caring for a client prescribed a low sodium diet. Which food, identified as a client favorite, will the nurse discourage?
A hot dog with catsup
The client is scheduled for a breast lump excision and sentinel node biopsy. What should the nurse know in planning care for the client with a negative biopsy report?
A wide excision of lump will be performed.
What is one process by which dissolved chemicals from one area of the body to another?
Active transport
Following surgery for adenocarcinoma, the client learns the tumor stage is T3, N1, M0. What treatment mode will the nurse anticipate?
Adjuvant therapy is likely.
A client presents to the community health office experiencing rapidly increasing symptoms of anaphylactic shock. Which nursing action would be completed first?
Administer an epinephrine injection.
You are caring for a client in shock who is deteriorating. You are infusing IV fluids and giving medications as ordered. What type of medications are you most likely giving to this client?
Adrenergic drugs
The nurse is caring for a client diagnosed with hypovolemic shock. Which outcome would be the best evidence of an improvement in client condition?
Alertness in level of consciousness
The nurse is caring for a client who has progressed to the decompensation stage of shock. Which intravenous medication does the nurse anticipate as a prophylactic means to prevent complications?
Heparin
A client diagnosed with cancer has his tumor staged and graded based on what factors?
How they tend to grow and the cell type
You are caring for a client who has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. You know that you should take extra care to check for signs of bruising or bleeding in what condition?
Hypocalcemia
Which of the following conditions does the nurse need to confirm when he or she taps the facial nerve of a client who has dysphagia?
Hypomagnesemia
You are caring for a client with shock. You are concerned about hypoxemia and metabolic acidosis with your client. What finding should you analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?
Arterial blood gas (ABG) findings
A nurse educator is teaching students the types of shock and associated causes. Which combination of shock type and causative factors are correct? Select all that apply.
Hypovolemic shock, blood loss; cardiogenic shock, myocardial infarction; anaphylactic shock, nuts; septic shock, infection
Which of the following advice does the nurse offer clients who are undergoing unsealed radiation therapy to reduce exposure?
Avoid kissing and sexual contact.
The nurse is providing nutritional instruction to the client diagnosed with hypovolemia. Which would the nurse emphasize as something to avoid?
Beverages with alcohol or caffeine
A client who is being treated for bladder cancer expreses his concern of passing cancer to his wife during intercourse. Which is the best response by the nurse.
Cancer is not transferred from person to person via direct contact
Upon shift report, the nurse states the following laboratory values: pH, 7.44; PCO2, 30 mm Hg; and HCO3, 21 mEq/L for a client with noted acid-base disturbances. Which acid-base imbalance do both nurses agree is the client's current state?
Compensated respiratory alkalosis
Which compensatory mechanism, during the first stage of shock, is the nurse most correct to identify as responsible for stabilization of fluid balance?
Corticosteroid hormones
A patient presents to the ED in shock. At what point in shock does the nurse know that metabolic acidosis is going to occur?
Decompensation
You are a nursing student preparing to care for an ICU client with shock. Your instructor asks you to name the different categories of shock. Which of the following is a category of shock?
Distributive
You are caring for a client who is in neurogenic shock. You know that this is a subcategory of what kind of shock?
Distributive
A client was admitted to your unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and his family? Select all that apply.
Drink at least eight glasses of fluid each day. , Drink water as an inexpensive way to meet fluid needs, respond to thirst
Based on the understanding of the effects of chemotherapy, the nurse would anticipate which of the following clinical findings in a client 2 weeks posttherapy?
Ease of bruising
The nurse is providing an educational presentation on dietary recommendations for reducing the risk of cancer. Which of the following food selections would demonstrate a good understanding of the information provided in the presentation? Select all that apply.
Egg white omelet with spinach and mushrooms, steamed broccoli and carrots, turkey breast on whole wheat bread
The community health nurse finds the client collapsed outdoors. The nurse assesses that the client is shallow breathing and has a weak pulse. The 911 is called by the neighbor. Which nursing action is helpful while waiting for the ambulance?
Elevate the legs higher than the heart.
The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process?
Elevated blood pressure
Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration?
Elevated hematocrit level
The nurse is caring for a thyroid cancer client following oral radioactive iodine treatment. Which teaching point is most important?
Flush the toilet twice after every use.
The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified?
In dehydration, only extracellular is depleted.
The nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock?
Increase in arterial oxygenation
The nurse is administering a medication to the client with a positive inotropic effect. Which action of the medication does the nurse anticipate?
Increase the force of myocardial contraction
While completing an admission assessment, the client reports a family history of ovarian cancer among a maternal grandmother, aunt, and sister. The nurse knows that these cancers are most likely associated with what etiology?
Inherited gene mutation
Which nursing action is anticipated by the nurse to restore colloidal osmotic pressure to clients with third-spacing?
Initiate an IV of albumin.
The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which?
Insensible fluid loss
When caring for a client who is receiving external beam radiation, which is the key point for the nurse to incorporate into the plan of care?
Inspect the skin frequently.
The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see a decrease in which fluid location which contains the most body water?
Intracellular fluid
A nursing instructor is teaching her class about burns. The instructor relates the following scenario: A nurse is caring for a severely burned client who now has elevated hematocrit and blood cell counts. What consequences should the nurse expect in this client?
Kidney stones and blood clots
The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?
Lungs and kidney
The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption?
Maintain activity restriction to bedrest.
The nurse performs a breast exam on a client and finds a firm, non-moveable lump in the upper outer quadrant of the right breast that the client reports was not there 3 weeks ago. What does this finding suggest?
Malignant tumor
Your clients lab values are sodium 166 mEq/L, potassium 5.0 mEq/L, chloride 115 mEq/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging by anion gap?
Metabolic acidosis
The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction. Which acid-base imbalance is most likely to occur?
Metabolic alkalosis
Cancer has many characteristics. What is one of the most discouraging characteristics of cancer?
Metastasis
The nurse working on a bone marrow unit knows that it is a priority to monitor which of the following in a client who has just undergone a stem cell transplant?
Monitor the client closely to prevent infection.
The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death?
Multiple organ failure
