FINAL EXAM

You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect? A) Hypophosphatemia B) Hypocalcemia C) Hypermagnesemia D) Hyperkalemia

B) Hypocalcemia

Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis? A) pH 7.60, PaCO2 40 mm Hg, HCO3- 30 mEq/L B) pH 7.53, PaCO2 30 mm Hg, HCO3- 24 mEq/L C) pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L D) pH 7.25, PaCO2 48 mm Hg, HCO3- 23 mEq/L

B) pH 7.53, PaCO2 30 mm Hg, HCO3- 24 mEq/L

The nurse reviews the plan of care for a client receiving antineoplastic therapy and sees a nursing diagnosis of risk for infection. What assessment finding would support this diagnosis? A) Alopecia B) Pancytopenia C) Stomatitis D) Dependent edema

B) Pancytopenia

A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acidbase imbalance? A) Respiratory acidosis B) Respiratory alkalosis C) Increased PaCO2 D) CNS disturbances

B) Respiratory alkalosis

The category "T" in the TNM system stands for: A) Time B) Tumor (primary) C) Tissue (primary) D) Tumor (secondary)

B) Tumor (primary)

The nurse is applying standard precautions in the care of a patient who has an immunodeficiency. What are key elements of standard precautions? Select all that apply. A) Using appropriate personal protective equipment B) Placing patients in negative-pressure isolation rooms C) Placing patients in positive-pressure isolation rooms D) Using safe injection practices E) Performing hand hygiene

A) Using appropriate personal protective equipment D) Using safe injection practices E) Performing hand hygiene

A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patients stools will have what characteristics? A) Watery with blood and mucus B) Hard and black or tarry C) Dry and streaked with blood D) Loose with visible fatty streaks

A) Watery with blood and mucus

The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which laboratory findings are consistent with metabolic acidosis? A) pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L B) pH 7.5, PaCO2 35 mm Hg, HCO3- 35 mEq/L C) pH 7.32, PaCO2 47 mm Hg, HCO3- 23 mEq/L D) pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L

A) pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L

Which information will the nurse include for a patient with newly diagnosed gastroesophageal reflux disease (GERD)? A) "Peppermint tea may reduce your symptoms." B) "Keep the head of your bed elevated on blocks." C) "You should avoid eating between meals to reduce acid secretion." D) "Vigorous physical activities may increase the incidence of reflux."

B) "Keep the head of your bed elevated on blocks."

While reviewing the health history of an older adult experiencing hearing loss the nurse notes the patient has had no trauma or loss of balance. What aspect of this patients health history is most likely to be linked to the patients hearing deficit? A) Recent completion of radiation therapy for treatment of thyroid cancer B) Routine use of quinine for management of leg cramps C) Allergy to hair coloring and hair spray D) Previous perforation of the eardrum

B) Routine use of quinine for management of leg cramps

You are caring for a patient with late-stage Alzheimers disease. The patients wife tells you that the patient has now become completely dependent and that she feels guilty if she takes any time for herself. What outcomes would be appropriate for the nurse to develop to assist the patients wife? A) The caregiver learns to explain to the patient why she needs time for herself. B) The caregiver distinguishes essential obligations from those that can be controlled or limited. C) The caregiver leaves the patient at home alone for short periods of time to encourage independence. D) The caregiver prioritizes her own health over that of the patient.

B) The caregiver distinguishes essential obligations from those that can be controlled or limited.

A patient admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely the best choice for this patient? A) Spinach B) Tofu C) Multigrain bagel D) Blueberries

B) Tofu

A 46-year-old female with gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement indicates that additional teaching about GERD is needed? A) "I take antacids between meals and at bedtime each night." B) "I sleep with the head of the bed elevated on 4-inch blocks." C) "I eat small meals during the day and have a bedtime snack." D) "I quit smoking several years ago, but I still chew a lot of gum.

C) "I eat small meals during the day and have a bedtime snack."

An 83-year-old woman was diagnosed with Alzheimers disease 2 years ago and the disease has progressed at an increasing pace in recent months. The patient has lost 16 pounds over the past 3 months, leading to a nursing diagnosis of Imbalanced Nutrition: Less than Body Requirements. What intervention should the nurse include in this patients plan of care? A) Offer the patient rewards for finishing all the food on her tray. B) Offer the patient bland, low-salt foods to limit offensiveness. C) Offer the patient only one food item at a time to promote focused eating. D) Arrange for insertion of a gastrostomy tube and initiate enteral feeding.

C) Offer the patient only one food item at a time to promote focused eating.

The nurse is administering eye drops to a patient with glaucoma. After instilling the patients first medication, how long should the nurse wait before instilling the patients second medication into the same eye? A) 30 seconds B) 1 minute C) 3 minutes D) 5 minutes

D) 5 minutes

Which problem is highest priority for the nurse to identify in the client who had an open cholecystectomy surgery? A) Alteration in nutrition. B) Alteration in skin integrity. C) Alteration in urinary pattern. D) Alteration in comfort.

D) Alteration in comfort.

A patient has just been diagnosed with Parkinsons disease and the nurse is planning the patients subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the patients family? A) Risk for infection B) Impaired spontaneous ventilation C) Unilateral neglect D) Risk for injury

D) Risk for injury

You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis? A) Hypertension B) Kussmaul respirations C) Increased DTRs D) Shallow respirations

D) Shallow respirations

A public health nurse is teaching a health promotion workshop that focuses on vision and eye health. What should this nurse cite as the most common causes of blindness and visual impairment among adults over the age of 40? Select all that apply. A) Diabetic retinopathy B) Trauma C) Macular degeneration D) Cytomegalovirus E) Glaucoma

A) Diabetic retinopathy C) Macular degeneration E) Glaucoma

The nurse is providing care for a patient with chronic obstructive pulmonary disease. When describing the process of respiration the nurse explains how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing what process? A) Diffusion B) Osmosis C) Active transport D) Filtration

A) Diffusion

A patient who has been treated for breast cancer is undergoing routine laboratory work. Which laboratory finding would cause the nurse to be most concerned about metastasis? A) Elevated serum calcium B) Decreased serum calcium C) Elevated serum potassium D) Decreased serum potassium

A) Elevated serum calcium

Which is an appropriate nursing intervention for the patient who is taking hydrochlorothiazide? A) Encourage intake of foods rich in potassium. B) Schedule the dose to be taken in the evening. C) Monitor serum calcium and sodium levels daily. D) Take the radial pulse for 1 full minute before administering the drug.

A) Encourage intake of foods rich in potassium.

A client who had a choledochostomy to explore the common bile duct is returned to the surgical unit with a T-tube in place. What is the priority intervention when caring for this client? A) Irrigate the T-tube as necessary B) Protect the abdominal skin from bile drainage C) Have the client wear a binder when out of bed D) Empty the T-tube drainage bag every two hours

B) Protect the abdominal skin from bile drainage

Which rationale explains why the nurse also monitors a client with a history of gastroesophageal reflux disease (GERD) for clinical manifestations of heart disease? A) Esophageal pain may imitate the symptoms of a heart attack. B) GERD may predispose the client to the development of heart disease. C) Strenuous exercise may exacerbate reflux problems. D) Similar laboratory study changes may occur in both problems.

A) Esophageal pain may imitate the symptoms of a heart attack.

The client is receiving a vesicant antineoplastic for the treatment of cancer. Which assessment finding would require the nurse to take immediate action? A) Extravasation B) Stomatitis C) Nausea/vomiting D) Bone pain

A) Extravasation

A patient presents to the clinic complaining of symptoms that suggest diabetes. What criteria would support checking blood levels for the diagnosis of diabetes? A) Fasting plasma glucose greater than or equal to 126 mg/dL B) Random plasma glucose greater than 150 mg/dL C) Fasting plasma glucose greater than 116 mg/dL on 2 separate occasions D) Random plasma glucose greater than 126 mg/dL

A) Fasting plasma glucose greater than or equal to 126 mg/dL

The nurse is providing health education to a patient newly diagnosed with glaucoma. The nurse teaches the patient that this disease has a familial tendency. The nurse should encourage the patients immediate family members to undergo clinical examinations how often? A) At least monthly B) At least once every 2 years C) At least once every 5 years D) At least once every 10 years

B) At least once every 2 years

A patient with prostate cancer asks the nurse the meaning of his high prostate-specific antigen (PSA) level. Which response by the nurse is correct?A) "PSA is a tumor marker that is elevated in patients with prostate cancer." B) "PSA levels are done routinely to determine whether your prostate cancer has spread to a new site." C) "The doctor orders PSA measurements to monitor the level of chemotherapy medication in your blood." D) "A PSA test allows the pathologist to view the cancer cells under the microscope to monitor the progression of cancer."

A) "PSA is a tumor marker that is elevated in patients with prostate cancer."

A nurse is providing care for a patient whose pattern of laboratory testing reveals longstanding hypocalcemia. What other laboratory result is most consistent with this finding? A) An elevated parathyroid hormone level B) An increased calcitonin level C) An elevated potassium level D) A decreased vitamin D level

A) An elevated parathyroid hormone level

A patient with mastoiditis is admitted to the post-surgical unit after undergoing a radical mastoidectomy. The nurse should identify what priority of postoperative care? A) Assessing for mouth droop and decreased lateral eye gaze B) Assessing for increased middle ear pressure and perforated ear drum C) Assessing for gradual onset of conductive hearing loss and nystagmus D) Assessing for scar tissue and cerumen obstructing the auditory canal

A) Assessing for mouth droop and decreased lateral eye gaze

The nurse is caring for a patient in metabolic alkalosis. The patient has an NG tube to low intermittent suction for a diagnosis of bowel obstruction. What drug would the nurse expect to find on the medication orders? A) Cimetidine B) Maalox C) Potassium chloride elixir D) Furosemide

A) Cimetidine

A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patients laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D) Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis

A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis

A patient has been brought to the emergency department by paramedics after being found unconscious. The patients Medic Alert bracelet indicates that the patient has type 1 diabetes and the patients blood glucose is 22 mg/dL (1.2 mmol/L). The nurse should anticipate what intervention? A) IV administration of 50% dextrose in water B) Subcutaneous administration of 10 units of Humalog C) Subcutaneous administration of 12 to 15 units of regular insulin D) IV bolus of 5% dextrose in 0.45% NaC

A) IV administration of 50% dextrose in water

A nurse is teaching a patient with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the patient to perform what action? A) Instill the medication in the conjunctival sac. B) Maintain a supine position for 10 minutes after administration. C) Keep the eyes closed for 1 to 2 minutes after administration. D) Apply the medication evenly to the sclera

A) Instill the medication in the conjunctival sac.

A nurse is providing care for a patient who has a diagnosis of irritable bowel syndrome (IBS). When planning this patients care, the nurse should collaborate with the patient and prioritize what goal? A) Patient will accurately identify foods that trigger symptoms. B) Patient will demonstrate appropriate care of his ileostomy. C) Patient will demonstrate appropriate use of standard infection control precautions. D) Patient will adhere to recommended guidelines for mobility and activity.

A) Patient will accurately identify foods that trigger symptoms.

. The nurse caring for a patient diagnosed with Parkinsons disease has prepared a plan of care that would include what goal? A) Promoting effective communication B) Controlling diarrhea C) Preventing cognitive decline D) Managing choreiform movements

A) Promoting effective communication

A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient? A) Renal B) Endocrine C) Respiratory D) Gastrointestinal

A) Renal

A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? A) Respiratory acidosis B) Metabolic alkalosis C) Respiratory alkalosis D) Metabolic acidosis

A) Respiratory acidosis

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 patient'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) The UAP assists the patient to use dental floss after eating.

A patient is postoperative day 6 following tympanoplasty and mastoidectomy. The patient has phoned the surgical unit and states that she is experiencing occasional sharp, shooting pains in her affected ear. How should the nurse best interpret this patients complaint? A) These pains are an expected finding during the first few weeks of recovery. B) The patients complaints are suggestive of a postoperative infection. C) The patient may have experienced a spontaneous rupture of the tympanic membrane. D) The patients surgery may have been unsuccessful.

A) These pains are an expected finding during the first few weeks of recovery.

A client is diagnosed with pancytopenia caused by chemotherapy. What should a nurse teach the client about this complication? A) Begin a program of meticulous mouth care. B) Avoid traumatic injury and exposure to infection. C) Increase oral fluid intake to at least 3 L/day. D) Report unusual muscle cramps or tingling sensations in the extremities

B) Avoid traumatic injury and exposure to infection.

A male patient presents to the clinic complaining of a headache. The nurse notes that the patient is guarding his neck and tells the nurse that he has stiffness in the neck area. The nurse suspects the patient may have meningitis. What is another well-recognized sign of this infection? A) Negative Brudzinskis sign B) Positive Kernigs sign C) Hyperpatellar reflex D) Sluggish pupil reaction

B) Positive Kernigs sign

A nurse is working with a patient who was diagnosed with HIV several months earlier. The nurse should recognize that a patient with HIV is considered to have AIDS at the point when the CD4+ T-lymphocyte cell count drops below what threshold? A) 75 cells/mm3 of blood B) 200 cells/mm3 of blood C) 325 cells/mm3 of blood D) 450 cells/mm3 of blood

B) 200 cells/mm3 of blood

A patient has just been diagnosed with type 2 diabetes. The physician has prescribed an oral antidiabetic agent that will inhibit the production of glucose by the liver and thereby aid in the control of blood glucose. What type of oral antidiabetic agent did the physician prescribe for this patient? A) A sulfonylurea B) A biguanide C) A thiazolidinedione D) An alpha glucosidase inhibitor

B) A biguanide

A patient who presents for an eye examination is diagnosed as having a visual acuity of 20/40. The patient asks the nurse what these numbers specifically mean. What is a correct response by the nurse? A) A person whose vision is 20/40 can see an object from 40 feet away that a person with 20/20 vision can see from 20 feet away. B) A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away. C) A person whose vision is 20/40 can see an object from 40 inches away that a person with 20/20 vision can see from 20 inches away. D) A person whose vision is 20/40 can see an object from 20 inches away that a person with 20/20 vision can see from 40 inches away.

B) A person whose vision is 20/40 can see an object from 20 feet away that a person with 20/20 vision can see from 40 feet away.

A nurse has administered a childs scheduled vaccination for rubella. This vaccination will cause the child to develop which of the following? A) Natural immunity B) Active acquired immunity C) Cellular immunity D) Mild hypersensitivity

B) Active acquired immunity

The clinic nurse caring for a patient with Parkinsons disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. For what common side effect of Sinemet would the nurse assesses this patient? A) Pruritus B) Dyskinesia C) Lactose intolerance D) Diarrhea

B) Dyskinesia

The nurse is caring for a patient who is in status epilepticus. What medication does the nurse know may be given to halt the seizure immediately? A) Intravenous phenobarbital (Luminal) B) Intravenous diazepam (Valium) C) Oral lorazepam (Ativan) D) Oral phenytoin (Dilantin)

B) Intravenous diazepam (Valium)

An occupational health nurse is screening a group of workers for diabetes. What statement should the nurse interpret as suggestive of diabetes? A) Ive always been a fan of sweet foods, but lately Im turned off by them. B) Lately, I drink and drink and cant seem to quench my thirst. C) No matter how much sleep I get, it seems to take me hours to wake up. D) When I went to the washroom the last few days, my urine smelled odd

B) Lately, I drink and drink and cant seem to quench my thirst.

A patient with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a patient with this diagnosis? A) Pain upon ankle dorsiflexion of the foot B) Neck flexion produces flexion of knees and hips C) Inability to stand with eyes closed and arms extended without swaying D) Numbness and tingling in the lower extremities

B) Neck flexion produces flexion of knees and hips

A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial pressure. This solution will increase the number of dissolved particles in the patients blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following? A) Hydrostatic pressure B) Osmosis and osmolality C) Diffusion D) Active transport

B) Osmosis and osmolality

A medical nurse educator is reviewing a patients recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis? A) The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. B) The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. C) The kidneys react rapidly to compensate for imbalances in the body. D) The kidneys regulate the bicarbonate level in the intracellular fluid.

B) The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.

The patient is receiving an IV vesicant chemotherapy drug. The nurse notices swelling and redness at the site. What should the nurse do first? A) Ask the patient if the site hurts. B) Turn off the chemotherapy infusion. C) Call the ordering health care provider. D) Administer sterile saline to the reddened area

B) Turn off the chemotherapy infusion.

The nurse is caring for a patient diagnosed with Parkinsons disease. The patient is having increasing problems with rising from the sitting to the standing position. What should the nurse suggest to the patient to use that will aid in getting from the sitting to the standing position as well as aid in improving bowel elimination? A) Use of a bedpan B) Use of a raised toilet seat C) Sitting quietly on the toilet every 2 hours D) Following the outlined bowel program

B) Use of a raised toilet seat

A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patients plan of care? A) Monitoring of pulse oximetry B) Administration of a low-protein diet C) Administration of thorough oral hygiene D) Fluid restriction as ordered

C) Administration of thorough oral hygiene

The nurse is caring for the immediate postoperative client who had a laparoscopic cholecystectomy. Which task could the nurse delegate to the unlicensed assistive personnel (UAP)? A) Check the abdominal dressings for bleeding. B) Increase the IV fluid if the blood pressure is low. C) Ambulate the client to the bathroom. D) Auscultate the breath sounds in all lobes.

C) Ambulate the client to the bathroom.

A patients health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohns disease, rather that ulcerative colitis, as the cause of the patients signs and symptoms? A) A pattern of distinct exacerbations and remissions B) Severe diarrhea C) An absence of blood in stool D) Involvement of the rectal mucosa

C) An absence of blood in stool

The health care provider performs a bone marrow aspiration from the posterior iliac crest on a patient with pancytopenia. Following the procedure, the nurse should: A) Use half-inch sterile gauze to pack the wound B) Administer an analgesic to control pain at the site C) Apply pressure over the site for 5-10 mins D) Elevate the HOB to 30 degrees

C) Apply pressure over the site for 5-10 mins

Which patient choice for a snack 2 hours before bedtime indicates that the nurse's teaching about gastroesophageal reflux disease (GERD) has been effective? A) Chocolate pudding B) Glass of low-fat milk C) Cherry gelatin with fruit D) Peanut butter and jelly sandwich

C) Cherry gelatin with fruit

A nurse is providing care for a patient with a diagnosis of late-stage Alzheimers disease. The patient has just returned to the medical unit to begin supplemental feedings through an NG tube. Which of the nurses assessments addresses this patients most significant potential complication of feeding? A) Frequent assessment of the patients abdominal girth B) Assessment for hemorrhage from the nasal insertion site C) Frequent lung auscultation D) Vigilant monitoring of the frequency and character of bowel movements

C) Frequent lung auscultation

The nurse is caring for a patient in acute kidney injury. Which of the following complications would most clearly warrant the administration of polystyrene sulfonate (Kayexalate)? A) Hypernatremia B) Hypomagnesemia C) Hyperkalemia D) Hypercalcemia

C) Hyperkalemia

A patient has returned to the floor after having a thyroidectomy for thyroid cancer. The nurse knows that sometimes during thyroid surgery the parathyroid glands can be injured or removed. What laboratory finding may be an early indication of parathyroid gland injury or removal? A) Hyponatremia B) Hypophosphatemia C) Hypocalcemia D) Hypokalemia

C) Hypocalcemia

You are caring for a 65-year-old male patient admitted to your medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the mornings blood work, you notice that the patients potassium is below reference range. You should recognize that the patient may be at risk for what imbalance? A) Hypercalcemia B) Metabolic acidosis C) Metabolic alkalosis D) Respiratory acidosis

C) Metabolic alkalosis

The nurse is planning the care of a patient with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this patients care? A) Risk for disturbed sensory perception B) Risk for unilateral neglect C) Risk for falls D) Risk for ineffective health maintenance

C) Risk for falls

A patient with Parkinsons disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. The patients nutritional needs should be met by what method? A) Total parenteral nutrition (TPN) B) Provision of a low-residue diet C) Semisolid food with thick liquids D) Minced foods and a fluid restriction

C) Semisolid food with thick liquids

A patient has been diagnosed with hearing loss related to damage of the end organ for hearing or cranial nerve VIII. What term is used to describe this condition? A) Exostoses B) Otalgia C) Sensorineural hearing loss D) Presbycusis

C) Sensorineural hearing loss

A nurse is admitting a patient with a severe migraine headache and a history of acute coronary syndrome. What migraine medication would the nurse question for this patient? A) Rizatriptan (Maxalt) B) Naratriptan (Amerge) C) Sumatriptan succinate (Imitrex) D) Zolmitriptan (Zomig)

C) Sumatriptan succinate (Imitrex)

Which action by a nursing assistant (NA) caring for a patient with a temporary radioactive cervical implant indicates that the RN should intervene? A) The NA places the patient's bedding in the laundry container in the hallway. B) The NA flushes the toilet once after emptying the patient's bedpan. C) The NA stands by the patient's bed for an hour talking with the patient. D) The NA gives the patient an alcohol-containing mouthwash for oral care.

C) The NA stands by the patient's bed for an hour talking with the patient.

The physician orders a patient's t-tube to be clamped 1 hour before and 1 hour after meals. You clamp the t-tube as prescribed. While the tube is clamped which finding requires immediate nursing intervention? A) The t-tube is not draining. B) The t-tube tubing is below the patient's waist. C) The patient reports nausea and abdominal pain. D) The patient's stool is brown and formed

C) The patient reports nausea and abdominal pain.

An older adult has a diagnosis of Alzheimers disease and has recently been experiencing fecal incontinence. However, the nurse has observed no recent change in the character of the patients stools. What is the nurses most appropriate intervention? A) Keep a food diary to determine the foods that exacerbate the patients symptoms. B) Provide the patient with a bland, low-residue diet. C) Toilet the patient on a frequent, scheduled basis. D) Liaise with the primary care provider to obtain an order for loperamide.

C) Toilet the patient on a frequent, scheduled basis.

A long-term care patient with moderate dementia develops increased restlessness and agitation. The nurse's initial action should be to A)administer the PRN dose of lorazepam (Ativan). B) reorient the patient to time and place. C) assess the patient for anything that might be causing discomfort. D) have a nursing assistant stay with the patient to ensure safety.

C) assess the patient for anything that might be causing discomfort.

A patient with Parkinson's disease is taking levodopa/carbidopa (Sinemet). The prescriber orders bromocriptine (Parlodel) to treat dyskinesias. The nurse notes that the patient is agitated, and the patient reports having frequent nightmares. The nurse will contact the provider to discuss: A) adding an antipsychotic medication. B) changing from bromocriptine to cabergoline (Dostinex). C) reducing the dose of bromocriptine. D) reducing the dose of levodopa/carbidopa

C) reducing the dose of bromocriptine.

A client diagnosed with gastroesophageal reflux disease (GERD) is being treated with antacid therapy. When teaching the client about the therapy, what does the nurse reinforce? A) Antacids should be taken 1 hour before meals. B) These should be scheduled at 4-hour intervals. C) Antacid tablets are just as fast and effective as the liquid form. D) Antacids commonly interfere with the absorption of other drugs.

D) Antacids commonly interfere with the absorption of other drugs.

The nurse helps the patient with a t-tube get up from the bed and sit in the bedside chair. Where will the nurse make it priority to position the tubing and drainage bag of the t-tube? A) Slightly elevated above the t-tube insertion site B) At heart level C) Midline with the t-tube insertion site D) At or below the waist

D) At or below the waist

A patient who was diagnosed with Parkinsons disease several months ago recently began treatment with levodopa-carbidopa. The patient and his family are excited that he has experienced significant symptom relief. The nurse should be aware of what implication of the patients medication regimen? A) The patient is in a honeymoon period when adverse effects of levodopa-carbidopa are not yet evident. B) Benefits of levodopa-carbidopa do not peak until 6 to 9 months after the initiation of treatment. C) The patients temporary improvement in status is likely unrelated to levodopa-carbidopa. D) Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment.

D) Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment.

The nurse is caring for a client admitted with peritonitis. Which finding in the medical record is most likely the cause? A) Gastritis B) Hiatal hernia C) Diverticulosis D) Bowel obstruction

D) Bowel obstruction

A client with leukemia has neutropenia. Which of the following functions must be frequently assessed? A) Blood pressure B) Bowel sounds C) Heart sounds D) Breath sounds

D) Breath sounds

A client with a diagnosis of dementia of the Alzheimer type has been taking donepezil 10 mg/day for 3 months. The client's partner calls the clinic and reports that the client has increasing restlessness and agitation accompanied by nausea. What does the nurse advise the partner to do? A) Give the medication with food B) Administer the medication to the partner at bedtime C) Omit one dose today and start with a lower dose tomorrow D) Bring the partner to the clinic for testing and a physical examination

D) Bring the partner to the clinic for testing and a physical examination

The nurse is creating a dietary plan for a client with cholecystitis who has been placed on a modified diet. Which will be most appropriate to include in the client's dietary plan? A) Offer soft-textured foods to reduce the digestive burden B) Offer low-cholesterol foods to avoid further formation of gallstones C) Increase protein intake to promote tissue healing and improve energy reserves D) Decrease fat intake to avoid stimulation of the cholecystokinin mechanism for bile release

D) Decrease fat intake to avoid stimulation of the cholecystokinin mechanism for bile release

When planning the care of a patient with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur? A) Active transport of hydrogen ions across the capillary walls B) Pressure of the blood in the renal capillaries C) Action of the dissolved particles contained in a unit of blood D) Hydrostatic pressure resulting from the pumping action of the heart

D) Hydrostatic pressure resulting from the pumping action of the heart

A nurse is assessing two clients. One client has ulcerative colitis and the other client has Crohn's disease. Which is more likely to be identified in the client with ulcerative colitis that in the client with Crohn's disease? A) Inclusion of transmural involvement of the small bowel wall B) Higher occurrence of fistulas and abscesses from changes in the bowel wall C) Pathology beginning proximally with intermittent plaques found along the colon D) Involvement starting distally with rectal bleeding that spreads continuously up the colon

D) Involvement starting distally with rectal bleeding that spreads continuously up the colon

A client is diagnosed with cancer of the rectum and has surgery for an abdominoperineal resection and colostomy. Which nursing care should be implemented during the postoperative period? A) Limiting fluid intake for several days B) Withholding fluids for 72 hours C) Having the client change the colostomy bag D) Keeping the client's skin around the stoma clean

D) Keeping the client's skin around the stoma clean

You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results? A) Respiratory acidosis with no compensation B) Metabolic alkalosis with a compensatory alkalosis C) Metabolic acidosis with no compensation D) Metabolic acidosis with a compensatory respiratory alkalosis

D) Metabolic acidosis with a compensatory respiratory alkalosis

A community health nurse is preparing for an initial home visit to a patient discharged following a total gastrectomy for treatment of gastric cancer. What would the nurse anticipate that the plan of care is most likely to include? A) Enteral feeding via gastrostomy tube (G tube) B) Gastrointestinal decompression by nasogastric tube C) Periodic assessment for esophageal distension D) Monthly administration of injections of vitamin B12

D) Monthly administration of injections of vitamin B12

A 62-year-old patient who has Parkinson's disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dose? A) The patient has a chronic dry cough. B) The patient has four loose stools in a day. C) The patient develops a deep vein thrombosis. D) The patient's blood pressure is 92/52 mm Hg.

D) The patient's blood pressure is 92/52 mm Hg.

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/µL C) Hemoglobin of 10 g/L D) White blood cell (WBC) count of 2700/µL

D) White blood cell (WBC) count of 2700/µL

The nurse will anticipate teaching a patient experiencing frequent heartburn about A) a barium swallow. B) radionuclide tests. C) endoscopy procedures. D) proton pump inhibitors.

D) proton pump inhibitors.

The nurse explaining esomeprazole (Nexium) to a patient with recurring heartburn describes that the medication A) reduces gastroesophageal reflux by increasing the rate of gastric emptying. B) neutralizes stomach acid and provides relief of symptoms in a few minutes. C) coats and protects the lining of the stomach and esophagus from gastric acid. D) treats gastroesophageal reflux disease by decreasing stomach acid production.

D) treats gastroesophageal reflux disease by decreasing stomach acid production.

The category "N" in the TNM system stand for: A) Number B) Necrosis C) Nodes D) Normal

C) Nodes

While doing a health history, a client tells you that her mother, her grandmother, and her sister died of breast cancer. The client wants to know what she can do to keep from getting cancer. What would be your best response? A) "You can't prevent cancer, but you can have your blood analyzed for tumor markers to see what your risk level is." B) "If you eat right, exercise, and get enough rest, you can always prevent breast cancer." C) "With your family history, there is nothing you can do to prevent getting cancer." D) "Cancer often skips a generation, so don't worry about it."

A) "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 checking the laboratory reports of a patient being treated with paclitaxel. Which platelet count might indicate spontaneous bleeding? A) 15,000/mm3 B) 60,000/mm3 C) 175,000/mm3 D) 300,000/mm3

A) 15,000/mm3

During a mumps outbreak at a local school, a patient, who is a school teacher, is exposed. She has previously been immunized for mumps. What type of immunity does she possess? A) Acquired immunity B) Natural immunity C) Phagocytic immunity D) Humoral immunity

A) Acquired immunity

A 50-year-old man diagnosed with leukemia will begin chemotherapy. What would the nurse do to combat the most common adverse effects of chemotherapy? A) Administer an antiemetic. B) Administer an antimetabolite. C) Administer a tumor antibiotic. D) Administer an anticoagulant.

A) Administer an antiemetic.

A nurse is performing the initial assessment of a patient who has a recent diagnosis of systemic lupus erythematosus (SLE). What skin manifestation would the nurse expect to observe on inspection? A) Petechiae B) Butterfly rash C) Jaundice D) Skin sloughing

B) Butterfly rash

The nurse is describing some of the major characteristics of cancer to a patient who has recently received a diagnosis of malignant melanoma. When differentiating between benign and malignant cancer cells, the nurse should explain differences in which of the following aspects? Select all that apply. A) Rate of growth B) Ability to cause death C) Size of cells D) Cell contents E) Ability to spread

A) Rate of growth B) Ability to cause death E) Ability to spread

A patient with gastroesophageal reflux disease (GERD) has a diagnosis of Barretts esophagus with minor cell changes. Which of the following principles should be integrated into the patients subsequent care? A) The patient will require an upper endoscopy every 6 months to detect malignant changes. B) Liver enzymes must be checked regularly, as H2 receptor antagonists may cause hepatic damage. C) Small amounts of blood are likely to be present in the stools and are not cause for concern. D) Antacids may be discontinued when symptoms of heartburn subside.

A) The patient will require an upper endoscopy every 6 months to detect malignant changes.

A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the RN caring for the patient indicates that the nurse should take action? A) The patient's visitors bring in some fresh peaches from home. B) The patient ambulates several times a day in the room. C) The patient uses soap and shampoo to shower every other day. D) The patient cleans with a warm washcloth after having a stool.

A) The patient's visitors bring in some fresh peaches from home.

A patient has had a laparoscopic cholecystectomy. The patient is now complaining of right shoulder pain. What should the nurse suggest to relieve the pain? A) Aspirin every 4 to 6 hours as ordered B) Application of heat 15 to 20 minutes each hour C) Application of an ice pack for no more than 15 minutes D) Application of liniment rub to affected area

B) Application of heat 15 to 20 minutes each hour

You're assessing a patient's t-tube and note that it is not draining bile. The patient is reporting nausea. The nurse will first? A) Notify the physician B) Assess if the tubing from the t-tube is kinked or clamped. C) Flush the tubing. D) Administer an antiemetic medication per physician order.

B) Assess if the tubing from the t-tube is kinked or clamped.

Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for abdominal surgery for an open cholecystectomy? A) Care for the surgical incision B) Medications used during surgery C) Deep breathing and coughing techniques D) Oral antibiotic therapy after discharge home

C) Deep breathing and coughing techniques

A client undergoes an abdominal cholecystectomy with common duct exploration. In the immediate postoperative period, what is the priority nursing action? A) Irrigating the T-tube every hour B) Changing the dressing every two hours C) Encouraging coughing and deep breathing D) Promoting an adequate fluid and food intake

C) Encouraging coughing and deep breathing

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 client with advanced prostatic cancer has opted for palliative care. At a care conference, the decision is made to pursue histrelin treatment. What should the nurse teach the client about this medication? A) "The advantage of this drug is that it involves just one intramuscular injection every 6 weeks." B) "These pills will likely give you a much higher quality of life." C) "This will involve giving you an implant of the drug" D) "We'll work with your family so that you can receive your IV infusions at home."

C) "This will involve giving you an implant of the drug"

A nurse is providing health promotion education to a patient diagnosed with an esophageal reflux disorder. What practice should the nurse encourage the patient to implement? A) Keep the head of the bed lowered. B) Drink a cup of hot tea before bedtime. C) Avoid carbonated drinks. D) Eat a low-protein diet.

C) Avoid carbonated drinks.

A patient had a cholecystectomy and has a t-tube in place. You're helping the nursing student understand how to care for the t-tube. The nursing student asks you where the t-tube is located in the body. Your response is the: A) Cystic duct B) Hepatic duct C) Bile duct D) Pancreatic duct

C) Bile duct

A 45-year-old woman has just undergone a radical hysterectomy for invasive cervical cancer. Prior to the surgery the physician explained to the patient that after the surgery a source of radiation would be placed near the tumor site to aid in reducing recurrence. What is the placement of the source of radiation called? A) Internal beam radiation B) Trachelectomy C) Brachytherapy D) External radiation

C) Brachytherapy

A patient with a large stomach tumor attached to the liver is scheduled for 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) Decreasing the tumor size will improve the effects of other therapy. D) Tumor growth will be controlled by the removal of malignant tissue

C) Decreasing the tumor size will improve the effects of other therapy.

A nurse is caring for a client who is postoperative following an open cholecystectomy. Which of the following actions should the nurse take when caring for the client's Jackson-Pratt (JP) drain? A) Measure the drainage every hour for the first 8 hr postoperative. B) Secure the drain to the client's bed sheet. C) Expel the air from the JP bulb after emptying to re-establish suction. D) Remove the JP drain when the drainage has ceased, covering the opening with sterile gauze.

C) Expel the air from the JP bulb after emptying to re-establish suction.

The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the patient have that could cause inadequate ventilation? A) Endocarditis B) Multiple myeloma C) Guillain-Barr syndrome D) Overdose of amphetamines

C) Guillain-Barr syndrome

The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a positive Chvosteks sign indicate? A) Hypermagnesemia B) Hyponatremia C) Hypocalcemia D) Hyperkalemia

C) Hypocalcemia

A nurse is performing the health history and physical assessment of a patient who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA? A) Cool joints with decreased range of motion B) Signs of systemic infection C) Joint stiffness, especially in the morning D) Visible atrophy of the knee and shoulder joints

C) Joint stiffness, especially in the morning

A home health nurse is planning care for a client who is receiving chemo and has neutropenia. Which of the following foods should the nurse include in the client's plan of care? A) Soft boiled eggs B) Brie cheese made with unpasteurized milk C) Cold deli meat sandwiches D) Baked chicken

D) Baked chicken

A patients most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the patients dietary intake of potassium. Which of the following would be a good source of potassium? A) Apples B) Asparagus C) Carrots D) Bananas

D) Bananas

A patient with lung cancer is receiving chemotherapy. Why should the nurse closely monitor the patient's white blood cell (WBC) count? A) Chemotherapy drugs cause polycythemia and can precipitate thrombosis. B) Chemotherapy drugs attack WBCs and shorten their life span, which increases risk for infection. C) Chemotherapy drugs cause proliferation of blood cells, which can lead to sluggish circulation. D) Chemotherapy drugs depress the bone marrow, which can lead to infection and an increase in WBC count.

D) Chemotherapy drugs depress the bone marrow, which can lead to infection and an increase in WBC count.

You are the nurse evaluating a newly admitted patients laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)? A) Increased serum sodium B) Decreased serum potassium C) Decreased hemoglobin D) Increased platelets

A) Increased serum sodium

The nurse is reviewing laboratory results and becomes concerned about one patient being treated for cancer. Which patient does the nurse suspect is in need of nutritional support? A) An 18-year-old with an albumin of 2.5 B) A 60-year-old with a calcium level of 8 mg/dL C) A 43-year-old with a platelet level of 180,000/mm3 D) A 56-year-old with a white cell count of 6000/mm3

A) An 18-year-old with an albumin of 2.5

A gardener sustained a deep laceration while working and requires sutures. The patient is asked about the date of her last tetanus shot, which is over 10 years ago. Based on this information, the patient will receive a tetanus immunization. The tetanus injection will allow for the release of what? A) Antibodies B) Antigens C) Cytokines D) Phagocytes

A) Antibodies

A patient, who has recovered from cholecystitis, is being discharged home. What meal options below are best for this patient? A) Baked chicken with steamed carrots and rice B) Broccoli and cheese casserole with gravy and mashed potatoes C) Cheeseburger with fries D) Fried chicken with a baked potato

A) Baked chicken with steamed carrots and rice

A male client is diagnosed as having a bowel tumor and several diagnostic tests are prescribed. The nurse understands that which test will confirm the diagnosis of malignancy? A) Biopsy of the tumor B) Abdominal ultrasound C) Magnetic resonance imaging D) Computerized tomography scan

A) Biopsy of the tumor

What is the MOST definitive test to confirm a diagnosis of multiple myeloma?A) Bone marrow biopsy B) Serum test for hypercalcemia C) Urine test for Bence Jones Protein D) X-ray films of the ribs, spine, and skull

A) Bone marrow biopsy

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) Cook food thoroughly before eating. C) Avoid public transportation such as buses. E) Talk to the oncologist before having any dental work done.

You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients most recent laboratory reports, you note that the patients magnesium levels are high. You should prioritize assessment for which of the following health problems? A) Diminished deep tendon reflexes B) Tachycardia C) Cool, clammy skin D) Acute flank pain

A) Diminished deep tendon reflexes

A nurse is working with a patient with rheumatic disease who is being treated with salicylate therapy. What statement would indicate that the patient is experiencing adverse effects of this drug? A) I have this ringing in my ears that just wont go away. B) I feel so foggy in the mornings and it takes me so long to wake up. C) When I eat a meal thats high in fat, I get really nauseous. D) I seem to have lost my appetite, which is unusual for me.

A) I have this ringing in my ears that just wont go away.

The category "M" in the TNM system gives details about: A) If the cancer has spread to other parts of the body and if this is the case, how much and the location of it B) The number and location of the lymph nodes that have cancer C) The size of the tumor that is growing into other tissues D) If the cancer cells appear abnormal

A) If the cancer has spread to other parts of the body and if this is the case, how much and the location of it

A patient has a diagnosis of rheumatoid arthritis and the primary care provider has now prescribed cyclophosphamide (Cytoxan). The nurses subsequent assessments should address what potential adverse effect? A) Infection B) Acute confusion C) Sedation D) Malignant hyperthermia

A) Infection

The nurse is caring for a 63-year-old patient with ovarian cancer. The patient is to receive chemotherapy consisting of Taxol and Paraplatin. For what adverse effect of this treatment should the nurse monitor the patient? A) Leukopenia B) Metabolic acidosis C) Hyperphosphatemia D) Respiratory alkalosis

A) Leukopenia

A 60-year-old patient with a diagnosis of prostate cancer is scheduled to have an interstitial implant for high-dose radiation (HDR). What safety measure should the nurse include in this patients subsequent plan of care? A) Limit the time that visitors spend at the patients bedside. B) Teach the patient to perform all aspects of basic care independently. C) Assign male nurses to the patients care whenever possible. D) Situate the patient in a shared room with other patients receiving brachytherapy.

A) Limit the time that visitors spend at the patients bedside.

A woman has been diagnosed with breast cancer and is being treated aggressively with a chemotherapeutic regimen. As a result of this regimen, she has an inability to fight infection due to the fact that her bone marrow is unable to produce a sufficient amount of what? A) Lymphocytes B) Cytoblasts C) Antibodies D) Capillaries

A) Lymphocytes

A patient with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the patient may be prescribed what drug? A) Metoclopramide (Reglan) B) Omeprazole (Prilosec) C) Lansoprazole (Prevacid) D) Famotidine (Pepcid)

A) Metoclopramide (Reglan)

A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (Select all that apply.) A) Offer the client a back rub. B) Remind the client to use incisional splinting. C) Identify the client's pain level. D) Assist the client to ambulate. E) Change the client's position.

A) Offer the client a back rub. B) Remind the client to use incisional splinting. C) Identify the client's pain level. E) Change the client's position.

What is the meaning of cancer is in situ? A) The tumor is found in its original place and has not spread from its original location. B) The tumor is formed outside its original place and has spread within its localized site. C) The tumor is cancerous and may spread. D) The tumor is distance from its original place.

A) The tumor is found in its original place and has not spread from its original location.

A patient with a diagnosis of peptic ulcer disease has just been prescribed omeprazole (Prilosec). How should the nurse best describe this medications therapeutic action? A) This medication will reduce the amount of acid secreted in your stomach. B) This medication will make the lining of your stomach more resistant to damage. C) This medication will specifically address the pain that accompanies peptic ulcer disease D) This medication will help your stomach lining to repair itself.

A) This medication will reduce the amount of acid secreted in your stomach.

The nurse is caring for a patient who has just returned from the ERCP removal of gallstones. The nurse should monitor the patient for signs of what complications? A) Pain and peritonitis B) Bleeding and perforation C) Acidosis and hypoglycemia D) Gangrene of the gallbladder and hyperglycemia

B) Bleeding and perforation

The nurse is caring for a patient who is returning to the unit after a liver biopsy. Which intervention implemented by the nurse is appropriate during the postintervention care of this patient? A) Maintain the patient on the left side for at least 2 hours after the procedure. B) Check vital signs every 15 minutes for the first hour and then according to protocol. C) Encourage the patient to keep the right arm above the head and to take frequent deep breaths. D) Change the pressure dressing every 30 minutes for the first 2 hours and assess the puncture site.

B) Check vital signs every 15 minutes for the first hour and then according to protocol.

A 54-year-old has a diagnosis of breast cancer and is tearfully discussing her diagnosis with the nurse. The patient states, They tell me my cancer is malignant, while my coworker's breast tumor was benign. I just don't understand at all. When preparing a response to this patient, the nurse should be cognizant of what characteristic that distinguishes malignant cells from benign cells of the same tissue type? A) Slow rate of mitosis of cancer cells B) Different proteins in the cell membrane C) Differing sizes of the cells D) Different molecular structure in the cells

B) Different proteins in the cell membrane

A 70-year-old man who has end-stage lung cancer is admitted to the hospital with confusion and oliguria for 2 days. Which finding would the nurse report immediately to the health care provider? A. Weight gain of 2 lb B. Urine specific gravity of 1.015 C. Blood urea nitrogen of 20 mg/dL D. Serum sodium level of 118 mEq/L

D. Serum sodium level of 118 mEq/L

A patient is post-op day 4 from a t-tube placement. Which finding below requires you to notify the physician? A) Drainage from the t-tube is yellowish green. B) Drainage from the t-tube within the past 24 hours is approximately 925 cc. C) Blood tinged drainage from the t-tube has decreased. D) Patient reports a decrease in nausea.

B) Drainage from the t-tube within the past 24 hours is approximately 925 cc

The nurse is caring for a patient with lung cancer who is receiving chemotherapy. Which assessment finding suggests that the patient is experiencing pericardial effusion? A) Bruising and tarry stools B) Edema and shortness of breath C) Nausea and decreased bowel sounds D) Peripheral numbness and tingling

B) Edema and shortness of breath

A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure? A) Elevate the head of the bed to 45 degrees. B) Have the patient lie on the left side for 1 hour. C) Apply a sterile 2-inch gauze dressing to the site. D) Use a half-inch sterile gauze to pack the wound.

B) Have the patient lie on the left side for 1 hour.

Results of a patient barium swallow suggest that the patient has GERD. The nurse is planning health education to address the patients knowledge of this new diagnosis. Which of the following should the nurse encourage? A) Eating several small meals daily rather than 3 larger meals B) Keeping the head of the bed slightly elevated C) Drinking carbonated mineral water rather than soft drinks D) Avoiding food or fluid intake after 6:00 p.m.

B) Keeping the head of the bed slightly elevated

A client has a tentative diagnosis of Hodgkin's lymphoma disease. How does the nurse expect the diagnosis to be confirmed? A) Bone scan B) Lymph node biopsy C) Computed tomography scan (CT) D) Radioactive iodine uptake study

B) Lymph node biopsy

A nurse is providing care for a patient who has just been diagnosed as being in the early stage of rheumatoid arthritis. The nurse should anticipate the administration of which of the following? A) Hydromorphone (Dilaudid) B) Methotrexate (Rheumatrex) C) Allopurinol (Zyloprim) D) Prednisone

B) Methotrexate (Rheumatrex)

A patient newly diagnosed with cancer is scheduled to begin chemotherapy treatment and the nurse is providing anticipatory guidance about potential adverse effects. When addressing the most common adverse effect, what should the nurse describe? A) Pruritis (itching) B) Nausea and vomiting C) Altered glucose metabolism D) Confusion

B) Nausea and vomiting

The TNM staging system has been used to stage your pt's cancer. The report says: T1N0M0. What is the meaning of N0? A) Cancer in regional lymph node can't be measured. B) No cancer present in regional lymph node. C) Cancer in distant lymph node can't be measured. D) No cancer found in other body parts.

B) No cancer present in regional lymph node.

A nurse is caring for a client who has just returned from the PACU after a traditional cholecystectomy. In which of the following positions should the nurse place the client? A) Prone B) Semi-Fowler's C) Supported Sims D) Dorsal recumbant

B) Semi-Fowler's

Which position is best for a patient with a t-tube? A) Supine B) Semi-Fowler's C) Right lateral recumbent D) Left lateral recumbent

B) Semi-Fowler's

What TNM classification below best describes this finding: very large tumor with 1 regional lymph node involvement, and spread to two regional organs? A) T1N1M2 B) T4N1M1 C) T1N1M1 D) T4N1M2

B) T4N1M1

Which assessment data indicate to the nurse the client recovering from an open cholecystectomy may require pain medication? A) The client's pulse is 65 beats per minute. B) The client has shallow respirations. C) The client's bowel sounds are 20 per minute. D) The client uses a pillow to splint when coughing.

B) The client has shallow respirations.

A nurse is providing discharge education to a patient who has undergone a laparoscopic cholecystectomy. During the immediate recovery period, the nurse should recommend what foods? A) High-fiber foods B) Low-purine nutrient-dense foods C) Low-fat foods high in proteins and carbohydrates D) Foods that are low-residue and low in fat

C) Low-fat foods high in proteins and carbohydrates

An intravenous solution of lactated Ringers is prescribed to replace the T-tube output of a client who had a cholecystectomy and common bile duct exploration. The nurse recalls that the condition that will improve if the administration of lactated Ringers solution is effective is: A) Urinary stasis B) Paralytic ileus C) Metabolic acidosis D) Increased potassium level

C) Metabolic acidosis

A client with cancer develops pancytopenia during the course of Chemotherapy. The client asks the nurse why this has occurred. What explanation will the nurse provide? A) Steroid hormones have a depressant effect on the spleen and bone marrow. B) Lymph node activity is depressed by radiation therapy used before chemotherapy. C) Noncancerous cells also are susceptible to the effects of chemotherapeutic drugs. D) Dehydration caused y nausea, vomiting, and diarrhea results in hemoconcentration.

C) Noncancerous cells also are susceptible to the effects of chemotherapeutic drugs.

The nurse is assisting with creating a plan of care for a client with pancytopenia as a result of chemotherapy. The nurse should suggest including which in the plan of care? Select all that apply: A) Restricting all visitors B) Restricting fluid intake C) Restricting fresh fruits and vegetables in the diet D) Applying a face mask to the client if outside the client room.5. Inserting an indwelling urinary catheter to prevent

C) Restricting fresh fruits and vegetables in the diet D) Applying a face mask to the client if outside the client room.5. Inserting an indwelling urinary catheter to prevent

The nurse assess a large amount of red drainage on the dressing of a client who is six hours postoperative open cholecystectomy. Which intervention should the nurse implement? A) Measure the abdominal girth. B) Palpate the lower abdomen for a mass C) Turn client onto side to assess for further drainage. D) Remove the dressing to determine the source.

C) Turn client onto side to assess for further drainage.

The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy: A) restrict all visitors B) restrict fluid intake C) teach client about need for hand hygiene D) insert foley to prevent skin break down

C) teach client about need for hand hygiene

A patient on chemotherapy and radiation for head and neck cancer has a WBC of 1.9x10^3; HGB 10.8 g/dL, and platelet count of 99x10^3. Based on the CBC results what is the most serious clinical finding? A) cough, rhinitis, and sore throat B) fatigue, nausea, and skin redness at site of radiation C) temp 101.9, fatigue, & SOB D) skin redness at side of radiation, headache, and constipation

C) temp 101.9, fatigue, & SOB

A patient with lung cancer is receiving chemotherapy. Why should the nurse closely monitor the patients white blood cell (WBC) count? A) Chemotherapy drugs cause polycythemia and can precipitate thrombosis. B) Chemotherapy drugs attack WBCs and shorten their life span, which increases risk for infection. C) Chemotherapy drugs cause proliferation of blood cells, which can lead to sluggish circulation. D) Chemotherapy drugs depress the bone marrow, which can lead to infection and an increase in WBC count.

D) Chemotherapy drugs depress the bone marrow, which can lead to infection and an increase in WBC count.

The TNM staging system for cancer can be used to help stage what type of cancer? A) Brain cancer B) Spinal cancer C) Leukemia D) Colon cancer

D) Colon cancer

You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance? A) Metabolic alkalosis B) Hypermagnesemia C) Hypercalcemia D) Hypovolemia

D) Hypovolemia

Which outcome should the nurse identify for the client scheduled to have a cholecystectomy? A) Decreased pain management. B) Ambulate first day postoperative C) No break in skin integrity. D) Knowledge of postoperative care.

D) Knowledge of postoperative care.

A nurse is admitting a client to the surgical unit from the PACU following a cholecystectomy. Which of the following assessments is the nurse's priority? A) Bowel sounds B) Surgical dressing C)Temperature D) Oxygen Saturation

D) Oxygen Saturation

The nurse cares for a client who is at risk for wound dehiscence after abdominal surgery. Which action is the priority to minimize this risk? A) Administer prescribed antibiotics. B) Use sterile technique for dressing changes. C) Keep sterile saline and sterile dressings at the bedside. D) Place a pillow over the incision site during deep breathing and coughing.

D) Place a pillow over the incision site during deep breathing and coughing

The client is four hours postoperative open cholecystectomy. Which data warrant immediate intervention by the nurse? A) Absent bowel sounds in all four quadrants. B) The T-tube has 60 mL of green drainage. C) Urine output of 100 mL in the past three hours.4 D) Refusal to turn, deep breathe, and cough.

D) Refusal to turn, deep breathe, and cough.

Which TNM classification has the poorest prognosis? A) T0N0M0 B) T2N2M1 C) T4N1M0 D) T4N3M1

D) T4N3M1

A patient has just been diagnosed with prostate cancer and is scheduled for brachytherapy next week. The patient and his wife are unsure of having the procedure because their daughter is 3 months pregnant. What is the most appropriate teaching the nurse should provide to this family? A) The patient should not be in contact with the baby after delivery. B) The patients treatment poses no risk to his daughter or her infant. C) The patients brachytherapy may be contraindicated for safety reasons. D) The patient should avoid close contact with his daughter for 2 months.

D) The patient should avoid close contact with his daughter for 2 months.

A client with small-cell lung cancer is receiving chemotherapy. A CBC is prescribed before each round of chemotherapy. Which component of the CBC is of greatest concern to the nurse? A) Platelets B) Hematocrit C) RBC's D) WBC's

D) WBC's

While giving care to a client with a internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action? A) call HCP B) reinster the implant into the vagina C) pick up implant with gloved hands and flush down toilet D) pick up the implant with long-handled forceps and place into a lead container

D) pick up the implant with long-handled forceps and place into a lead container

A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to A) choose low-fat foods from the menu. B) perform leg exercises hourly while awake. C) ambulate the evening of the operative day. D) turn, cough, and deep breathe every 2 hours

D) turn, cough, and deep breathe every 2 hours