HEC Exam 3
Another women in the class said she heard that there is a genetic test that would diagnose breast cancer. What. is the best response by the nurse? A. "A positive test for the BRCA1 mutation identifies and increased risk for breast cancer, but is not a certainty." B. "If the BRCA1 mutation test is positive it indicates an increased risk for emphysema." C. "If the BRCA1 mutation test is positive, a bilateral mastectomy is required." D. "A positive BRCA2 mutation gene indicates breast cancer metastasis."
ANS: A
Chandra is disappointed to learn that she will not benefit from hormonal therapy, but she states that her friend indicated that taking the medication was like experiencing menopause. How should the nurse respond? A. "The medication decreases estrogen levels, which is what also causes the symptoms of menopause." B. "With the medication, the effects of estrogen are enhanced, which is what women in menopause experience." C. "The medication was probably not the cause of her symptoms. They were probably related to the cancer." D. "If she also had breast cancer, she probably would have those symptoms even without the medication."
ANS: A
Chandra shares with the group that a lump she felt during breast self-exam was the only symptom she had. Which description of a breast lump is most typical of breast cancer? A. Hard, irregular, and does not move freely B. Soft and mashes down easily when touched C. Raised, warm, and tender when palpated D. Moves easily under the skin with very defined boarders
ANS: A
Nursing considerations related to the administration of chemotherapeutic drugs include: A. many chemotherapeutic agents are vesicants that can cause severe cellular damage if the drug infiltrates. B. good hand washing is essential when handling chemotherapeutic drugs, but gloves are not necessary. C. infiltration will not occur unless superficial veins are used for the intravenous infusion. D. anaphylaxis cannot occur because the drugs are considered toxic to normal cells.
ANS: A
The RN working on an oncology unit has just received report on these clients. Which client should be assessed first? A. Client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature B. Client with lymphoma who will need administration of an antiemetic before receiving chemotherapy C. Client with metastatic breast cancer who is scheduled for external beam radiation in 1 hour D. Client with xerostomia associated with laryngeal cancer who needs oral care before breakfast
ANS: A
The nurse is caring for a client receiving chemotherapy who reports anorexia. Which measure does the nurse use to best monitor for cachexia? A. Monitor weight. B. Trend red blood cells and hemoglobin and hematocrit. C. Monitor platelets. D. Observe for motor deficits.
ANS: A
The nurse is caring for a client undergoing mastectomy who asks the nurse about breast reconstruction. Which of these will the nurse include in the discussion? A. Many women want breast reconstruction using their own tissue immediately after mastectomy. B. Placement of saline or gel-filled prostheses is not recommended because of the nature of the surgery. C. Reconstruction of the nipple-areola complex is the first stage in the reconstruction of the breast. D. The surgeon would offer the option of breast reconstruction surgery once healing has occurred after a mastectomy.
ANS: A
The nurse is teaching postmastectomy exercises to a client. Which statement made by the client indicates that teaching has been effective? A. "For the pulley exercise, I'll drape a 6-foot (1.8 meter)-long rope over a shower curtain rod or over the top of a door." B. "In rope turning, I'll hold the rope with my arms flexed." C. "In rope turning, I'll start by making large circles." D. "With hand wall climbing, I'll walk my hands up the wall and back down until they are at waist level."
ANS: A
The nurse is teaching the parents about the implanted port. Which statement by the nurse is correct regarding the primary purpose of the port? A. "It is to increase the child's quality of life." B. "It can quickly be inserted by the nurse at the bedside." C. "It is placed to decrease the risk of infection." D. "It allows the parents to assist in the child's care."
ANS: A
The oncology nurse is caring for a group of clients receiving chemotherapy. The client with which sign/symptom is displaying bone marrow suppression? A. Hemoglobin of 7.4 g/dL (74 mmol/L) and hematocrit of 21.8% B. Potassium level of 2.9 mEq/L (2.9 mmol/L) and diarrhea C. 250,000 platelets/mm3 (250 × 109/L) D. 5000 white blood cells/mm3 (5 × 109/L)
ANS: A
Upon entering the room, the nurse finds the patient, who has just had a mastectomy, crying. When the nurse asks about her crying, the patient states, "I know I shouldn't cry because this surgery may well save my life." What is the nurse's best response? A. "It is okay to cry; mourning the loss of your breast is important for getting past this." B. "I know this is hard, but chances of survival are greatly improved now." C. "Would you like to talk to someone who also has had a mastectomy?" D. "How have you coped with difficult situations in the past?"
ANS: A
What priority intervention will the nurse employ to prevent injury to the patient with bone cancer? A. Using a lift sheet when repositioning the patient B. Positioning the patient so the heels do not touch the mattress C. Providing small, frequent meals rich in calcium and phosphorus D. Applying pressure for a full 5 minutes after intramuscular injections
ANS: A
Which of the following statements is essential when teaching a patient who has received an injection of iodine-131? A. "Do not share a toilet with anyone else for 3 days." B. "You need to save all your urine for the next 7 days." C. "No special precautions are needed, because this is a weak type of radiation." D. "You need to avoid contact with everyone except family members until the radiation device is removed."
ANS: A
A client who has been diagnosed with breast cancer tells the nurse she wishes to use only natural and complementary interventions. Which of these will the nurse explain to the client? A. If chemotherapy has been recommended, complementary therapies are contraindicated B. This type of therapy would not replace standard treatment C. There are many natural hormonal therapy replacements that can be used D. Complementary therapies can only be used after surgery
ANS: B
A mass is seen on Chandra's mammogram, and a follow-up stereotactic core needle biopsy is performed. The tumor specimen is found to be cancerous. Chandra learns that she has a cancerous tumor requiring surgery. She tells the nurse, "They make mistakes. I know that happens. My specimen probably got switched with someone else's, right?" What is the best response by the nurse? A. "I will notify the healthcare provider that you would like the test repeated." B. "It's hard to believe that this is happening, isn't it?" C. "Tell me why you fell an error was made on the test." D. "Right now you are feeling denial. It takes time to accept this."
ANS: B
A pediatric patient has been diagnosed with leukemia and presents with a white blood cell (WBC) count of 80,000 mm3. Which statement if provided by a nursing student indicates that additional teaching is needed with regard to pathophysiological mechanisms of leukemia? A. The increase in WBC provides protection against bacterial infections. B. Although the WBC count is elevated, there are increased blast cells which help to protect the patient against infection. C. The amount of white blood cells is greatly increased, which affords protection against viral infections. D. Increases in white blood cells are expected but associated with a low leukocyte count.
ANS: B
Based on Roberto's lab results, which factors place him at high risk for acute lymphoblastic leukemia (ALL)? A. RBC and platelet count B. Sex and WBC C. Platelet count and reticulocyte count D. Hemoglobin and hematocrit
ANS: B
Chandra talks about the modifiable risk factors for breast cancer. Which modifiable risk factors should Chandra discuss? A. Avoid having children B. Breastfeed for a year or more C. Consume 2 to 3 glasses of wine per day D. Avoid tight support bras
ANS: B
Since Chandra's tumor is estrogen-receptor negative, she is not a candidate for hormonal therapy. Tamoxifen (Nolvadex) is an antiestrogen drug that is often used to prevent or treat recurrent breast cancer. Chandra states that a friend of hers took this drug and has no recurrence of her breast cancer. The nurse asks Chandra if her friend experienced any problems when taking tamoxifen (Nolvadex). Which side effect is most often associated with tamoxifen? A. Weight loss B. Hot flashes C. Hypertension D. Anemia
ANS: B
The client who received combination chemotherapy 7 days ago for breast cancer calls the oncology clinic to report a temperature of 100.5F (38.06C) and has no other symptoms of infection. What is the nurse's best response? A. "This is a normal immune-related response to the chemotherapy." B. "Please go to the nearest emergency room for a full workup for infection." C. "You are most likely dehydrated. Come to the clinic now for IV fluids." D. "There is no concern at this time but call if your temperature reaches 101.5F (38.6C)."
ANS: B
The nurse is caring for a client with end-stage ovarian cancer who needs clarification on the purpose of palliative surgery. Which outcome should the nurse teach the client is the goal of palliative surgery? A. Cure of the cancer B. Relief of symptoms or improved quality of life C. Allowing other therapies to be more effective D. Prolonging the client's survival time
ANS: B
The nurse would incorporate which of the following into the plan of care as a primary prevention strategy for reduction of the risk for cancer? A. Yearly mammography for women aged 40 years and older B. Using skin protection during sun exposure while at the beach C. Colonoscopy at age 50 and every 10 years as follow-up D. Yearly prostate specific antigen (PSA) and digital rectal exam for men aged 50 and over
ANS: B
What is the priority nursing diagnosis for a patient experiencing chemotherapy-induced anemia? A. Risk for injury related to poor blood clotting B. Fatigue related to decreased cellular oxygenation C. Disturbed body image related to skin color changes D. Imbalanced nutrition, less than body requirements related to anorexia
ANS: B
Which action can the same-day surgery charge nurse delegate to an experienced unlicensed assistive personnel (UAP) who is helping with the care of a client who is having a breast biopsy? A. Assess anxiety level about the surgery. B. Monitor vital signs after surgery. C. Obtain data about breast cancer risk factors. D. Teach about postoperative routine care.
ANS: B
Which client problem does the nurse set as the priority for the client experiencing chemotherapy-induced peripheral neuropathy? A. Potential for lack of understanding related to side effects of chemotherapy B. Potential for injury related to sensory and motor deficits C. Potential for ineffective coping strategies related to loss of motor control D. Altered sexual function related to erectile dysfunction
ANS: B
Which manifestation of an oncologic emergency requires the nurse to contact the health care provider immediately? A. New onset of fatigue B. Edema of arms and hands C. Dry cough D. Weight gain
ANS: B
Which medication does the nurse plan to administer to a client before chemotherapy to decrease the incidence of nausea and vomiting? A. Morphine B. Ondansetron (Zofran) C. Naloxone (Narcan) D. Diazepam (Valium)
ANS: B
B. Provide answers to the family's questions abou
ANS: B,C
After surgery, Chandra is admitted to the PACU for immediate postoperative management. Which nursing actions have the highest priority in the initial postoperative period? (Select all that apply.) A. Review hand and wrist exercises with Chandra. B. Observe the Jackson-Pratt drainage device. C. Place head of the bed up at least 30 degrees with affected arm elevated on a pillow. D. Provide privacy for Chandra. E. Monitor vital signs and pulse oximetry.
ANS: B,C,E
The nurse is teaching a client how to perform breast self-examination (BSE). Which of these techniques does the nurse include in the teaching session? Select all that apply. A. Instruct the client to keep her arm by her side while performing the examination. B. Ensure that the setting in which BSE is demonstrated is private and comfortable. C. Ask the client to remove her shirt. The bra may be left in place. D. Ask the client to demonstrate her own method of BSE. E. Use the fingertips, which are more sensitive than the finger pads, to palpate the breasts.
ANS: B,D
Because of her relatively young age, and the presence of positive lymph node, Chandra elects to take chemotherapy to reduce her risk for recurrence. The nurse prepares Chandra for common adverse effects that she may experience. Which adverse effects most often associated with antineoplastic chemotherapy used to treat breast neoplasms should be included in this discussion? (Select all that apply.) A. Loss of vision B. Diarrhea C. Seizures D. Tinnitus E. Alopecia
ANS: B,E
Which nursing care measures will be most beneficial in the management of Chandra's highest priority problem? (Select all that apply.) A. Place Chandra in a semi-Fowler's position B. Apply a sequential compression device C. Review hand exercises Chandra can perform D. Provide high protein snacks between meals E. Elevate the affected arm
ANS: B,E
A 48-year-old woman who has been diagnosed with breast cancer with the BRCA genetic mutation requests information about early detection for her daughter because of her daughter's genetic risk. Which information will the nurse convey? A. Breast self-examination (BSE) beginning at 20 years of age is the best way to detect breast cancer B. Hormone replacement therapy (HRT) combining estrogen and progesterone may be recommended by your daughter's primary health care provider C. MRI for screening typically begins at an age that is 10 years younger than your present age. D. The primary health care provider will most likely discuss prophylactic mastectomy with daughters of women with genetic mutations
ANS: C
A client who has undergone breast surgery is struggling with issues concerning her sexuality. What is the best way for the nurse to address the client's concerns? A. Ask the client if she is using her surgery as an excuse not to have any more sexual relations with her partner. B. Remind the client to avoid sexual intercourse for 2 months after the surgery. C. Ask the client about satisfaction with sexual relations with her partner. D. Teach the client that birth control is a priority.
ANS: C
A multi-lumen central line has been inserted, and the nurse is preparing to administer a dose of chemotherapy through the central line by first flushing the IV lumens. The nurse notes that two of the four lumens do not flush easily. What intervention is appropriate for the nurse to implement? A. Hold the scheduled dose of chemotherapy until a chest x-ray is done. B. Ask Chandra two perform the Valsalva maneuver while flushing the lines. C. Notify the HCP that the central line is no longer functional. D. Label the two lumens as nonfiction, and use one of the remaining lumens.
ANS: C
A newly graduated RN has just finished a 6-week orientation to the oncology unit. Which client is most appropriate to assign to the new graduate? A. A 30-year-old with acute lymphocytic leukemia who will receive combination chemotherapy today B. A 40-year-old with chemotherapy-induced nausea and vomiting who has had no urine output for 16 hours C. A 45-year-old with pancytopenia who will require IV administration of erythropoietin (Procrit) D. A 72-year-old with tumor lysis syndrome who is receiving normal saline IV at a rate of 250 mL/hr
ANS: C
A patient with breast cancer asks the nurse why 6 weeks of daily radiation treatments is necessary. What is the nurse's best response? A. "Your cancer is widespread and requires more than the usual amount of radiation treatment." B. "The cost of larger doses of radiation for a shorter period of time is justified by the results." C. "Research has shown more cancer cells are killed if the radiation is given in smaller doses over a longer period of time." D. "It is less likely your hair will fall out or you will become anemic if radiation is given in smaller doses over a longer period of time."
ANS: C
Chandra decides to have surgery and is scheduled for a modified radical mastectomy with immediate abdominal myocutaneous flap reconstruction. A modified radical mastectomy involves removal of breast tissue and lymph nodes, but it conserves the pectorals major muscle. The reconstruction involves the use of a flap of skin and muscle from the abdomen to create a breast mound. Chandra arrives at the Surgery Center 2 hours before her scheduled surgery. The nurse confirms Chandra's NPO status. Chandra states, "I had a cracker this morning before I came here. I am so nervous. I have to have this surgery today, or I will back out. Please don't tell anyone." What is the best response by the nurse? A. "Since it was only crackers, that won't be harmful and I won't record it in the chart." B. "Eating the crackers increases your risk of aspirating during surgery." C. "To ensure your safety, I need to notify the surgeon of the crackers you ate." D. "You should not have eaten the crackers. Any intake means a delay in surgery."
ANS: C
Chandra demonstrates BSE techniques for the nurse using a practice model. She uses her finger pads and states that when lying down, her arm should be relaxed at her side. What instructions should the nurse provide? A. "You have demonstrated BSE successfully; practice this every month." B. "Use your fingertips rather than the pads of your fingers." C. "When you are lying down, your arm should be positioned over your head." D. "Place your hand on your hip and flex your arm while lying down."
ANS: C
Nursing care of the child with myelosuppression from leukemia or chemotherapeutic agents should include: A. restricting oral fluids. B. instituting strict isolation. C. using good handwashing. D. giving immunizations appropriate for age.
ANS: C
The nurse corrects the nursing student when caring for a client with neutropenia secondary to chemotherapy in which circumstance? A. The student demonstrates asepsis by scrubbing the hub of IV tubing before administering an antibiotic. B. The nurse overhears the student explaining to the client the importance of handwashing. C. The student teaches the client that symptoms of neutropenia include fatigue and weakness. D. The nurse observes the student educating the client about hygiene and perineal care.
ANS: C
The nurse enters Chandra's room and observes that a graduate nurse is assessing Chandra's dressing while the unlicensed assistive personnel (UAP) takes postoperative vital signs. The UAP is preparing to take Chandra's BP on her operative side because there is an IV in the other arm. Which action should the nurse implement first? A. Assign the UAP to place a sign over the bed to avoid BPs on the operative side. B. Tell the graduate nurse that it is a nursing responsibility to supervise the UAP correctly. C. Advise the UAP to immediately stop and obtain the blood pressure in the nonoperative arm. D. Leave the room with the graduate nurse and UAP to discuss the situation in the conference room.
ANS: C
The nurse is aware that treatment with antineoplastic chemotherapeutic agents can cause immunosuppression, which predisposed the client to infection. Which assessment finding would cause the nurse to suspect that an immunosuppressed client has an infection? A. Tingling in fingers B. Nausea C. Oral temperature of 99.5 D. Epistaxis
ANS: C
The nurse is discussing the situation with the graduate nurse and UAP. What should the nurse emphasize in the discussion? A. Assessment of postoperative vital signs should not be assigned to a UAP. B. As the supervising nurse, the graduate nurse is fully responsible for the incorrect action taken. C. Both the graduate nurse and the UAP are at fault for the incorrect action of the UAP. D. The UAP is certified to take vital signs and is fully responsible for the action taken.
ANS: C
The nurse is planning care based on the prescribed chemotherapeutic agent. Before initiating treatment, the nurse understands that chemotherapeutic agents are classified according to which criteria? A. Side effects B. Therapeutic effects C. Mechanism of action D. Frequency of administration
ANS: C
The oncology nurse should use which intervention to prevent disseminated intravascular coagulation (DIC)? A. Monitoring platelets B. Administering packed red blood cells C. Using strict aseptic technique to prevent infection D. Administering low-dose heparin therapy for clients on bedrest
ANS: C
What additional information is vital for the nurse to obtain from Roberto's history? A. The family's employment history B. History of cancer in the family C. Roberto's immunization status D. Family's educational level
ANS: C
When caring for a client receiving chemotherapy, the nurse plans care during the nadir of bone marrow activity to prevent which complication? A. Drug toxicity B. Polycythemia C. Infection D. Dose-limiting side effects
ANS: C
When caring for the client with chemotherapy-induced mucositis, which intervention will be most helpful? A. Administering a biological response modifier B. Encouraging oral care with commercial mouthwash C. Providing oral care with a disposable mouth swab D. Maintaining NPO until the lesions have resolved
ANS: C
Which client report indicates to the nurse that spinal cord compression may be present? A. The client reports having a headache for the past 7 hours. B. The client has reduced breath sounds in the left lung. C. The client has worsening mid-thoracic back pain. D. Pedal edema is now present bilaterally.
ANS: C
Which finding alarms the nurse when caring for a client receiving chemotherapy who has a platelet count of 17,000/mm3 (17 × 109/L)? A. Increasing shortness of breath B. Diminished bilateral breath sounds C. Change in mental status D. Weight gain of 4 pounds (1.8 kg) in 1 day
ANS: C
Which instruction is most appropriate for the nurse to convey to the client with chemotherapy-induced neuropathy? A. Bathe in cold water. B. Wear cotton gloves when cooking. C. Consume a diet high in fiber. D. Make sure shoes are snug.
ANS: C
Which nursing diagnosis should be reflected in Chandra's plan of care? A. Prolonged grieving B. Dysfunctional grieving C. Anticipatory grieving D. Lack of grieving
ANS: C
Which of the following findings during a female breast examination should the nurse report as suspicious for breast cancer? A. Multiple nodules of round, lumpy, tender tissue in both breasts B. A single soft, mobile, lobular nodule that is nontender C. A poorly defined, firm lump that is nontender and nonmovable D. A single soft lump that is well-defined and tender
ANS: C
Which statement made by a client allows the nurse to recognize whether the client receiving brachytherapy for ovarian cancer understands the treatment? A. "I may lose my hair during this treatment." B. "I must be positioned in the same way during each treatment." C. "I will have a radioactive device in my body for a short time." D. "I will be placed in a semiprivate room for company."
ANS: C
A client tells the nurse in the gynecology clinic that she doesn't get a yearly mammogram because she is afraid of what might be found. Which teaching will the nurse provide? A. If your screening for breast cancer is low risk, you can always have a MRI which is cheaper. B. Detection of breast cancer before or after axillary node invasion yields the same outcome. C. Mammography as a baseline screening is recommended by the American Cancer Society at 30 years of age. D. Mammograms help with early detection of localized breast cancer which has a high 5-year survival rate.
ANS: D
A client who is undergoing chemotherapy for breast cancer reports problems with concentration and memory. Which nursing intervention is indicated at this time? A. Explain that this occurs in some clients and is usually permanent. B. Inform the client that a small glass of wine may help her relax. C. Protect the client from infection. D. Allow the client an opportunity to express her feelings.
ANS: D
A pediatric oncology patient has developed a nose bleed. Which finding would account for this occurrence? A. Increased white blood cell count B. Increased neutrophils C. Decreased hemoglobin and hematocrit D. Decreased platelet count
ANS: D
After the diagnosis of ALL is confirmed, the HCP orders a lumbar puncture (LP). Which explanation by the nurse best describes the purpose of the LP? A. measure intrathecal pressure B. Instill. anesthetics C. classify the type of leukemia D. determine whether cancer cells have spread to the spinal fluid
ANS: D
An outpatient client is receiving photodynamic therapy. Which environmental factor is a priority for the client to adjust for protection? A. Storing drugs in dark locations at room temperature B. Wearing soft clothing C. Wearing a hat and sunglasses when going outside D. Reducing all direct and indirect sources of light
ANS: D
At the community education program, Chandra learns that breast self-exam (BSE) is best performed 7 days after the start of the menstrual flow when the breasts are least engorged and tender. Since Chandra had a hysterectomy 5 years ago, she does not have periods. She asks the nurse if she still needs to perform BSE, and if so, when? What is the best response by the nurse? A. "If you take hormone replacement therapy (HRT), you should perform BSE every week." B. "Since you have had a hysterectomy, performing BSE twice a year is adequate." C. "Follow the same timing cycle you used when you had regular menstrual periods." D. "Select whatever day you can best remember to perform BSE consistently every month."
ANS: D
Chandra goes on to say, "I can control this. I will start exercising and I will change my eating habits. That will take care of it." How should the nurse respond? A. "You need to recognize that you have cancer that needs surgery." B. "Tell me what kind of diet changes you are planning to make." C. "Have you considered biotherapy?" D. "It. sounds like you do no want to have surgery."
ANS: D
Chandra has completed her first round of chemotherapy. She calls the nurse to report that she cut her arm on the operative side while doing yard work the previous day, and now her arm appears very swollen and tender. Chandra is admitted to the hospital with a medical diagnosis of lymphedema and possible cellulitis. Which assessment findings led to the diagnosis of lymphedema? A. Purulent drainage with an odor B. Thinning of the skin in affected arm C. Thin and brittle fingernails D. Swelling and numbness in the affected arm
ANS: D
Chandra seems happy and she tells the nurse that she received some good news. She states that her tumor was negative for estrogen receptor sites. She continues, "That means I have less likelihood of a recurrence or spread of the cancer." What action should the nurse take first? A. Review the meaning of negative estrogen receptor sites with Chandra. B. Contact Chandras HCP to confirm the test results. C. Review the operative report and tissue analysis in Chandras medical record. D. Ask Chandra to clarify how she learned this information so that a plan for further teaching can be developed.
ANS: D
Francie states that she will schedule a mammogram and she asks the nurse if the x-ray is painful. How should the nurse respond? A. "The pain of the procedure its worth the benefit you will gain." B. "Tell me what your concerns are related to experiencing pain." C. "X-ray procedures do not typically cause any sort of discomfort." D. "You may experience some discomfort, but only for a few minutes."
ANS: D
In taking care of a pediatric oncology patient, which diagnostic finding would indicate a critical concern for the development of bleeding? A. Absolute neutrophil count of 1000 mm3 B. Temperature of 99.2° F C. White blood cell count 18,000 mm3 D. Platelet count 50,000 mm3
ANS: D
The nurse at the gynecology clinic is examining a woman's breasts. Which assessment finding will the nurse report immediately to the primary health care provider? A. A 1-cm freely mobile rubbery mass discovered by the client B. Ill-defined painful rubbery lump in the outer breast quadrant C. Backache and breast fungal infection D. Nipple discharge and dimpling
ANS: D
The nurse confirms that Chandra has signed the informed consent for surgery, but learns that Chandra does not understand the procedure for breast reconstruction that is to be performed. What action should the nurse implement? A. Describe the procedure to Chandra using simple language and drawings. B. Offer reassurance and support, since the consent is already signed. C. Affirm that Chandra has made a good choice in having immediate reconstruction. D. Notify the surgeon that further explanation of the procedure is necessary.
ANS: D
The nurse is caring for a patient who received a bone marrow transplant 10 days ago. The nurse would monitor for which of the following clinical manifestations that could indicate a potentially life-threatening situation? A. Mucositis B. Confusion C. Depression D. Mild temperature elevation
ANS: D
The nurse is caring for four clients. Which client does the nurse recognize as having the highest risk for development of breast cancer? A. 55-year-old male with gynecomastia and obesity B. 60-year-old female whose father died from colon cancer C. 65-year-old male whose mother had ovarian cancer D. 75-year-old female who was treated for breast cancer 5 years ago
ANS: D
The nurse is discussing treatment options with a client newly diagnosed with breast cancer. Which statement by the client indicates a need for further teaching? A. "Hormonal therapy is only used to prevent the growth of cancer. It won't get rid of it." B. "I might have chemotherapy before surgery." C. "If I get radiation, I am not radioactive to others." D. "Radiation will remove the cancer, so I might not need surgery."
ANS: D
The nurse is preparing to discharge a client who has had drains placed after a mastectomy. The nurse recognizes the client understands care of the drains when she states which of these? A. "The surgeon will pull the drains before I leave the hospital." B. "The drain will help prevent postoperative infection." C. "I may shower tomorrow morning as long as I don't face the shower spray." D. "Drains are generally removed when drainage is less than an ounce (30 ml) for three consecutive days."
ANS: D
The nurse reviews signs and symptoms of breast cancer, including nipple discharge and retraction. The nurse describes a change called beau d'orange. Which symptom of breast cancer does this describe? A. Alteration in the shape of the breast B. Change in the color of the skin C. Pain and ulceration of the skin D. Unusual skin texture
ANS: D
The nurse teaches a client that intraperitoneal chemotherapy will be delivered to which part of the body? A. Veins of the legs B. Lung C. Heart D. Abdominal cavity
ANS: D
What instructions does the nurse provide for following a bone marrow procedure being performed on a pediatric patient for detection of leukemia? A. The patient will have to remain on a low-bacteria diet until the results are obtained. B. Patient should expect to have slight swelling at the site which will lessen within 24 hours of the procedure. C. Round the clock pain medication will be prescribed for the first 24 hours following the procedure. D. No activity restrictions are provided.
ANS: D
Which client being cared for on the medical-surgical unit will be best to assign to a nurse who has floated from the intensive care unit (ICU)? A. Recent radical mastectomy client requiring chemotherapy administration B. Modified radical mastectomy client needing discharge teaching C. Stage III breast cancer client requesting information about radiation and chemotherapy D. Client with a Jackson-Pratt drain who just arrived from the postanesthesia care unit after a mastectomy
ANS: D
Which client's history indicates the person at highest risk for breast cancer? A. A 35-year-old, unemployed, obese women, who has five children and two grandchildren B. A. 40-year-old female attorney with delayed pubertal development, including starting her period at age 17. C. A 45-year-old female nurse who is starting to experience menopausal symptoms D. A 65-year-old woman, who is a retired teach and who never married or had children
ANS: D
While the nurse is obtaining the health history of a 75-year-old female patient, which of the following has the greatest implication for the development of cancer? A. Being a woman B. Family history of hypertension C. Cigarette smoking as a teenager D. Advancing age
ANS: D
The nurse is teaching a client who is receiving an antiestrogen drug about the side effects she may encounter. Which side effects does the nurse include in the discussion? Select all that apply. A. Heavy menses B. Smooth facial skin C. Hyperkalemia D. Breast tenderness E. Weight loss F. Deep vein thrombosis
ANS: D,F
After receiving vancomycin (Vancocin) for 7 days, Chandra complains that her mouth is painful when she swallows. When assessing her mouth, the nurse visualizes white, patchy lesions. What is the most probable cause of this finding? A. Candida superinfection B. Nonhealing skin lesion C. Anemia D. Metastasis of cancer
ANS: A
A female patient complains of a "scab that just won't heal" under her left breast. During your conversation, she also mentions chronic fatigue, loss of appetite, and slight cough, attributed to allergies. What is the nurse's best action? A. Continue to conduct a symptom analysis to better understand the patient's symptoms and concerns. B. End the appointment and tell the patient to use skin protection during sun exposure. C. Suggest further testing with a cancer specialist and provide the appropriate literature. D. Tell her to put a bandage on the scab and set a follow-up appointment in one week.
ANS: A
After Chandra is awake and stable, she his moved from the PACU to the regular post-op unit. The nurses observes Chandra performing wrist flexion and extension exercises 4 hours after surgery? What action should the nurse take? A. Encourage Chandra to continue performing these exercises. B. Advice Chandra to exercise only her fingers for the first 24 hours. C. Instruct Chandra to avoid any exercises until the next morning. D. Remind Chandra that she can also begin arm range of motion (ROM) activities.
ANS: A
A client is receiving chemotherapy treatment for breast cancer and asks for additional interventions for managing the associated nausea and vomiting. Which complementary and integrative therapy does the nurse suggest? A. Ginger B. Journaling C. Meditation D. Yoga
ANS: A
A client is struggling with body image after breast cancer surgery. Which behavior indicates to the nurse that the client's coping is maladaptive? A. Avoiding eye contact with staff B. Saying, "I feel like less of a woman" C. Requesting a temporary prosthesis D. Saying, "This is the ugliest scar ever"
ANS: A
A client who has just been notified that the breast biopsy indicates a malignancy tells the nurse, "I just don't know how this could have happened to me." Which response by the nurse is best? A. "Please tell me what you mean when you say you don't know how this could have happened to you." B. "Do you have a family history that might make you more likely to develop breast cancer?" C. "Would you like me to help you find more information about how breast cancer develops?" D. "Many risk factors for breast cancer have been identified, so it is difficult to determine what might have caused it."
ANS: A
While performing a BSE, Chandra discovers a lump. After seeing her HCP, Chandra is. scheduled for a mammogram. Chandra brings her 60-year-old-sister-in-law, Francie with her to the Women's Health Center to learn about mammograms. Francie tells the nurse that she does not need a mammogram annually because she has no risk factors for breast cancer, except that her father's sister had breast cancer when she was 50. What intervention should the nurse implement first? A. Teach France that even women with no identified risk factors are at risk. B. Reassure Francie that her father's sister is not a first-degree relative. C. Schedule Francie for a mammogram as soon as its can be arranged. D. Show Francie the equipment used to perform a mammogram.
ANS: A
While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is the most appropriate nursing intervention? A. Prioritization and administration of nursing care throughout the day B. Completing all nursing care in the morning so the patient can rest the remainder of the day C. Completing all nursing care in the evening when the patient is more rested D. Limiting visitors, thus promoting the maximal amount of hours for sleep
ANS: A
The nurse is planning care for a patient with hypercalcemia secondary to bone metastasis. Which of the following interventions will be included in the plan of care? (Select all that apply). A. Increasing oral fluids B. Placement of an oral airway at the bedside C. Monitoring for Chvostek's sign D. Implementing seizure precautions E. Hyperactive reflex assessment F. Observation for muscle weakness
ANS: A, F
The community health nurse is providing education to a group of women about risks for breast cancer. Which of these risk factors will the nurse include in the education session? Select all that apply. A. High breast density B. Nulliparity C. Male with gynecomastia D. Middle-aged woman E. First child at age 25
ANS: A,B
Which findings are not consistent with tumor lysis syndrome? Select all that apply. A. Hypercalcemia and hyperkalemia B. Hypochloremia and hypokalemia C. Hyponatremia and hyperphosphatemia D. Hyperuricemia and hyperkalemia E. Hypercalcemia and hypokalemia
ANS: A,B
When monitoring a client with suspected syndrome of inappropriate antidiuretic hormone (SIADH), the nurse reviews the client's medical record, which contains the following information. The nurse notifies the health care provider for which signs and symptoms consistent with this syndrome? Physical Assessment FindingsDiagnostic FindingsMedicationsNeuro: Episodes of confusionCardiac: Pulse 88 and regularMusculoskeletal: Weakness, tremorsNa: 115 mEq/L (115 mmol/L)K: 4.2 mEq/L (4.2 mmol/L)Creatinine: 0.8 mg/dL (70.8 mcmol/L)Ondansetron (Zofran)Cyclophosphamide (Cytoxan) Select all that apply. A. Hyponatremia B. Mental status changes C. Azotemia D. Bradycardia E. Weakness
ANS: A,B,E
When caring for the client receiving cancer chemotherapy, which signs or symptoms related to thrombocytopenia should the nurse report to the health care provider? Select all that apply. A. Bruises B. Fever C. Petechiae D. Epistaxis E. Pallor
ANS: A,C,D
Which assessment findings in a client who has neutropenia from cancer chemotherapy indicate to the nurse that severe disseminated intravascular coagulation (DIC) is present? (Select all that apply.) A. The client is bleeding from the nose, IV sites, and rectum. B. The client's temperature is 99F (37.2C). C. The client's pulse rate is 130 beats per minute. D. The client's respiratory rate is 24 breaths per minute. E. The client's white blood cell count is 3200/mm3 (3.2 × 109/L) F. The client's hourly urine output is 100 mL.
ANS: A,C,D
Which potential side effects does the nurse include in the teaching plan for a client undergoing radiation therapy for laryngeal cancer? Select all that apply. A. Fatigue B. Changes in color of hair C. Change in taste D. Changes in skin of the neck E. Difficulty swallowing
ANS: A,C,D,E
During the child's initial assessment, which assessment findings would be of concern to the nurse? (Select all that apply). A. Pallor B. Alopecia C. Bruises on the legs D. Bone pain E. Weight gain F. Fever
ANS: A,C,D,F
The nurse has received in report that a client receiving chemotherapy has severe neutropenia. Which interventions does the nurse plan to implement? Select all that apply. A. Assess for fever. B. Observe for bleeding. C. Administer pegfilgrastim (Neulasta). D. Do not permit fresh flowers or plants in the room. E. Do not allow the client's 16-year-old son to visit. F. Teach the client to omit raw fruits and vegetables from the diet.
ANS: A,C,D,F
The nurse is assigned to care for a client who has undergone a modified radical right mastectomy for breast cancer. When delegating care, which statements by the nursing assistant would require further teaching by the nurse? (Select all that apply.) A. "I will irrigate the drainage tube after I empty it." B. "If the client says she is in pain, I will tell you right away." C. "It is important for me to take blood pressure on the client's right arm." D. "When helping the client walk, I'll remind her to stand straight." E. "I'll let you know if her surgical dressing is intact and dry."
ANS: A,C,E
Which statements regarding care of the client receiving radiotherapy in the form of unsealed radioactive isotopes guide the nurse's care planning? (Select all that apply.) A. The client may have restrictions on who can visit and for how long. B. The client must be in total isolation while the isotopes are in place. C. When "seeds" are used for prostate cancer therapy, the client must have them removed before he leaves the hospital. D. The client's urine and stool must be handled as radioactive material. E. The nurse must ensure that all personnel entering the client's room use appropriate precautions. F. Only those female nurses who are past menopause can be assigned to care for this client.
ANS: A,D,E
A cancer patient's susceptibility to the syndrome of inappropriate antidiuretic hormone (SIADH) can be suspected with which of the following laboratory results? A. Serum potassium of 5.2 mmol/L B. Serum sodium of 120 mmol/L C. Hematocrit of 40% D. Blood urea nitrogen (BUN) of 10 mg/dL
ANS: B
A client for whom a mastectomy is planned tells the surgical nurse, "I wish there was someone who went through this that I could speak to about how she managed it all." Which community resource will the nurse recommend? A. National Breast Cancer Coalition B. Reach to Recovery C. Susan G. Komen for the Cure D. Young Survival Coalition
ANS: B