MEDSURG3 Exam #1

A nurse is developing a care plan for bone marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable? 24 hours 2 to 4 days 21 to 28 days 7 to 14 days

7 to 14 days Explanation: Bone marrow suppression becomes noticeable 7 to 14 days after floxuridine administration. Bone marrow recovery occurs in 21 to 28 days.

What is the most important postoperative instruction a nurse must give to a client who has just returned from the operating room after receiving a subarachnoid block? "Notify a nurse if you experience blood in your urine." "Avoid drinking liquids until the gag reflex returns." "Avoid eating milk products for 24 hours." "Remain supine for the time specified by the physician."

"Remain supine for the time specified by the physician." Explanation: The nurse should instruct the client to remain supine for the time specified by the physician. Local anesthetics used in a subarachnoid block don't alter the gag reflex. No interactions between local anesthetics and food occur. Local anesthetics don't cause hematuria.

The nurse is preparing a client for paracentesis. What should the nurse do? Put the client on nothing-by-mouth (NPO) status 4 hours before the procedure. Scrub the client's abdomen with povidone-iodine solution. Have the client void before the procedure. Position the client supine.

Have the client void before the procedure. Explanation: Before paracentesis, the client is asked to void. This is done to collapse the bladder and decrease the risk of accidental bladder perforation. The abdomen is not prepared with an antiseptic cleansing solution. The client is placed in a Fowler's position. The client does not need to be put on NPO status before the procedure.

Which finding is an early indicator of bladder cancer? Painless hematuria Occasional polyuria Dysuria Nocturia

Painless hematuria Explanation: Initially, as cancer cells destroy normal bladder tissue, bleeding occurs and causes painless hematuria. (Pain is a late symptom of bladder cancer.) Occasional polyuria may occur with diabetes mellitus or increased alcohol or caffeine intake. Nocturia commonly accompanies benign prostatic hypertrophy. Dysuria may indicate a urinary tract infection.

potassium = 4 sodium = 142 calcium = 12.4 Document these results on the medical record. Report the elevated potassium level immediately. Report the elevated calcium level immediately. Refrain from reporting the results because the client is in hospice care.

Report the elevated calcium level immediately. Explanation: The normal calcium level is 9.0 to 10.5 mg/dL. Hypercalcemia is commonly seen with malignant disease and metastases. The other laboratory values are normal. Hypercalcemia can be treated with fluids, furosemide, or administration of calcitonin. Failure to treat hypercalcemia can cause muscle weakness, changes in level of consciousness, nausea, vomiting, abdominal pain, and dehydration. Although the client is on hospice care, she will still need palliative treatment. Comfort and risk reduction are components of hospice care.

A client has just begun treatment with busulfan, 4 mg by mouth daily, for chronic myelogenous leukemia. The client receives busulfan until his white blood cell (WBC) count falls to between 10,000/mm3 and 25,000/mm3. Then the drug is stopped. When should treatment resume? When the WBC count rises to 50,000/mm3 When the client displays anemia When the WBC falls to 5,000/mm3 When lost hair begins to grow back

When the WBC count rises to 50,000/mm3 Explanation: Busulfan treatment should resume when the WBC count rises to 50,000/mm3. Hair growth and anemia aren't appropriate markers for resuming busulfan treatment.

A middle-aged female with a history of breast-conserving surgery, axillary node dissection, and radiation therapy reports that her arm is red, warm to touch, and slightly swollen. Which action should the nurse suggest? See the health care provider (HCP) immediately. Schedule an appointment within 2 to 3 weeks. Apply warm compresses to the affected arm. Elevate the arm on two pillows.

See the health care provider (HCP) immediately. Explanation: Redness, warmth, and swelling are all signs of infection. Treatment with antibiotics is usually indicated. Infection usually increases fluid accumulation and could worsen the lymphedema. Warm compresses could also increase fluid accumulation. Elevation will not treat the infection. It is critical that the client not delay treatment.

At what age is an individual most at risk for acquiring acute lymphocytic leukemia (ALL)? 40 to 50 years 60 to 70 years 4 to 12 years 20 to 30 years

4 to 12 years Explanation: The peak incidence of ALL is at 4 years of age. ALL is uncommon after 15 years of age. The median age at incidence of CML is 40 to 50 years. The peak incidence of AML occurs at 60 years of age. Two-thirds of cases of chronic lymphocytic leukemia occur in clients older than 60 years of age.

Which client does the nurse determine has the highest risk for developing ovarian cancer? 35-year-old woman who breast fed one of her four children 45-year-old woman taking oral contraceptives for 5 years 50-year-old woman who has had multiple pregnancies 60-year-old obese woman who has never been pregnant

60-year-old obese woman who has never been pregnant Explanation: Risk factors for ovarian cancer include age over 55, body mass index over 30, and inherited gene mutations (BRCA I and II). Interrupting the menstrual cycle by means of oral contraceptives, pregnancy, and breast feeding are considered protective factors.

When conducting a focused assessment of the respiratory system, what should the nurse note as an early sign of laryngeal cancer? difficulty swallowing persistent mild hoarseness chronic foul breath nagging, unproductive cough

persistent mild hoarseness Explanation: Hoarseness occurs early in the course of most laryngeal cancers because the tumor prevents accurate approximation of the vocal cords during phonation. Large tumors eventually produce difficulty and pain in swallowing, but this is not an early sign. Foul breath and expectoration of blood are late symptoms. A nagging cough has no direct relationship to laryngeal cancer.

Pancreatic enzyme replacements are prescribed for the client with chronic pancreatitis. When should the nurse instruct the client to take them to obtain the most therapeutic effect? in the morning and at bedtime every 4 hours, at specified times three times daily between meals with each meal and snack

with each meal and snack Explanation: In chronic pancreatitis, destruction of pancreatic tissue requires pancreatic enzyme replacement. Pancreatic enzymes are prescribed to facilitate the digestion of proteins and fats and should be taken in conjunction with every meal and snack. Specified hours or limited times for administration are ineffective because the enzymes must be taken in conjunction with food ingestion.

A nurse is performing discharge teaching with a client who had a total gastrectomy. Which statement indicates the need for further teaching? "I will weight myself each day and record the weight." "I will have to take vitamin B12 shots up to 1 year after surgery." "I'm going to visit my pastor weekly for a while." "I will call my physician if I begin to have abdominal pain."

"I will have to take vitamin B12 shots up to 1 year after surgery." Explanation: After a total gastrectomy, a client will need to take vitamin B12 shots for life. Dietary B12 is absorbed in the stomach, and the inability to absorb it could lead to pernicious anemia. Visiting clergy for emotional support is normal after receiving a cancer diagnosis. This action should be encouraged by the nurse. It's appropriate for the client to call the physician if he experiences signs and symptoms of intestinal blockage or obstruction, such as abdominal pain. Because a client with a total gastrectomy will receive enteral feedings or parenteral feedings, he should weigh himself each day and keep a record of the weights.

The nurse is instructing a client on how to care for skin that has become dry after radiation therapy. Which statement by the client indicates that the client understands the teaching? "I should take antihistamines to decrease the itching I am experiencing." "A heating pad, set on the lowest setting, will help decrease my discomfort." "I can apply an over-the-counter cortisone ointment to relieve the dryness." "It is safe to apply a nonperfumed lotion to my skin."

"It is safe to apply a nonperfumed lotion to my skin." Explanation: Irradiated skin can become dry and irritated, resulting in itching and discomfort. The client should be instructed to clean the skin gently and apply nonperfumed, nonirritating lotions to help relieve dryness. Taking an antihistamine does not relieve the skin dryness that is causing the itching. Heat should not be applied to the area because it can cause further irritation. Medicated ointments should not be applied to the skin without the prescription of the radiation therapist.

During a breast examination, which finding most strongly suggests that a client has breast cancer? Bloody discharge from the nipple Multiple firm, round, freely movable masses that change with the menstrual cycle A fixed nodular mass with dimpling of the overlying skin Slight asymmetry of the breasts

A fixed nodular mass with dimpling of the overlying skin Explanation: A fixed nodular mass with dimpling of the overlying skin is common during late stages of breast cancer. Many women have slightly asymmetrical breasts. Bloody nipple discharge is a sign of intraductal papilloma, a benign condition. Multiple firm, round, freely movable masses that change with the menstrual cycle indicate fibrocystic breasts, a benign condition.

A few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing which problem? A hemolytic allergic reaction caused by an antigen reaction A hemolytic reaction caused by bacterial contamination of donor blood A hemolytic reaction to Rh-incompatible blood A hemolytic reaction to mismatched blood

A hemolytic allergic reaction caused by an antigen reaction Explanation: Hemolytic allergic reactions are fairly common and may cause chills, fever, urticaria, tachycardia, dyspnea, chest pain, hypotension, and other signs of anaphylaxis a few minutes after blood transfusion begins. Although rare, a hemolytic reaction to mismatched blood can occur, triggering a more severe reaction and, possibly, leading to disseminated intravascular coagulation. A hemolytic reaction to Rh-incompatible blood is less severe and occurs several days to 2 weeks after the transfusion. Bacterial contamination of donor blood causes a high fever, nausea, vomiting, diarrhea, abdominal cramps and, possibly, shock.

Which health promotion activity should the nurse to suggest that the client with cirrhosis add to the daily routine at home? Limit contact with other people whenever possible. Abstain from drinking alcohol. Take a sleeping pill at bedtime. Supplement the diet with daily multivitamins.

Abstain from drinking alcohol. Explanation: General health promotion measures include maintaining good nutrition, avoiding infection, and abstaining from alcohol. Rest and sleep are essential, but an impaired liver may not be able to detoxify sedatives and barbiturates. Such drugs must be used cautiously, if at all, by clients with cirrhosis. The client does not need to limit contact with others but should exercise caution to stay away from ill people.

A client has an abnormal result on a Papanicolaou test. The client asks the nurse what dysplasia means. Which definition should the nurse provide? Alteration in the size, shape, and organization of differentiated cells Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found Increase in the number of normal cells in a normal arrangement in a tissue or an organ Presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin

Alteration in the size, shape, and organization of differentiated cells Explanation: The nurse should explain that dysplasia refers to an alteration in the size, shape, and organization of differentiated cells. The presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin is called anaplasia. An increase in the number of normal cells in a normal arrangement in a tissue or an organ is called hyperplasia. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found is called metaplasia.

A client is beginning external beam radiation therapy to the right axilla after a lumpectomy for breast cancer. Which information should the nurse include in client teaching? Use a heating pad under the right arm. Apply deodorant only under the left arm. Immobilize the right arm. Place ice on the area after each treatment.

Apply deodorant only under the left arm. Explanation: The nurse should instruct the client to avoid applying chemicals (such as a deodorant) or heat or cold (such as with a heating pad or ice pack) to the area being treated. The client should be encouraged to use the extremity to prevent muscle atrophy and contractures.

A client who has ulcerative colitis is taking sulfasalazine to treat inflammation. Which instructions related to drug therapy should the nurse include in the client's teaching plan? Select all that apply. Take the medication with meals. Avoid exposure to direct sunlight. Drink a full glass of water when taking the medication. Report any bruising or bleeding. Take the medication with an antacid to decrease gastrointestinal side effects.

Avoid exposure to direct sunlight. Drink a full glass of water when taking the medication. Report any bruising or bleeding. Explanation: Sulfasalazine is a sulfonamide antibiotic. The nurse should instruct clients who are taking sulfasalazine to take it 1 hour before or 2 hours following a meal for adequate absorption. The medication should also be taken with a full glass of water to help prevent crystalluria and renal calculi. Photosensitivity can develop, so the client should avoid exposure to direct sunlight. Blood disorders, such as hemolytic anemia and aplastic anemia, may develop with prolonged use; clients should be instructed to report any unusual bruising or bleeding tendencies. Antacids can interfere with the absorption of the medication and should not be taken with the drug

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan? Wearing a lead apron during direct contact with the client Avoiding using deodorant soap on the irradiated areas Applying talcum powder to the irradiated areas daily after bathing Removing thoracic skin markings after each radiation treatment

Avoiding using deodorant soap on the irradiated areas Explanation: Because external radiation commonly causes skin irritation, the nurse should wash the irradiated area with water and a mild soap only and leave the area open to air. No deodorants or powders should be applied. A lead apron is unnecessary because no radiation source is present in the client's body or room. Skin in the area to be irradiated is marked to position the radiation beam as precisely as possible; skin markings must not be removed.

A client receiving chemotherapy for cervical cancer indicates that she has an advance directive. She tells the nurse that she worries her children will not honor her wishes if her condition should worsen. In order to facilitate the honoring of the client's wishes, what should the nurse encourage the client to do? Appoint a proxy who is not a family member. Obtain additional legal documents. Recommend that the client contact her attorney. Discuss her end-of-life wishes with her family.

Discuss her end-of-life wishes with her family. Explanation: Family opposition does not override an advance directive. However, the client should ensure that family members know what her wishes are, even if they do not agree with them. After discussing her wishes with her family, the client can decide if she should seek additional legal advice, obtain legal documents, or name an outside proxy.

A client with cirrhosis of the liver is in the hospital. The nurse involves the client in developing a plan of care. What would be important aspects to include in this plan? Identifying nursing goals and explaining the importance of following these goals Discussing collaborative goals and involving the client in identifying and prioritizing important interventions Identifying the potential and actual problems, informing the client about options, and arranging for the client to attend Alcoholics Anonymous Informing the client of the extent of damage to the liver and drawing up a contract to start the rehabilitative process

Discussing collaborative goals and involving the client in identifying and prioritizing important interventions Explanation: Involvement of the client in determining the goals and interventions is very important to enhance the client's compliance with the care measures. The other choices do not directly address the goals and a plan of care.

A client is admitted with increased ascites related to cirrhosis. The client has a large round and firm abdomen. The client is not able to lie flat in bed and requests to be placed in a high Fowler's position to sleep. Which nursing diagnosis should receive top priority? Fatigue Imbalanced nutrition: Less than body requirements Ineffective breathing pattern Excess fluid volume

Ineffective breathing pattern Explanation: In ascites, accumulation of large amounts of fluid causes extreme abdominal distention, which may put pressure on the diaphragm and interfere with respiration. If uncorrected, this problem may lead to atelectasis or pneumonia. Although fluid volume excess is present, the diagnosis Ineffective breathing pattern takes precedence because it can lead more quickly to life-threatening consequences. The nurse can deal with fatigue and altered nutrition after the client establishes and maintains an effective breathing pattern.

A client is to start chemotherapy to treat lung cancer. A venous access device has been placed to permit administration of chemotherapeutic medications. Three days later at the scheduled appointment to receive chemotherapy, the nurse assesses that the client is dyspneic and the skin is warm and pale. The vital signs are blood pressure 80/30 mm Hg, pulse 132 bpm, respirations 28 breaths/min, temperature 103° F (39.4° C), and oxygen saturation 84%. The central line insertion site is inflamed. After calling the rapid response team, what should the nurse do next? Place cold, wet compresses on the client's head. Obtain a portable ECG monitor. Insert a peripheral intravenous fluid line and infuse normal saline. Administer a prescribed antipyretic.

Insert a peripheral intravenous fluid line and infuse normal saline. Explanation: The client is experiencing severe sepsis, and it is essential to increase circulating fluid volume to restore the blood pressure and cardiac output. The wet compress, administering the antipyretic, and monitoring the client's cardiac status may be beneficial for this client, but they are not the highest priority action at this time. These three interventions may require the nurse to leave the client, which is not advisable at this time.

A client with cancer is being evaluated for possible metastasis. What is one of the most common metastasis sites for cancer cells? Reproductive tract Colon Liver White blood cells (WBCs)

Liver Explanation: The liver is one of the five most common cancer metastasis sites. The others are the lymph nodes, lung, bone, and brain. The colon, reproductive tract, and WBCs are occasional metastasis sites.

A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of [12.0 mg/dl (3.0 mmol/L)], a serum potassium level of [3.9 mEq/L (3.9 mmol/L)], a serum chloride level of [101 mEq/L (11 mmol/L)], and a serum sodium level of [140 mEq/L (140 mmol/L)]. Based on this information, the nurse determines that the client will likely need which of the following interventions? Calcium gluconate 10% at 10 ml slow IV push Sodium polystyrene sulfonate Potassium chloride 10 mEq/100ml IV infusion Mithramycin 25 mcg/kg/day SUBMIT ANSWER

Mithramycin 25 mcg/kg/day Explanation: The normal reference range for serum calcium is [9 to 11 mg/dl (2.25 to 2.75 mmol/L)]. A serum calcium level of [12 mg/dl (3.0 mmol/L)] clearly indicates hypercalcemia. Mithramycin will lower the serum calcium level. The sodium polystyrene sulfonate would be indicated for hyperkalemia; calcium gluconate for hypocalcemia; and potassium chloride for hypokalemia.

An adult male client with lymphoma reports cough, difficulty swallowing, and shortness of breath. On physical exam his face and neck are swollen and his upper extremities are cyanotic. Which of the following is the nurse's best course of action? Monitor the respiratory pattern of the client continually Reassure the client that that this is to be expected with this type of cancer Limit physical activities Limit activities to bed rest

Monitor the respiratory pattern of the client continually Explanation: The client has symptoms of superor vena cava syndrome. The symptoms are not expected side effects. The client should be monitored for respiratory distress. Activities may be limited, but the priority action of the nurse is early recognition of impending respiratory distress.

What should the nurse do for a client who is receiving hormone replacement for prostate cancer? Select all that apply. Inform the client that increased libido is expected with hormone therapy. Reassure the client that erectile dysfunction will not occur as a consequence of hormone therapy. Provide the client the opportunity to communicate concerns and needs. Utilize communication strategies that enable the client to gain some feeling of control.

Provide the client the opportunity to communicate concerns and needs. Utilize communication strategies that enable the client to gain some feeling of control. Explanation: Hormone manipulation deprives tumor cells of androgens or their byproducts and, thereby, alleviates symptoms and retards disease progression. Complications of hormonal manipulation include hot flashes, nausea and vomiting, gynecomastia, and sexual dysfunction. As part of supportive care, provide explanations of diagnostic tests and treatment options and help the client gain some feeling of control over his disease and decisions related to it. To help achieve optimal sexual function, give the client the opportunity to communicate his concerns and sexual needs. Inform the client that decreased libido is expected after hormonal manipulation therapy, and that impotence may result from some surgical procedures and radiation. A psychiatrist is not needed.

After the physician explains the risks and benefits of a clinical trial to a client, the client agrees to participate. Later that day, the client requests clarification of the process involved in the clinical trial. As a member of the multidisciplinary team, how should the nurse respond? Provide the information requested. Not provide the information because it's beyond the scope of nursing practice. Tell the client that the information should come from the physician who first presented it to him. Encourage the client to withdraw from the trial.

Provide the information requested. Explanation: As part of the multidisciplinary team, the nurse is empowered to assist the client to better understand the process, as long as the nurse has an understanding of the treatment plan. The nurse shouldn't discourage the client from participating in the research study. Providing information to the client about the clinical trial isn't beyond the scope of nursing practice. The information doesn't need to come from the physician who originally presented the material to the client.

A client suspected of having colorectal cancer requires which diagnostic study to confirm the diagnosis? Sigmoidoscopy Carcinoembryonic antigen (CEA) Abdominal computed tomography (CT) scan Stool Hematest

Sigmoidoscopy Explanation: Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection of two-thirds of all colorectal cancers. Stool Hematest detects blood, which is a sign of colorectal cancer; however, the test doesn't confirm the diagnosis. CEA may be elevated in colorectal cancer but isn't considered a confirming test. An abdominal CT scan is used to stage the presence of colorectal cancer.

A nurse is completing an admission interview of a client newly diagnosed with multiple myeloma. The client tells the nurse he is concerned that his insurance coverage and limited savings will not pay for all of his family's needs when he is not working. Based on this information, to whom would the nurse initiate a referral? Pastoral care Social services Hospital accounts Case management

Social services Explanation: A social worker can be extremely beneficial in helping clients identify additional personal and community funding resources and support groups. A pastoral care referral would be appropriate if the client had expressed spiritual concerns. The nurse should refer the client to hospital accounts only if there is a need to discuss payment arrangements after identifying existing resources. A referral to case management would be contingent on the client's insurance requirements and would not address the immediate concern.

A nurse is administering daunorubicin to a patient with lung cancer. Which situation requires immediate intervention? The laboratory reports a white blood cell (WBC) count of 1,000/mm3. The client states he is nauseous. The I.V. site is red and swollen. The client begins to shiver.

The I.V. site is red and swollen. Explanation: A red, swollen I.V. site indicates possible infiltration. Daunorubicin is a vesicant chemotherapeutic agent and can be very damaging to tissue if it infiltrates. The nurse should immediately stop the medication, apply ice to the site, and notify the physician. Although nausea, WBC count of 1,000/mm3, and shivering require interventions, these findings aren't a high priority at this time.

A client diagnosed with terminal lung cancer tells the nurse that he would like to seek spiritual advice. Which intervention by the nurse best provides spiritual support for this client? The nurse could ask the client who his spiritual advisor is and make the contact. The nurse could ask the client if he would like to talk to speak to her (the nurse). The nurse could identify the name of the spiritual advisor from the client's admission history. The nurse could contact the most available spiritual advisor such as clergy from another faith.

The nurse could ask the client who his spiritual advisor is and make the contact. Explanation: The nurse may contact the client's spiritual advisor if he so desires. The nurse can listen to the client herself, but spiritual support is best from someone proficient in that field, such as a spiritual advisor. It would be appropriate for the nurse to contact the clergy of another faith, only if no other resources are available and if the client consents. The nurse should speak with the client and get the information from him firsthand, before researching the admission history.

A client presents to the emergency department with reports of acute GI distress, bloody diarrhea, weight loss, and fever. A family history of which of the following would be significant to this client's diagnosis? Appendicitis Ulcerative colitis Peptic ulcers Crohn's disease

Ulcerative colitis Explanation: A family history of ulcerative colitis, particularly if the relative affected is a first-degree relative, increases the likelihood of the client having ulcerative colitis. Crohn's disease does not have inflammatory symptoms, but rather more abdominal pain related. A family history of peptic ulcers is not a genetic risk factor as well as appendicitis.

A 32-year-old woman recently diagnosed with Hodgkin's disease is admitted for staging by undergoing a bone marrow aspiration and biopsy. To obtain more information about the client's nutrition status, the nurse should review the results of which test? red blood cell count albumin level reticulocyte count direct and indirect bilirubin levels

albumin level Explanation: Serum albumin levels help determine whether protein intake is sufficient. Proteins are broken down into amino acids during digestion. Amino acids are absorbed in the small intestine, and albumin is built from amino acids. The red blood cell count, bilirubin levels, and reticulocyte count do not indicate protein intake.

A client, who had intracavity radiation treatment for cervical cancer 1 month earlier, reports small amounts of vaginal bleeding. This finding most likely represents: infection secondary to a change in vaginal flora. recurrence of the carcinoma. development of a rectovaginal fistula. an expected effect of the radiation therapy.

an expected effect of the radiation therapy. Explanation: After intracavity radiation, some vaginal bleeding occurs for 1 to 3 months. Intermittent, painless vaginal bleeding is a classic symptom of cervical cancer, but given the client's history, bleeding in more likely a result of the radiation. The passage of feces through the vagina, not vaginal bleeding, is a sign of rectovaginal fistula. Vaginal infections are indicated by various types of vaginal discharge, not vaginal bleeding.

The client who is in end stages of cancer is requesting spiritual support. The nurse should: call a chaplain and set up an appointment for spiritual guidance. help the client reflect on past accomplishments. ask the client what spiritual activities would be most helpful. inform the family and ask for their suggestions.

ask the client what spiritual activities would be most helpful. Explanation: It is important to allow the client to choose his or her own form of spiritual support and the nurse can begin by asking the client what would be most supportive now. The client must be consulted before referral to a chaplain is made. Reflection on past accomplishments may be comforting to the client, but it does not directly address spiritual concerns. The client is able to communicate with the nurse, and discussing the conversation with the family does not respect the client's right to privacy.

A client is admitted with a diagnosis of ulcerative colitis. The nurse should assess the client for: steatorrhea. bloody, diarrheal stools. alternating periods of constipation and diarrhea. constipation.

bloody, diarrheal stools. Explanation: Diarrhea is the primary symptom of ulcerative colitis. It is profuse and severe; the client may pass as many as 15 to 20 watery stools per day. Stools may contain blood, mucus, and pus. The frequent diarrhea is often accompanied by anorexia and nausea. Constipation is not a sign or symptom of ulcerative colitis. Steatorrhea (fatty stools) is more typical of pancreatitis and cholecystitis. Alternating diarrhea and constipation is associated with irritable bowel syndrome.

A client diagnosed with cancer is receiving chemotherapy. The nurses should assess which diagnostic value while the client is receiving chemotherapy? pancreatic enzymes liver tissues heart tissues bone marrow cells

bone marrow cells Explanation: The fast-growing, normal cells most likely to be affected by certain cancer treatments are blood-forming cells in the bone marrow, as well as cells in the digestive track, reproductive system, and hair follicles. Fortunately, most normal cells recover quickly when treatment is over. Bone marrow suppression (a decreased ability of the bone marrow to manufacture blood cells) is a common side effect of chemotherapy. A low white blood cell count (neutropenia) increases the risk of infection during chemotherapy, but other blood cells made in the bone marrow can be affected as well. Most cancer agents do not affect tissues and organs, such as heart, liver, and pancreas.

A 56-year-old female is currently receiving radiation therapy to the chest wall for recurrent breast cancer. She has pain while swallowing and burning and tightness in her chest. The nurse should further assess the client for indications of: stomatitis. radiation enteritis. esophagitis. hiatal hernia.

esophagitis. Explanation: Difficulty in swallowing, pain, and tightness in the chest are signs of esophagitis, which is a common complication of radiation therapy of the chest wall. Hiatal hernia is a herniation of a portion of the stomach into the esophagus. The client could experience burning and tightness in the chest secondary to a hiatal hernia, but not pain when swallowing. Also, hiatal hernia is not a complication of radiation therapy. Stomatitis is an inflammation of the oral cavity characterized by pain, burning, and ulcerations. The client with stomatitis may experience pain with swallowing, but not burning and tightness in the chest. Radiation enteritis is a disorder of the large and small bowel that occurs during or after radiation therapy to the abdomen, pelvis, or rectum. Nausea, vomiting, abdominal cramping, the frequent urge to have a bowel movement, and watery diarrhea are the signs and symptoms.

A young female client is receiving chemotherapy and mentions to the nurse that she and her husband are using a diaphragm for birth control. Which information is most important for the nurse to discuss? infection control transmission of sexually transmitted diseases body changes related to hormones inconvenience of the diaphragm

infection control Explanation: The risk of becoming neutropenic during chemotherapy is very high. Therefore, an inserted foreign object such as a diaphragm may be a nidus for infection. Although the nurse may wish to inform the client about the ease with which various contraceptive modalities may be used, the focus of this discussion should be on preventing an infection, which can be fatal for the neutropenic client. There are no data to suggest the client is at risk for acquiring a sexually transmitted disease. The client will not be experiencing body changes directly related to hormonal changes.

Atropine sulfate is included in the preoperative prescriptions for a client undergoing a modified radical mastectomy. The expected outcome is to: decrease pulse and respiratory rates. promote general muscular relaxation. inhibit oral and respiratory secretions. decrease nausea.

inhibit oral and respiratory secretions. Explanation: Atropine sulfate, a cholinergic blocking agent, is given preoperatively to reduce secretions in the mouth and respiratory tract, which assists in maintaining the integrity of the respiratory system during general anesthesia. Atropine is not used to promote muscle relaxation, decrease nausea and vomiting, or decrease pulse and respiratory rates. It causes the pulse to increase.

Immediately after surgery to create an ileostomy, which goal has the highest priority? minimizing odor formation maintaining fluid and electrolyte balance assisting the client with self-care activities providing relief from constipation

maintaining fluid and electrolyte balance Explanation: A high-priority outcome after ileostomy surgery is the maintenance of fluid and electrolyte balance. The client will experience continuous liquid to semiliquid stools. The client should be engaged in self-care activities, and minimizing odor formation is important; however, these goals do not take priority over maintaining fluid and electrolyte balance.

The nurse is conducting a cancer risk assessment for a middle-aged client. Which environmental factor increases the risk of cancer? gender immunologic status age nutrition

nutrition Explanation: Environmental factors include place of residence, nutrition, occupation, personal habits, iatrogenic factors, and physical environment. Gender, immunologic status, and age are individual factors.

Which position would be best for a client's right arm when she returns to her room after a right modified radical mastectomy with multiple lymph node excisions? on pillows, with her hand higher than her elbow and her elbow higher than her shoulder across her chest wall in the position that affords her the greatest comfort without placing pressure on the incision at her side at the same level as her body

on pillows, with her hand higher than her elbow and her elbow higher than her shoulder Explanation: Lymph nodes can be removed from the axillary area when a modified radical mastectomy is done and each of the nodes is biopsied. To facilitate drainage from the arm on the affected side, the client's arm should be elevated on pillows with her hand higher than her elbow and her elbow higher than her shoulder. A sentinel node biopsy procedure is associated with a decreased risk of lymphedema because fewer nodes are excised.

A client is receiving monthly doses of chemotherapy for treatment of stage III colon cancer. Which laboratory results should the nurse report to the oncologist before the next dose of chemotherapy is administered? Select all that apply. blood urea nitrogen (BUN) level of 12 mg/dL (4.3 mmol/L) white blood cell count of 2,300/mm3 (2.3 X 109/L) temperature of 101.2° F (38.4° C) hemoglobin of 14.5 g/dL (145 g/L) platelet count of 40,000/mm3 (40 X 109/L) urine specific gravity of 1.020

platelet count of 40,000/mm3 (40 X 109/L) white blood cell count of 2,300/mm3 (2.3 X 109/L) temperature of 101.2° F (38.4° C) Explanation: Chemotherapy causes bone marrow suppression and risk of infection. A platelet count of 40,000/mm3 (40 X 109/L) and a white blood cell count of 2,300/mm3 (2.3 X 109/L) are low. A temperature of 101.2° F (38.4° C) is high and could indicate an infection. Further assessment and examination should be performed to rule out infection. The BUN, hemoglobin, and specific gravity values are normal.

A client with colon cancer has developed ascites. The nurse should conduct a focused assessment for which signs and symptoms? Select all that apply. respiratory distress fluid and electrolyte imbalance infection weight gain bleeding

respiratory distress fluid and electrolyte imbalance Explanation: Ascites limits the movement of the diaphragm leading to respiratory distress. Fluid shift from the intravascular space precipitates fluid and electrolyte imbalances. Weight gain is not a direct consequence of ascites, but weight loss may result in decreased albumin levels. Decreased albumin in the intravascular space results in decreased oncotic pressure precipitating movement of fluid out of space. A client with ascites is not at increased risk for infection unless a peritoneal tap is done to remove fluid. The risk of bleeding is a result of alterations in liver enzymes affecting coagulation.

A nurse is teaching an older adult who has had a left modified radical mastectomy with axillary node dissection about lymphedema. The nurse should tell the client that lymphedema occurs: if all cancer cells are not removed. only with radical mastectomy. in older women. at any time after surgery.

sexual drive and libido are unchanged. Explanation: The remaining testicle undergoes hyperplasia and produces enough testosterone to maintain sexual drive, libido, and secondary sexual characteristics. Testosterone levels will return to normal. Sperm count can decrease after a unilateral orchiectomy; this is attributed to the stress of the surgery. Secondary sexual characteristics do not change because the remaining testicle continues to produce testosterone.

Following surgery for a radical neck dissection for laryngeal cancer, the priority for nursing care is: maintaining complete bed rest until postsurgical swelling decreases. suctioning the laryngectomy tube as often as needed. taking vital signs once a shift until the client is stable. starting a clear liquid diet at 48 hours

suctioning the laryngectomy tube as often as needed. Explanation: The nurse must maintain patency of the airway with frequent suctioning of the laryngectomy tube that can become occluded from secretions, blood, and mucus plugs. Once the client is hemodynamically stable, getting out of bed should be encouraged to prevent postoperative complications. Vital signs should be monitored more frequently in a postoperative client. A swallow study is done at approximately 5 to 7 days after surgery, prior to starting oral intake.

Cancer prevalence is defined as: all cancer cases more than 5 years old. the likelihood cancer will occur in a lifetime. the number of persons with cancer at a given point in time. the number of new cancers in a year.

the number of persons with cancer at a given point in time. Explanation: The word prevalence in a statistical setting is defined as the number of cases of a disease present in a specified population at a given time.

The nurse is assessing a client who is suspected of being in the early symptomatic stages of human immunodeficiency virus (HIV) infection. Which indications of infection should the nurse detect during this stage? dyspnea bloody diarrhea whitish yellow patches in the mouth raised, hyperpigmented lesions on the legs

whitish yellow patches in the mouth Explanation: Oropharyngeal candidiasis, or thrush, is the most common infection associated with the early symptomatic stages of HIV infection. Thrush is characterized by whitish yellow patches in the mouth. Various other opportunistic diseases can occur in clients with HIV infection, but they tend to occur later, after the diagnosis of acquired immunodeficiency syndrome has been made. Dyspnea can be indicative of pneumonia, which is caused by a variety of infective organisms. Bloody diarrhea is indicative of cytomegalovirus infection. Hyperpigmented lesions are indicators of Kaposi's sarcoma.

A client has advanced cirrhosis of the liver. The client's spouse asks the nurse why his abdomen is swollen, making it very difficult for him to fasten his pants. How should the nurse respond to provide the most accurate explanation of the disease process? "Blood is not able to flow readily through the liver now, and the liver cannot make protein to keep fluid inside the blood vessels." "He must have forgotten to take his daily water pill." "The swelling in his ankles must have moved up closer to his heart so the fluid circulates better." "He must have been eating too many foods with salt in them. Salt pulls water with it."

"Blood is not able to flow readily through the liver now, and the liver cannot make protein to keep fluid inside the blood vessels." Explanation: Portal hypertension and hypoalbuminemia as a result of cirrhosis cause a fluid shift into the peritoneal space causing ascites. In a cardiac or kidney problem, not cirrhosis, sodium can promote edema formation and subsequent decreased urine output. Edema does not migrate upward toward the heart to enhance its circulation. Although diuretics promote the excretion of excess fluid, occasionally forgetting or omitting a dose will not yield the ascites found in cirrhosis of the liver.

The nurse is assessing a client with hepatitis A and notices that the aspartate transaminase (AST) and alanine transaminase (ALT) lab values have increased. Which statement by the client indicates the need for further instruction by the nurse? "I eat dry toast to relieve my nausea." "I require increased periods of rest." "I take acetaminophen for arthritis pain." "I follow a low-fat, high-carbohydrate diet."

"I take acetaminophen for arthritis pain." Explanation: Acetaminophen is toxic to the liver and should be avoided in a client with liver dysfunction. Increased periods of rest allow for liver regeneration. A low-fat, high-carbohydrate diet and dry toast to relieve nausea are appropriate.

A client is learning about caring for an ileostomy. Which statement would indicate that the client understands how to care for the ileostomy pouch? "I must apply a new pouch system every day." "I can take my pouch off at night." "I will empty my pouch when it is about one-third full." "I should change my pouch immediately after lunch."

"I will empty my pouch when it is about one-third full." Explanation: The pouch should be emptied when it is about one-third full to prevent the pouch's weight from breaking the seal. The client with an ileostomy must wear a pouch at all times to collect stool. The client should change the pouch at a time when the stoma is least likely to function; 2 to 4 hours after a meal is generally the most appropriate time. A pouch can be worn for 3 to 7 days before being changed.

A client diagnosed with colon cancer has a colostomy. The nurse has completed discharge teaching. Which of the following statements would indicate that the client is in need of further teaching? "I will exercise and swim as I normally do." "I will have to adapt my daily routine around my colostomy changing schedule." "I will change my colostomy as needed by myself." "I will still be able to have a sexual relationship with my boyfriend."

"I will have to adapt my daily routine around my colostomy changing schedule." Explanation: The client with the colostomy can lead a normal life. The colostomy can be changed by the client without assistance. Sex, exercise, and swimming are all possible with the colostomy. The daily routine does not need to be altered just because the client has a colostomy.

The nurse is evaluating if a client with Hodgkin's disease understands the monitoring that needs to be done at home between radiation treatments. Which statement would indicate that the client knows how to detect a major complication? "I will take my temperature every day." "I will monitor the loss of body hair every week." "I will check the circulation in my arms every day." "I will measure my neck circumference every day."

"I will take my temperature every day." Explanation: Clients with Hodgkin's disease are extremely vulnerable to infection because of the defective immune responses caused by the tumor as well as the bone marrow depression and low white blood cell count that result from radiation therapy. Fever is the most sensitive indicator of infection and should be reported immediately so that treatment can be initiated. Measuring neck circumference is not related to any major complications associated with Hodgkin's disease and radiation therapy. Loss of hair is unusual with radiation therapy to the neck. Upper extremity circulation is not related to any major complication associated with Hodgkin's disease and radiation therapy.

Which statement by a client undergoing external radiation therapy indicates the need for further teaching? "I'll wear protective clothing when outside." "I'll wash my skin with mild soap and water only." "I'm worried I'll expose my family members to radiation." "I'll not use my heating pad during my treatment."

"I'm worried I'll expose my family members to radiation." Explanation: The client undergoing external radiation therapy requires further teaching when he voices a concern that he might expose his family to radiation. Internal radiation, not external radiation, poses a risk to the client's family. The client requires no further teaching if he states that he should wash his skin with mild soap and water, wear protective clothing when outside, and avoid using a heating pad.

On the night before a 58-year-old wife and mother is to have a lobectomy for lung cancer, she remarks to the nurse, "I am so scared of this cancer. I should have quit smoking years ago. Now I have brought all this fear and sadness on myself and now my family." The nurse should tell the client: "Do not be so hard on yourself. You do not know if your smoking caused the cancer." "It is normal to be scared. I would be, too. We will help you through it." "Do you feel guilty because you smoked?" "It is okay to be scared. What is it about cancer that you are afraid of?"

"It is okay to be scared. What is it about cancer that you are afraid of?" Explanation: Acknowledging the basic feeling that the client expressed and asking an open-ended question allows the client to explain her fears. Saying, "It is normal to be scared. We will help you through it," does not focus on the client's feelings; rather, it gives reassurance. Asking if the client feels guilty for having smoked assumes guilt, which might be present, but additional information is needed to confirm. Telling the client not to be so hard on herself does not acknowledge the client's feelings at all.

A 52-year-old client is scheduled for a total abdominal hysterectomy for cervical cancer. When discussing the potential impact of this procedure on the client's sexuality, the nurse should respond by saying: "All women experience sexual problems with this surgical procedure. Do you have any questions?" "When can I schedule an appointment with you and your partner to discuss any issues either of you may have regarding sexuality?" "Do you anticipate any problems with sex related to your scheduled hysterectomy?" "Most women have concerns about their sexuality after this type of surgery. Do you have any concerns or questions?"

"Most women have concerns about their sexuality after this type of surgery. Do you have any concerns or questions?" Explanation: This question introduces some basic information and allows for support for the client who may be experiencing some sexuality concerns. Not all women experience sexual problems after undergoing a hysterectomy. Assuming that the client will want to schedule an appointment with her partner is inappropriate and may embarrass her. Simply asking the client whether she expects to have problems with sex is too abrupt and does not provide any information.

A 52-year-old client is scheduled for a total abdominal hysterectomy for cervical cancer. When discussing the potential impact of this procedure on the client's sexuality, the nurse should respond by saying: "Do you anticipate any problems with sex related to your scheduled hysterectomy?" "When can I schedule an appointment with you and your partner to discuss any issues either of you may have regarding sexuality?" "All women experience sexual problems with this surgical procedure. Do you have any questions?" "Most women have concerns about their sexuality after this type of surgery. Do you have any concerns or questions?"

"Most women have concerns about their sexuality after this type of surgery. Do you have any concerns or questions?" Explanation: This question introduces some basic information and allows for support for the client who may be experiencing some sexuality concerns. Not all women experience sexual problems after undergoing a hysterectomy. Assuming that the client will want to schedule an appointment with her partner is inappropriate and may embarrass her. Simply asking the client whether she expects to have problems with sex is too abrupt and does not provide any information.

A client newly diagnosed with ulcerative colitis who has been placed on steroids asks the nurse why steroids are prescribed. The nurse should tell the client: "Ulcerative colitis can be cured by the use of steroids." "Steroids are used in severe flare-ups because they can decrease the incidence of bleeding." "Long-term use of steroids will prolong periods of remission." "The side effects of steroids outweigh their benefits to clients with ulcerative colitis."

"Steroids are used in severe flare-ups because they can decrease the incidence of bleeding." Explanation: Steroids are effective in management of the acute symptoms of ulcerative colitis. Steroids do not cure ulcerative colitis, which is a chronic disease. Long-term use is not effective in prolonging the remission and is not advocated. Clients should be assessed carefully for side effects related to steroid therapy, but the benefits of short-term steroid therapy usually outweigh the potential adverse effects.

A client with stage IV pancreatic cancer is admitted to hospice. The spouse breaks down crying, stating "I just don't know what I will do if he dies!" Which is the best response by the nurse? "Do you want to speak with someone in the same situation?" "What has helped you cope with his illness so far?" "Your husband has the best doctors and will take good care of him." "I see you are upset. I will come back in 10 minutes and we can talk." SUBMIT ANSWER

"What has helped you cope with his illness so far?" Explanation: The nurse needs to identify coping mechanisms in order to support the spouse. Peer support may be indicated but does not address this woman's immediate statement nor does telling her that the doctors are capable. The client should not be left alone before the nurse addresses her statement.

On the third postoperative day after a radical mastectomy, the drainage tube is removed, and the dressings are changed. The client appears shocked when she sees the operative area and exclaims, "I look horrible! Will it ever look better?" Which response by the nurse would be most appropriate? "After it heals and you are dressed, you will not even know you had surgery." "Do not worry. You know the tumor is gone, and the area will heal very soon." "You are shocked by the sudden change in your appearance as a result of this surgery, are you not?" "Would you like to meet Ms. Paul? She looks just great and she had a mastectomy, too."

"You are shocked by the sudden change in your appearance as a result of this surgery, are you not?" Explanation: When a client appears shocked by her appearance after surgery, such as after having a mastectomy, the nurse should help her express her feelings and offer the supportive care that she needs at this time. Telling the client that her disfigurement will not show when she is dressed dismisses her concerns and blocks expression of her feelings. Telling the client not to worry avoids the issues. Having the client meet someone who has had breast surgery is often helpful but is better done later, when the client is convalescing and accustomed to the appearance of the operative site. The client needs support now when the dressings are removed, not later.

A 36-year-old female is scheduled to receive external radiation therapy and a cesium implant for cancer of the cervix and is asking about the effects of the radiation on sexual relations. The nurse should inform the client about which potential effects of radiation therapy on sexuality? "You may notice some vaginal relaxation after treatment is completed." "You will continue to have normal menstrual periods during treatment." "You can have sexual intercourse while the implant is in place." "You may notice some vaginal dryness after treatment is completed."

"You may notice some vaginal dryness after treatment is completed." Explanation: Radiation fields that include the ovaries usually result in premature menopause. Vaginal dryness will occur without estrogen replacement. There should be no sexual intercourse while the implant is in place. Cesium is a radioactive isotope used for therapeutic irradiation of cancerous tissue. There is no documentation to support vaginal relaxation after treatment. Because the client will have premature menopause, she will not have normal menstrual periods.

A nurse is conducting a cancer risk screening program. Which client is at greatest risk for skin cancer? 30-year-old butcher 60-year-old mountain biker 15-year-old high school student 45-year-old health care worker

60-year-old mountain biker Explanation: Basal cell carcinoma occurs most commonly in sun-exposed areas of the body. The incidence of skin cancer is highest in older people who live in the mountains or spend outdoor leisure time at higher altitudes.

A client with suspected lung cancer is scheduled for thoracentesis as part of the diagnostic workup. The nurse reviews the client's history for conditions that might contraindicate this procedure. Which condition is a contraindication for thoracentesis? Chronic obstructive pulmonary disease (COPD) A seizure disorder Anemia A bleeding disorder

A bleeding disorder Explanation: A bleeding disorder is a contraindication for thoracentesis because a hemorrhage may occur during or after this procedure, possibly causing death. Although a history of a seizure disorder, COPD, or anemia calls for caution, it doesn't contraindicate thoracentesis.

A client has been diagnosed with cirrhosis. When obtaining a health history, the nurse should specifically determine if the client takes? Acetaminophen. Spironolactone. Cimetidine. Neomycin sulfate.

Acetaminophen. Explanation: The client with cirrhosis should be cautioned against taking any over-the-counter medications that may be hepatotoxic, because the liver will not be able to metabolize these drugs. Acetaminophen is an example of such a drug. Cimetidine, neomycin, and spironolactone are not hepatoxic, and the client can use these drugs.

Which nursing goal is appropriate for a client with multiple myeloma? Achieve effective management of bone pain. Decrease episodes of nausea and vomiting. Avoid hyperkalemia. Recover from the disease with minimal disabilities.

Achieve effective management of bone pain. Explanation: In multiple myeloma, neoplastic plasma cells invade the bone marrow and begin to destroy the bone. As a result of this skeletal destruction, pain can be significant. There is no cure for multiple myeloma. Nausea and vomiting are not characteristics of the disease, although the client may experience anorexia. The client should be monitored for signs of hypercalcemia resulting from bone destruction, not for hyperkalemia.

When caring for a client with nonresectable colon cancer, which nursing diagnosis requires the nurse to function collaboratively to achieve the best outcome related to client comfort? Acute pain Risk for deficient fluid volume Imbalanced nutrition: Less than body requirements Activity intolerance

Acute pain Explanation: A nurse must collaborate with a physician to achieve the best pain control for the client. A nurse may not give medications, such as analgesics and antibiotics, without a physician order, and she assesses the client's response to pain medications and provides feedback to the physician. The nurse may assist the client with nonpharmacologic activities for pain control. She may implement independent nursing interventions, such as performing assessments, providing appealing fluids, pacing nursing care to promote rest and minimize client fatigue, and providing small frequent meals to address Risk for imbalanced fluid volume, Activity intolerance, and Imbalanced nutrition.

The nurse is collaborating with the health care provider (HCP) to develop a care plan to help control chronic pain in a client with cancer who is receiving hospice home care. Which plan is most appropriate for preventing and reducing the client's pain? Administer analgesics on a regular basis with administration of additional analgesics for breakthrough pain. Administer analgesics when the client's vital signs indicate that the severity of the pain is increasing. Keep the client sedated with tranquilizers to prevent awareness of pain sensations. Encourage the client to avoid intravenous pain medication until the condition has reached the terminal stage.

Administer analgesics on a regular basis with administration of additional analgesics for breakthrough pain. Explanation: Maintaining a steady blood level of analgesics is beneficial for the client with chronic cancer pain. Administering analgesics on a regular basis helps to control pain more efficiently. It may also be necessary for the client to have additional doses of medication ordered to be administered for breakthrough pain. Keeping the client overly sedated may not help to control pain, and intravenous analgesics are more effective at controlling pain as they are more predictable in their distribution than many oral medications. Vital signs are not a reliable indicator of how much pain the client is experiencing.

A client with metastatic ovarian cancer is ordered cisplatin. Before administering the first dose, the nurse reviews the client's medication history for drugs that may interact with cisplatin. Which drug may cause significant interactions when given concomitantly with cisplatin? A tetracycline A cephalosporin An aminoglycoside Erythromycin

An aminoglycoside Explanation: An aminoglycoside may cause nephrotoxicity and ototoxicity when given concomitantly with cisplatin. No significant interactions occur when erythromycin, a tetracycline, or a cephalosporin is given concomitantly with cisplatin.

Which guideline reflects the current American and Canadian Cancer Societies' recommendations for screening for colon cancer in individuals who are not at high risk? Annual digital rectal examination should begin at age 40. Individuals should obtain a baseline colonoscopy at age 45. Individuals should obtain a baseline barium enema at age 40. Annual fecal testing for occult blood should begin at age 50.

Annual fecal testing for occult blood should begin at age 50. Explanation: Annual fecal testing for occult blood should begin at age 50. Annual digital rectal examinations are recommended in men beginning at age 50 to screen for prostate cancer. Baseline barium enemas or colonoscopies are recommended at age 50. Baseline barium enemas and colonoscopies are not performed on individuals in their 40s unless they experience signs or symptoms that indicate the need for such diagnostic testing, or are considered to be at high risk.

A client with advanced cirrhosis of the liver is jaundiced and malnourished. Which of the following problems is associated with cirrhosis of the liver? Dilute urine in large amounts related to kidney excretion of bile byproducts Mental alertness and increased perception Small bowel ulcerations related to jaundice Ascites related to portal hypertension

Ascites related to portal hypertension Explanation: The jaundice is a result of inability of the liver to break down the end products from red blood cells, resulting in elevated bilirubin levels. Small bowel ulcerations do not occur as a result of elevated bilirubin levels and are not problems commonly associated with cirrhosis. The remaining choices are all associated with advanced cirrhosis. Ascites presents because of portal hypertension; clear dilute urine is incorrect as it would be dark due to the inability to eliminate some of the bile byproducts. Confusion and disorientation would occur when the brain is inundated by high levels of circulating toxins because of a failing liver not mental alertness and increased perception.

The nurse develops a teaching plan for the client about how to prevent the transmission of hepatitis A. Which discharge instruction is appropriate for the client? Ask family members to wash their hands frequently. Disinfect all clothing and eating utensils. Spray the house to eliminate infected insects. Tell family members to try to stay away from the client.

Ask family members to wash their hands frequently. Explanation: The hepatitis A virus is transmitted via the fecal-oral route. It spreads through contaminated hands, water, and food, especially shellfish growing in contaminated water. Certain animal handlers are at risk for hepatitis A, particularly those handling primates. Frequent handwashing is probably the single most important preventive action. Insects do not transmit hepatitis A. Family members do not need to stay away from the client with hepatitis. It is not necessary to disinfect food and clothing.

A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's stoma appears dusky. How should the nurse interpret this finding? The ostomy bag should be adjusted. This is a normal finding 1 day after surgery. Blood supply to the stoma has been interrupted. An intestinal obstruction has occurred.

Blood supply to the stoma has been interrupted. Explanation: An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin, creating an artificial opening for waste elimination. The stoma should appear cherry red, indicating adequate arterial perfusion. A dusky stoma suggests decreased perfusion. The nurse should interpret this finding as an indication that the stoma's blood supply is interuppted, which may lead to tissue damage or necrosis. A dusky stoma isn't a normal finding 1 day after surgery. Adjusting the ostomy bag wouldn't affect stoma color, which depends on blood supply to the area. An intestinal obstruction also wouldn't change stoma color.

A 30-year-old client whose mother died of breast cancer at age 44 and whose sister has ovarian cancer, is concerned about developing cancer. As a member of the oncology multidisciplinary team, the nurse should suggest that the client ask the physician about which topic? Mammogram Contacting the American Cancer Society (Canadian Cancer Society) Papanicolaou (Pap) testing every 6 months Genetic counseling

Genetic counseling Explanation: The nurse should suggest that the client ask the physician about genetic counseling. Genetic counseling is indicated for those at high risk because of family or personal cancer history. Genetic counseling involves obtaining a detailed medical and three-generational family history; calculating a personalized risk assessment; providing options for prevention, surveillance, and genetic testing; coordinating and interpreting genetic testing; and developing a management plan based on the test results. Mammography will assist with early detection of most breast cancers, but it won't establish a risk assessment and provide options for prevention, surveillance, and genetic testing. Pap testing every 6 months assists in early detection of most cervical cancers, but it won't establish a risk assessment. Contacting the American Cancer Society (Canadian Cancer Society) won't help assess the client's risk for developing cancer.

What should a male client older than age 50 do to help ensure early identification of prostate cancer? Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly. Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine levels checked yearly. Have a transrectal ultrasound every 5 years. Perform monthly testicular self-examinations, especially after age 50.

Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly. Explanation: The incidence of prostate cancer increases after age 50. The digital rectal examination, which identifies enlargement or irregularity of the prostate, and PSA test, a tumor marker for prostate cancer, are effective diagnostic measures that should be done yearly. Testicular self-examinations won't identify changes in the prostate gland because of its location in the body. A transrectal ultrasound, CBC, and BUN and creatinine levels are usually done after diagnosis to identify the extent of the disease and potential metastasis.

When developing a plan of care to manage a client's pain from cancer, what should the nurse plan to do? Administer pain medication as soon as the client requests it. Change pain medications periodically to avoid drug tolerance. Individualize the pain medication regimen for the client. Select medications that are least likely to lead to addiction.

Individualize the pain medication regimen for the client. Explanation: The nurse should work with the client to individualize the plan of care for managing pain. Cancer pain is best managed with a combination of medications, and each client needs to be worked with individually to find the treatment regimen that works best. Cancer pain is commonly undertreated because of fear of addiction. The client who is in pain needs the appropriate level of analgesic and needs to be reassured that addiction is unlikely. Cancer pain is best treated with regularly scheduled doses of medication. Administering the medication only when the client asks for it will not lead to adequate pain control. As drug tolerance develops, the dosage of the medication can be increased.

A nurse is reviewing instructions for a low-residue diet with a client who has an acute exacerbation of colitis. To evaluate the client's understanding of the diet, the nurse asks the client to plan a menu. Which of the following food selections by the client indicates an understanding of a low-residue diet? Lean roast beef, white rice, and tea with sugar Cream soup and crackers, peas, and orange juice Baked fish, macaroni with cheese, and milk Stewed chicken, baked potatoes, and milk

Lean roast beef, white rice, and tea with sugar Explanation: A low-residue diet decreases the amount of fecal material in the lower intestinal tract. This is necessary in the acute phase of ulcerative colitis to prevent irritation of the colon. Orange juice contains cellulose, which is not absorbed and irritates the colon. Cream soup and milk contain lactose, which is irritating to the colon.

A physician orders spironolactone, 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? Loss of 2.2 lb (1 kg) in 24 hours Serum sodium level of 135 mEq/L Serum potassium level of 3.5 mEq/L Blood pH of 7.25

Loss of 2.2 lb (1 kg) in 24 hours Explanation: Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client's serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone.

The nurse is teaching the family of a client diagnosed with leukemia about ways to prevent infection. Which instruction has the most impact? Covering the client's mouth when coughing Maintaining an intact skin integrity Ingesting a plant-based diet Bathing the client daily

Maintaining an intact skin integrity Explanation: A client with leukemia has a compromised immune system. Maintaining skin integrity is a priority as the skin is a barrier to pathogens. If a pathogen enters the client's system, the client may not be able to fight off the bacteria and it will multiply and spread. Bathing daily can decrease bacteria on the skin but unless there is a break in the skin, the bacteria will remain on the skin. Covering the mouth when coughing protects others but does not have an impact on the client. Ingesting a plant-based diet may be nutritious which helps the immune system but this does not have the most impact.

A medication nurse is preparing to administer 9 a.m. medications to a client with liver cancer. Which consideration is the nurse's highest priority? Purpose of the medication Frequency of the medication Metabolism of the medication Necessity of the medication

Metabolism of the medication Explanation: The rate and ability of the liver to metabolize medications will be altered in a client with liver cancer. Therefore, it is essential to understand how each medication is metabolized. The other considerations are important but not as vital.

A client tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client's lump is cancerous? Mobile mass that is soft and easily delineated Nonpalpable right axillary lymph nodes Eversion of the right nipple and mobile mass Nonmobile mass with irregular edges

Nonmobile mass with irregular edges Explanation: Breast cancer tumors are fixed, hard, and poorly delineated with irregular edges. A mobile mass that is soft and easily delineated is most commonly a fluid-filled benign cyst. Axillary lymph nodes may or may not be palpable on initial detection of a cancerous mass. Nipple retraction — not eversion — may be a sign of cancer.

A nurse is screening participants at a health fair for cancer risk. Which of the following clients will the nurse refer for further evaluation? Select all that apply. Young adult female with systemic lupus erythematosus Middle-aged female with human papillomavirus (HPV) Older adult female who works as a toll collector Older adult male with a history of smoking Young adult male who drinks nutrition supplements

Older adult male with a history of smoking Older adult female who works as a toll collector Middle-aged female with human papillomavirus (HPV) Explanation: Most head and neck cancers occur in people ages 50 and older with prolonged exposure to tobacco and alcohol. Inhalation of noxious fumes, infection with HPV, and a diet lacking fruits and vegetables are also contributing factors. Men are affected two to five times more often than women. Autoimmune disorders are not risk factors for laryngeal cancer.

A nurse is teaching a community class about how to decrease the risk of cancer. What is the best food for the nurse to recommend? Baked beans Decaffeinated coffee Oranges Low-fat hot dogs

Oranges Explanation: A diet high in vitamin C and citrus may help reduce the risk of certain cancers, such as stomach and esophageal cancers. Hot dogs, smoked and cured foods are high in nitrates, which may be linked to esophageal and gastric cancers. The chemical process used to decaffeinate coffee contributes to cancer.

A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin with decreased turgor, hypotension, and weak, thready pulses. What should the nurse should do first? Turn and reposition every 2 hours. Monitor vital signs every shift. Encourage the client to drink at least 1,000 mL/day. Provide parenteral rehydration therapy as prescribed

Provide parenteral rehydration therapy as prescribed. Explanation: Initially, the extracellular fluid (ECF) volume with isotonic IV fluids until adequate circulating blood volume and renal perfusion are achieved. Vital signs should be monitored as parenteral and oral rehydration are achieved. Oral fluid intake should be greater than 1,000 mL/day. Turning and repositioning the client at regular intervals aids in the prevention of skin breakdown, but it is first necessary to rehydrate this client.

The nurse is completing a health history and physical assessment on a client admitted with esophageal varices and cirrhosis. What signs and symptoms alert the nurse to a potential internal hemorrhage? Pulse 60 bpm, temperature 102.2°F (39°C), rebound tenderness in the right lower quadrant, and diarrhea Pulse 80 bpm, temperature 99.1°F (37.3°C), pain in the right lower quadrant, and constipation Pulse 108 bpm, temperature 97.7°F (36.5°C), distended abdomen, and nausea Pulse 110 bpm, temperature 102.2°F (38.9°C), soft abdomen, and sounds in all four quadrants

Pulse 108 bpm, temperature 97.7°F (36.5°C), distended abdomen, and nausea Explanation: Increased pulse rate, a distended abdomen, and nausea signify the possibility of hemorrhage. The other choices are incorrect. Remediation:

The nurse administers lactulose to a client with cirrhosis. What is the expected outcome from the administration of the lactulose? Reduced peripheral edema and ascites. Prevention of hemorrhage. Stimulation of peristalsis of the bowel. Reduced serum ammonia levels.

Reduced serum ammonia levels. Explanation: Lactulose is used to treat hepatic encephalopathy by reducing serum ammonia levels. It is not used to stimulate bowel peristalsis, even though diarrhea can be a side effect of the drug. Lactulose does not have any effect on edema, ascites, or hemorrhage.

A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement? Related to impaired balance Related to visual field deficits Related to difficulty swallowing Related to psychomotor seizures

Related to impaired balance Explanation: A client with a cerebellar brain tumor may suffer injury from impaired balance as well as disturbed gait and incoordination. Visual field deficits, difficulty swallowing, and psychomotor seizures may result from dysfunction of the pituitary gland, pons, occipital lobe, parietal lobe, or temporal lobe — not from a cerebellar brain tumor. Difficulty swallowing suggests medullary dysfunction. Psychomotor seizures suggest temporal lobe dysfunction.

A nurse is caring for a client receiving chemotherapy. Which assessment finding places the client at the greatest risk for an infection? Reports fatigue after sitting in the chair for 15 minutes Temperature of 99.8° F (37.6° C) Stage 3 pressure ulcer on the left heel White blood cell (WBC) count of 9000 cells/mm3

Stage 3 pressure ulcer on the left heel Explanation: A stage 3 pressure ulcer is a break in the skin's protective barrier, which could lead to infection in a client who is receiving chemotherapy. The WBC count is within normal limits. The temperature is slightly elevated, but not as relevant as the pressure ulcer. It is common to report fatigue while receiving chemotherapy.

A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which assessment made after the procedure would indicate the development of a potential complication? The client experiences a sudden increase in temperature. The client displays signs of sedation. The client demonstrates a lack of appetite. The client has a sore throat.

The client experiences a sudden increase in temperature. Explanation: The most likely complication of an endoscopic procedure is perforation. A sudden temperature spike within 1 to 2 hours after the procedure is indicative of a perforation and should be reported immediately to the health care provider. A sore throat is to be anticipated after an endoscopy. Clients are given sedatives during the procedure, so it is expected that they will display signs of sedation after the procedure is completed. A lack of appetite could be the result of many factors, including the disease process.

A nurse is assessing a client with a family history of cancer. Which finding requires immediate follow-up? The client complains of pain in his knees upon rising. The client states he feels like he always has a lump in his throat. The client has a blood pressure of 135/80 mm Hg and a pulse rate of 70 beats/minute. The client has gained 10 lb (4.5 kg) over the past year.

The client states he feels like he always has a lump in his throat. Explanation: The sensation of a lump in throat is one of the warning signs of esophageal cancer and requires immediate follow-up. Other symptoms of esophageal cancer include dysphagia, substernal pain, regurgitation of undigested food, foul breath, and hiccups. A weight gain of 10 lb in a year, a blood pressure of 135/70 mm Hg, and a pulse rate of 70 beats/minute are normal findings. Although the nurse should ultimately investigate the complaint of pain in the knees upon rising, this finding isn't the priority at this time.

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse. The client's morning ammonia level is 110 mcg/dl. The nurse should suspect which situation? The client has had a change in renal filtration. The client is relaxed and not in pain. The client's hepatic function is decreasing. The client didn't take his morning dose of lactulose.

The client's hepatic function is decreasing. Explanation: The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings are not indicative of reduced renal filtration.

A nurse is caring for a terminally ill cancer client who is being transferred to hospice care. Which information regarding hospice care would the nurse include in the teaching plan? Select all that apply. A multidisciplinary team provides care. Hospice care is provided only in hospice centers. Bereavement care is provided to the family. Services are provided on third party insurance reimbursement. Care is provided in the home, independent of physicians. The focus of care is on controlling symptoms and relieving pain.

The focus of care is on controlling symptoms and relieving pain. A multidisciplinary team provides care. Bereavement care is provided to the family. Explanation: Hospice care focuses on controlling symptoms and relieving pain at the end of life. A multidisciplinary team—consisting of nurses, physicians, chaplains, aides, and volunteers—provides the care. After the client's death, hospice provides bereavement care to the grieving family. Hospice services are provided based on need, not on the ability to pay or insurance reimbursement. Hospice care may be provided in a variety of settings, such as freestanding hospice centers, the home, a hospital, or a long-term care facility. Care is provided under the direction of a physician, who is a key member of the hospice team.

A client is admitted with advanced hepatic failure, including symptoms of fatigue and confusion. These symptoms are likely due to which of the following? The medications usually used to treat liver failure often cause confusion. Hepatorenal syndrome is now presenting, which results in metabolic alkalosis. Portal hypertension is impairing the blood flow to the brain. The liver is not breaking down the ammonia, and it acts as a neurotoxin on the brain.

The liver is not breaking down the ammonia, and it acts as a neurotoxin on the brain. Explanation: The increase in toxins because the liver has lost its capacity to detoxify will result in increased blood levels. The liver is responsible for breaking down ammonia and converting it to urea, so it can be excreted by the kidneys. High ammonia levels affect all the cells of the body, but are particularly toxic to the brain. Hepatorenal syndrome will result in metabolic acidosis--both the liver and kidneys are malfunctioning. Portal hypertension causes increased back-up pressure in the digestive organs, rather than in the brain. Medications are judiciously given in hepatic failure because the liver cannot detoxify the medications.

A nurse is working with a dying client and the client's family. Which communication technique is most important to use? Avoid asking for more information from the client and family members. Offer the family different coping mechanisms. Allow the family to initiate communication when they are ready. Use active listening and silence when communicating.

Use active listening and silence when communicating. Explanation: When working with a dying client and the client's family, the nurse should use active listening and silence to assess their feelings, coping skills, and immediate and long-term needs. Active listening also helps the nurse select other appropriate strategies, such as reflection and clarification. Interpretation should be used sparingly to avoid making false inferences or putting the client or family on the defensive. Initiate the conversation whenever possible and assess the family and client's coping mechanisms, including what has worked for them in the past. If the nurse is uncertain how to respond, the nurse should ask for more information or clarification from the family not avoid speaking to them.

The nurse is developing a plan of care for a client with Crohn's disease who is receiving total parenteral nutrition (TPN). Which interventions should the nurse include? Select all that apply. Change the central venous line dressing daily. Tape all IV tubing connections securely. Weigh the client daily. Monitor the IV infusion rate hourly. Monitor vital signs once a shift.

Weigh the client daily. Monitor the IV infusion rate hourly. Tape all IV tubing connections securely. Explanation: When caring for a client who is receiving TPN, the nurse should plan to weigh the client daily, monitor the IV fluid infusion rate hourly (even when using an IV fluid pump), and securely tape all IV tubing connections to prevent disconnections. Vital signs should be monitored at least every 4 hours to facilitate early detection of complications. It is recommended that the IV dressing be changed once or twice per week or when it becomes soiled, loose, or wet.

After completing assessment rounds, which client should the nurse discuss with the health care provider (HCP) first? a client with stable vital signs that has been receiving IV cipro following a cholecystectomy for 1 day and has developed a rash on the chest and arms a client with hepatitis whose pulse was 84 bpm and regular and is now 118 bpm and irregular a client with cirrhosis who is depressed and has refused to eat for the past 2 days a client with pancreatitis whose family requests to speak with the HCP regarding the treatment plan

a client with hepatitis whose pulse was 84 bpm and regular and is now 118 bpm and irregular Explanation: A change in a client's baseline vital signs should be brought to the HCP's attention immediately. In this case, the client's heart rate has increased, and the rhythm appears to have changed; the HCP may prescribe an ECG to determine if treatment is necessary. The nurse should also have a complete set of current vital signs as well as a physical assessment before providing the HCP information using the SBAR format. The nutritional as well as psychological needs of a client must be addressed but are not first priority. A rash that develops after a new antibiotic is started must be brought to the HCP attention; however, this client is stable and is not the first priority. The nurse is responsible to facilitate discussion between the client, the client's family, and the HCP but only after all of the immediate physical and psychological needs of all clients have been met.

A nurse is teaching an older adult who has had a left modified radical mastectomy with axillary node dissection about lymphedema. The nurse should tell the client that lymphedema occurs: if all cancer cells are not removed. at any time after surgery. in older women. only with radical mastectomy.

at any time after surgery. Explanation: Lymphedema after breast cancer surgery is the accumulation of lymph tissue in the tissues of the upper extremity extending down from the upper arm. It may occur at any time after surgery in women of any age. It is caused by the interruption or removal of lymph channels and nodes after axillary node dissection. Removal results in less efficient filtration of lymph fluid and a pooling of lymph fluid in the tissues on the affected side. Treatments or interventions should be instituted as soon as lymphedema is noted to prevent or reduce further progression. Range-of-motion exercises, elevation, and avoidance of injury in the affected arm are important when completing client teaching. The health care provider (HCP) may also prescribe a compression sleeve. Lymphoma is not caused by failure to remove all cancer cells. Lymphedema can occur after any surgery that disrupts lymph flow, not just radical mastectomy.

A 42-year-old female is interested in making dietary changes to reduce her risk of colon cancer. What dietary selections should the nurse suggest? bran muffin, skim milk, stir-fried broccoli croissant, granola and peanut butter squares, whole milk oatmeal-raisin cookies, baked potato with sour cream, turkey sandwich granola, bagel with cream cheese, cauliflower salad

bran muffin, skim milk, stir-fried broccoli Explanation: High-fiber, low-fat diets are recommended to reduce the risk of colon cancer. Stir-frying, poaching, steaming, and broiling are all low-fat methods to prepare foods. Croissants are made of refined flour. They are also high in fat, as are peanut butter squares, whole milk, granola, cream cheese, and sour cream.

A nurse is performing a home visit for a client who received chemotherapy within the past 24 hours. The nurse observes a small child playing in the bathroom, where the toilet lid has been left up. Based on these observations, the nurse modifies the client's teaching plan to include: reinforcement of the client's medication regimen. signs and symptoms of infection. chemotherapy exposure and risk factors. expected chemotherapy-related adverse effects.

chemotherapy exposure and risk factors. Explanation: The raised toilet lid exposes the child playing in the bathroom to the risk of inhaling or ingesting chemotherapy agents. The nurse should modify her teaching plan to include content related to chemotherapy exposure and its associated risk factors. Because the client has received chemotherapy, the plan should already include information about expected adverse effects, signs and symptoms of infection, and reinforcement of the medication regimen.

When assessing a client who has been diagnosed with hepatic cirrhosis, the nurse should obtain which information when conducting a focused assessment? Select all that apply. mental status capillary refill time current use of alcohol heart sounds nutritional status.

current use of alcohol nutritional status. mental status Explanation: For the client with hepatic cirrhosis, it would be important to assess the client's current use of alcohol because alcohol consumption can have a significant impact on liver function and is, in fact, the major cause of cirrhosis. Continued use of alcohol further destroys liver cells and affects liver function. Assessing the client's nutritional status is also important because impaired nutrition develops in many clients due to gastrointestinal problems and the inability of the liver to metabolize nutrients. Mental status can be affected by the accumulation of ammonia in the blood, leading to hepatic coma if left untreated. The assessments of heart sounds and capillary refill time, while important components of a physical examination, are not priority assessments in the client with cirrhosis.

The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which would be an indication that hepatic encephalopathy is developing? labored respirations decreased urine output decreased mental status elevated blood pressure

decreased mental status Explanation: The client should be monitored closely for changes in mental status. Ammonia has a toxic effect on central nervous system tissue and produces an altered level of consciousness, marked by drowsiness and irritability. If this process is unchecked, the client may lapse into coma. Increasing ammonia levels are not detected by changes in blood pressure, urine output, or respirations.

The nurse should institute which measure to prevent transmission of the hepatitis C virus to health care personnel? administering hepatitis C vaccine to all health care personnel decreasing contact with blood and blood-contaminated fluids wearing a gown and mask when providing direct care wearing gloves when emptying the bedpan

decreasing contact with blood and blood-contaminated fluids Explanation: Hepatitis C is usually transmitted through blood exposure or needlesticks. A hepatitis C vaccine is currently under development, but it is not available for use. The first line of defense against hepatitis B is the hepatitis B vaccine. Hepatitis C is not transmitted through feces or urine. Wearing a gown and mask will not prevent transmission of the hepatitis C virus if the caregiver comes in contact with infected blood or needles.

A client who has ulcerative colitis says to the nurse, "I cannot take this anymore; I am constantly in pain, and I cannot leave my room because I need to stay by the toilet. I do not know how to deal with this." Based on these comments, the nurse should determine the client is experiencing: difficulty coping. a sense of isolation. disturbed thought. extreme fatigue.

difficulty coping. Explanation: It is not uncommon for clients with ulcerative colitis to become apprehensive and have difficulty coping with the frequency of stools and the presence of abdominal cramping. During these acute exacerbations, clients need emotional support and encouragement to verbalize their feelings about their chronic health concerns and assistance in developing effective coping methods. The client has not expressed feelings of fatigue or isolation or demonstrated disturbed thought processes

A hospitalized client with end-stage heart failure does not want to be resuscitated. The health care provider (HCP) has written the do-not-resuscitate (DNR) prescription on the client's record. The client has a cardiac arrest, and the wife tells the nurse she wants the client to be resuscitated and asks the nurse to "do something." The nurse should: call a "code." page the HCP. discuss the DNR prescription with the wife. being CPR.

discuss the DNR prescription with the wife. Explanation: The nurse must respect the wishes of the client who has indicated that he does not wish to be resuscitated and not to initiate CPR. Nurses who resuscitate clients who have directed otherwise may be considered to be battering the client. In this situation the HCP has written the DNR prescription, and it is not necessary for the nurse to page the HCP. The nurse can be most helpful by explaining the client's decision to the wife and helping her manage her understand her husband's wishes and manage her own grief.

After a subtotal gastrectomy, the nurse is developing a plan with the client to assist the client to gain weight. To help the client meet nutritional goals at home, the nurse should: explain that if vomiting occurs after a meal, nothing more should be eaten that day. inform the client that bland foods are typically less nutritional and should be used minimally. encourage the client to eat smaller amounts more frequently. instruct the client to increase the amount eaten at each meal.

encourage the client to eat smaller amounts more frequently. Explanation: Because of the client's reduced stomach capacity, frequent small feedings are recommended. Early satiety can result, and large quantities of food are not well tolerated. Each client should progress at his or her own pace, gradually increasing the amount of food eaten. The goal is three meals daily if possible, but this can take 6 months or longer to achieve. Nausea can be episodic and can result from eating too fast or eating too much at one time. Eating less and eating more slowly, rather than not eating at all, can be a solution. Bland foods are recommended as starting foods because they are easily digested and are less irritating to the healing mucosa. Bland foods are not less nutritional.

After a lobectomy for lung cancer, the nurse instructs the client to perform deep-breathing exercises to: elevate the diaphragm to enlarge the thorax so that the lung surface area available for gas exchange is increased. expand the alveoli and increase lung surface available for ventilation. decrease blood flow to the lungs for rest and increased surface alveoli ventilation. control the rate of air flow to the remaining lobe to decrease the risk of hyperinflation.

expand the alveoli and increase lung surface available for ventilation. Explanation: Deep breathing helps prevent microatelectasis and pneumonitis and also helps force air and fluid out of the pleural space into the chest tubes. It does not decrease blood flow to the lungs or control the rate of air flow. The diaphragm is the major muscle of respiration; deep breathing causes it to descend, thereby increasing the ventilating surface.

The client with a laryngectomy does not want to be observed by the family because the opening in the throat is "disgusting." The nurse should: initiate teaching about the care of a stoma. inform the client of the benefits of family support. explore why the client believed the stoma is "disgusting." explain that the stoma will not always look as it does now.

explore why the client believed the stoma is "disgusting." Explanation: Changes in body image are expected after a laryngectomy, and the nurse should first explore what is upsetting the client the most at this time. Many clients are concerned about how their family members will respond to the physical changes that have occurred as a result of a laryngectomy, but discussing the importance of family support is not helpful; instead, the nurse should allow the client to communicate any negative feelings or concerns that exist because of the surgery. The client's feelings are not related to a knowledge deficit, and therefore, it is too early to begin teaching about stoma care. It is also not helpful to offer reassurances about the change in appearance; the client will require time to adjust to the changed body image.

The nurse is creating a presentation about early detection of colon cancer. Which symptom should the nurse encourage members of the audience to report to their health care providers? Select all that apply. rectal bleeding fatigue bowel changes weight gain positive fecal occult blood testing

fatigue rectal bleeding bowel changes positive fecal occult blood testing Explanation: Colorectal cancer may be asymptomatic, or symptoms vary according to the location of the tumor and the extent of involvement. Fatigue, weight loss, and iron deficiency anemia, even without rectal bleeding or bowel changes, should prompt investigation for colorectal cancer. Fecal occult blood testing commonly reveals evidence of carcinoma when the client is otherwise asymptomatic. Weight gain is not an early indicator of colon cancer.

A client with lung cancer is being cared for by his wife at home. His pain is increasing in severity. The nurse recognizes that teaching has been effective when the wife: Select all that apply. has her husband use a pain-rating scale to measure the effectiveness at reaching his individual pain goal. avoids long-acting opioids due to her concern about addiction. substitutes acetaminophen to avoid tolerance to the medications. uses an immediate-release medication (oxycodone) for breakthrough pain. gives her husband a long-acting or sustained-release oral pain medication regularly around the clock. uses music for distraction as well as heat or cold in combination with medications.

gives her husband a long-acting or sustained-release oral pain medication regularly around the clock. uses an immediate-release medication (oxycodone) for breakthrough pain. uses music for distraction as well as heat or cold in combination with medications. has her husband use a pain-rating scale to measure the effectiveness at reaching his individual pain goal. Explanation: Scheduled use of long-acting opioids and an around-the-clock dosing are necessary to achieve a steady level of analgesia. Whatever the route or frequency, a prescription should be available for "breakthrough" pain medication to be administered in addition to the regularly scheduled medication. Oral drug administration is the route of choice for economy, safety, and ease of use. Even severe pain requiring high doses of opioids can be managed orally as long as the client can swallow medication and has a functioning gastrointestinal system. Tolerance occurs due to the need for increasing doses to achieve the same pain relief and will not be avoided with the use of acetaminophen. Addiction is a complex condition in which the drug is used for psychological effect and not analgesia. Nurses need to educate families about the appropriate use of opioids and assure them that addiction is not a concern when managing cancer pain. Nonpharmacologic methods are useful as an adjunct to assist in pain control. Self-report is the best assessment of pain and is an individual response.

Which diet would be most appropriate for the client with ulcerative colitis? low-sodium, &high-carbohydrate high-protein, &low-residue high-calorie, &low-protein low-fat, &high-fiber

high-protein, low-residue Explanation: Clients with ulcerative colitis should follow a well-balanced high-protein, high-calorie, low-residue diet, avoiding such high-residue foods as whole-wheat grains, nuts, and raw fruits and vegetables. Clients with ulcerative colitis need more protein for tissue healing and should avoid excess roughage. There is no need for clients with ulcerative colitis to follow low-sodium diets.

A client with severe inflammatory bowel disease is receiving total parenteral nutrition (TPN). When administering TPN, the nurse must take care to maintain the ordered flow rate because giving TPN too rapidly may cause: dumping syndrome. air embolism. constipation. hyperglycemia.

hyperglycemia. Explanation: Hyperglycemia may occur if TPN is administered too rapidly, exceeding the client's glucose metabolism rate. With hyperglycemia, the renal threshold for glucose reabsorption is exceeded and osmotic diuresis occurs, leading to dehydration and electrolyte depletion. Although air embolism may occur during TPN administration, this problem results from faulty catheter placement, not overly rapid administration. TPN may cause diarrhea, not constipation, especially if administered too rapidly. Dumping syndrome results from food moving through the GI tract too quickly; because TPN is given I.V., it can't cause dumping syndrome.

A client with cirrhosis begins to develop ascites. Spironolactone is prescribed to treat the ascites. The nurse should monitor the client closely for which drug-related adverse effect? irregular pulse hyperkalemia dysuria constipation

hyperkalemia Explanation: Spironolactone is a potassium-sparing diuretic; therefore, clients should be monitored closely for hyperkalemia. Other common adverse effects include abdominal cramping, diarrhea, dizziness, headache, and rash. Constipation and dysuria are not common adverse effects of spironolactone. An irregular pulse is not an adverse effect of spironolactone but could develop if serum potassium levels are not closely monitored.

A client has had an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than 1 week. The nurse should assess the client for which complication? hypocalcemia hypokalemia deep vein thrombosis heart failure

hypokalemia Explanation: Excessive diarrhea causes significant depletion of the body's stores of sodium and potassium as well as fluid. The client should be closely monitored for hypokalemia and hyponatremia. Ulcerative colitis does not place the client at risk for heart failure, deep vein thrombosis, or hypocalcemia.

A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping, abdominal pain, and weight loss. The nurse should monitor the client for: hypercalcemia. thrombocytopenia. hyperalbuminemia. hypokalemia.

hypokalemia. Explanation: Hypokalemia is the most expected laboratory finding owing to the diarrhea. Hypoalbuminemia can also occur in Crohn's disease; however, the client's potassium level is of greater importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected development, but thrombocytopenia is not. Calcium levels are not affected.

The health care provider (HCP) instructs a client with alcohol-induced cirrhosis to stop drinking alcohol. The expected outcome of this intervention is: having a balanced diet. reduced weight. absence of delirium tremens. improved liver function.

improved liver function. Explanation: The goal of abstinence from alcohol in clients with alcohol-induced cirrhosis is to improve the liver function; most clients have improved liver function when they abstain from alcohol. Clients with cirrhosis do not necessarily have delirium tremens. Abstaining from alcohol may allow the client to improve nutritional status, but additional dietary counseling may be needed to achieve that goal. Clients with cirrhosis may have weight gain from ascites, but this is managed with diuretics.

The nurse should teach the client with hepatitis A to: increase carbohydrates and protein in the diet. limit caloric intake and reduce weight. avoid contact with others and sleep in a separate room. intensify routine exercise and increase strength.

increase carbohydrates and protein in the diet. Explanation: Low-fat, high-protein, high-carbohydrate diet is encouraged for a client with hepatitis to promote liver rejuvenation. Nutrition intake is important because clients may be anorexic and experience weight loss. Activity should be modified and adequate rest obtained to promote recovery. Social isolation should be avoided, and education on preventing transmission should be provided; the client does not need to sleep in a separate room.

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of: wearing an appliance pouch only at bedtime. consuming a low-protein, high-fiber diet. taking only enteric-coated medications. increasing fluid intake to prevent dehydration.

increasing fluid intake to prevent dehydration. Explanation: Because stool forms in the large intestine, an ileostomy typically drains liquid waste. To avoid fluid loss through ileostomy drainage, the nurse should instruct the client to increase fluid intake. The nurse should teach the client to wear a collection appliance at all times because ileostomy drainage is incontinent, to avoid high-fiber foods because they may irritate the intestines, and to avoid enteric-coated medications because the body can't absorb them after an ileostomy.

A nurse on a medical surgical unit is assessing a client and obtains the following findings: abdominal discomfort, mild diarrhea, and a temperature of 100° F (37.8° C). The nurse suspects that these are symptoms often associated with: diverticulitis. liver failure. colorectal cancer. inflammatory bowel disease (IBD).

inflammatory bowel disease (IBD). Explanation: IBD is a collective term for several GI inflammatory diseases with unknown causes. The most prominent sign of IBD is mild diarrhea, which sometimes is accompanied by fever and abdominal discomfort. Colorectal cancer is usually diagnosed after the client complains of bloody stools; the client will rarely have abdominal discomfort with colorectal cancer; the bloody stools will present first. A client with diverticulitis commonly states he/she has chronic constipation with occasional diarrhea, nausea, vomiting, and abdominal distention. Jaundice, coagulopathies, edema, and hepatomegaly are common signs of liver failure.

The client asks the nurse to explain what it means that his Hodgkin's disease is diagnosed at stage 1A. What describes the involvement of the disease? involvement of a single lymph node involvement of two or more lymph nodes on the same side of the diaphragm diffuse disease of one or more extra lymphatic organs involvement of lymph node regions on both sides of the diaphragm

involvement of a single lymph node Explanation: In the staging process, the designations A and B signify that symptoms were or were not present when Hodgkin's disease was found, respectively. The Roman numerals I through IV indicate the extent and location of involvement of the disease. Stage I indicates involvement of a single lymph node; stage II, two or more lymph nodes on the same side of the diaphragm; stage III, lymph node regions on both sides of the diaphragm; and stage IV, diffuse disease of one or more extralymphatic organs.

Which goal for the client's care should take priority during the first days of hospitalization for an exacerbation of ulcerative colitis? promoting self-care and independence promoting rest and comfort maintaining adequate nutrition managing diarrhea

managing diarrhea Explanation: Diarrhea is the primary symptom in an exacerbation of ulcerative colitis, and decreasing the frequency of stools is the first goal of treatment. The other goals are ongoing and will be best achieved by halting the exacerbation. The client may receive antidiarrheal agents, antispasmodic agents, bulk hydrophilic agents, or anti-inflammatory drugs.

The nurse is giving preoperative instructions to a client who will have a reversal of a colostomy. The nurse should prepare the client to expect which nursing actions during the immediate postoperative period? Select all that apply. calculation of intake and output every 8 hours nasogastric (NG) tube attached to low intermittent suction daily measurement of abdominal girth assessment of vital signs every 6 hours administration of IV fluids

nasogastric (NG) tube attached to low intermittent suction administration of IV fluids calculation of intake and output every 8 hours Explanation: After bowel surgery, an NG tube attached to low intermittent suction is used to remove gastric fluids. The amount of fluid from the NG tube suction is important because it contributes to the client's overall fluid and electrolyte balance. IV fluids are used to maintain hydration, and intake and output is measured to determine hydration status. Postoperative vital signs are assessed more frequently than every 6 hours. Bowel sounds will be auscultated to determine when they return. Measuring abdominal girth is not necessary following colostomy reversal.

The nurse should teach the client with chronic pancreatitis to monitor the effectiveness of pancreatic enzyme replacement therapy by: recording daily fluid intake. performing glucose fingerstick tests twice a day. observing stools for steatorrhea. testing urine for ketones.

observing stools for steatorrhea. Explanation: If the dosage and administration of pancreatic enzymes are adequate, the client's stool will be relatively normal. Any increase in odor or fat content would indicate the need for dosage adjustment. Stable body weight would be another indirect indicator. Fluid intake does not affect enzyme replacement therapy. If diabetes has developed, the client will need to monitor glucose levels. However, glucose and ketone levels are not affected by pancreatic enzyme therapy and would not indicate effectiveness of the therapy.

A client has a nasogastric tube inserted at the time of abdominal perineal resection with permanent colostomy. This tube will most likely be removed when the client demonstrates: absence of nausea and vomiting. absence of stomach drainage for 24 hours. passage of flatus and feces from the colostomy. passage of mucus from the rectum.

passage of flatus and feces from the colostomy. Explanation: A sign indicating that a client's colostomy is open and ready to function is passage of feces and flatus. When this occurs, gastric suction is ordinarily discontinued, and the client is allowed to start taking fluids and food orally. Absence of bowel sounds would indicate that the tube should remain in place because peristalsis has not yet returned. Neither absence of stomach drainage nor absence of nausea and vomiting is a criterion for judging whether gastric suction should be continued. Passage of mucus from the rectum will not occur in this client because the rectum is removed in this surgery.

A client is admitted with severe abdominal pains and the diagnosis of acute pancreatitis. The nurse should develop a plan of care during the acute phase of pancreatitis that will involve interventions to manage: drug and alcohol abuse. ineffective airway clearance. severe pain. risk for injury.

severe pain. Explanation: Acute pancreatitis is very painful; management involves interventions for pain. Although alcohol abuse is often implicated in pancreatitis, drug and alcohol counseling will be an individual consideration. Risk for injury and ineffective airway clearance are not typically associated with acute pancreatitis.

On discharge, a client who underwent left modified radical mastectomy expresses relief that "the cancer" has been treated. When discussing this issue with the client, the nurse should stress that she: will have irregular menses. should schedule a follow-up appointment in 6 months. is lucky that the cancer was caught in time. should continue to perform breast self-examination on her right breast.

should continue to perform breast self-examination on her right breast. Explanation: Having breast cancer on her left side puts the client more at risk for cancer on the opposite side and chest wall. Therefore, the nurse should stress the importance of monthly breast self-examinations and annual mammograms. Although the tumor was found, it was large enough to require a mastectomy, and could put the patient at risk for metastasis. Follow-up appointments should be monthly for the first few months and then scheduled at the direction of her health care provider. Modified radical mastectomy shouldn't affect the menstrual cycle.

A client had a mastectomy followed by chemotherapy 6 months ago. She reports that she is now "unable to concentrate at her card game" and "it seems harder and harder to finish her errands because of exhaustion." Based on this information, the nurse should suggest that the client: take frequent naps. avoid contact with others. increase fluid intake. limit activities.

take frequent naps. Explanation: This client is likely experiencing fatigue and should increase her periods of rest. The fatigue may be caused by anemia from depletion of red blood cells due to the chemotherapy. Asking the client to limit her activities may cause the client to become withdrawn. The information given does not support limiting activity. Increasing fluid intake will not reduce the fatigue. The information does not indicate that the client is immunosuppressed and should avoid contact with others.

A client had a total abdominal hysterectomy and bilateral oophorectomy for ovarian carcinoma yesterday. She received 2 mg of morphine sulfate I.V. by patient-controlled analgesia (PCA) 10 minutes ago. The nurse was assisting her from the bed to a chair when the client felt dizzy and fell into the chair. The nurse should: discontinue the PCA pump. assist the client back to bed. take the client's blood pressure. administer oxygen.

take the client's blood pressure. Explanation: The nurse should take the client's blood pressure. She is likely experiencing orthostatic hypotension. The PCA pump does not need to be discontinued because as soon as the blood pressure stabilizes the pain medication can be resumed. Administering oxygen is not necessary unless the oxygen saturation also drops. The client should sit in the chair until the blood pressure stabilizes.

Which client is at highest risk for colorectal cancer? the client who has a family history of lung cancer the client who smokes the client who has been treated for Crohn's disease for 20 years the client who eats a vegetarian diet

the client who has been treated for Crohn's disease for 20 years Explanation: Clients over age 50 who have a history of inflammatory bowel disease are at risk for colon cancer. The client who smokes is at high risk for lung cancer. While the exact cause is not always known, other risk factors for colon cancer are a diet high in animal fats, including a large amount of red meat and fatty foods with low fiber, and the presence of colon cancer in a first-generation relative.

The client who has been hospitalized with pancreatitis does not drink alcohol because of religious convictions. The client comes upset when the health care provider (HCP) persists in asking about alcohol intake. The nurse should explain that the reason for these questions is that: there is a strong link between alcohol use and acute pancreatitis. the HCP must obtain the pertinent facts, regardless of religious beliefs. alcohol intake can interfere with the tests used to diagnose pancreatitis. alcoholism is a major health problem, and all clients are questioned about alcohol intake.

there is a strong link between alcohol use and acute pancreatitis. Explanation: Alcoholism is a major cause of acute pancreatitis in the United States and Canada. Because some clients are reluctant to discuss alcohol use, staff may inquire about it in several ways. Generally, alcohol intake does not interfere with the tests used to diagnose pancreatitis. Recent ingestion of large amounts of alcohol, however, may cause an increased serum amylase level. Large amounts of ethyl and methyl alcohol may produce an elevated urinary amylase concentration. All clients are asked about alcohol and drug use on hospital admission, but this information is especially pertinent for clients with pancreatitis. HCPs do need to seek facts, but this can be done while respecting the client's religious beliefs. Respecting religious beliefs is important in providing holistic client care.

The nurse is preparing a community presentation on oral cancer. Which is a primary risk factor for oral cancer that the nurse should include in the presentation? lack of vitamin B12 use of alcohol frequent use of mouthwash lack of regular teeth cleaning by a dentist

use of alcohol Explanation: Chronic and excessive use of alcohol can lead to oral cancer. Smoking and use of smokeless tobacco are other significant risk factors. Additional risk factors include chronic irritation such as a broken tooth or ill-fitting dentures, poor dental hygiene, overexposure to sun (lip cancer), and syphilis. Use of mouthwash, lack of vitamin B12, and lack of regular teeth cleaning appointments have not been implicated as primary risk factors for oral cancer.

Which is an appropriate nursing goal for the client who has ulcerative colitis? The client: verbalizes the importance of small, frequent feedings. uses a heating pad to decrease abdominal cramping. maintains a daily record of intake and output. accepts that a colostomy is inevitable at some time in his life.

verbalizes the importance of small, frequent feedings. Explanation: Small, frequent feedings are better tolerated by clients with ulcerative colitis as they lessen the amount of fecal material present in the gastrointestinal tract and decrease stimulation. The client does not need to maintain a daily record of intake and output unless an exacerbation of the disease occurs. A heating pad should not be applied to the intestine as it is inflamed. It is not inevitable that the client will require surgery to treat the ulcerative colitis as about 85% respond favorably to conservative therapy. If the severity of the disease mandates surgery, the colon will be removed, resulting in an ileostomy.

The nurse is encouraging an unlicensed assistive personnel (UAP) to interact with a dying client and family. The nurse should help the UAP understand that: the dying person requires minimal physical care to be comfortable, and it is not necessary to provide daily care. when health care personnel do not understand their own feelings about death and dying, they often avoid the client. the family members who are present can provide essential care. to protect a person's right to die with dignity, it is best to avoid interrupting the client.

when health care personnel do not understand their own feelings about death and dying, they often avoid the client. Explanation: Health care personnel may avoid the terminally ill client because they are uncomfortable about death and do not understand their own feelings about dying. Family members should not be expected to assume responsibility for the client's care, but they should be involved in the client's care to the extent they desire. Skilled and knowledgeable nursing care is required to make a dying person comfortable. Interrupting the client does not necessarily interfere with the right to die with dignity.