NURS 7001: Unit 4 Review Questions

The nurse is caring for a patient with microcytic, hypochromic anemia. What teaching should the nurse provide about medication therapy? a. Take enteric-coated iron with each meal. b. Take cobalamin with green leafy vegetables. c. Take the iron with orange juice 1 hour before meals. d. Decrease the intake of the antiseizure medications to improve.

c. Take the iron with orange juice 1 hour before meals. With microcytic, hypochromic anemia may be caused by iron, vitamin B6, or copper deficiency; thalassemia; or lead poisoning. The iron prescribed should be taken with orange juice 1 hour before meals as it is best absorbed in an acid environment. Megaloblastic anemias occur with cobalamin (vitamin B12) and folic acid deficiencies. Vitamin B12 may help red blood cell (RBC) maturation if the patient has the intrinsic factor in the stomach. Green leafy vegetables provide folic acid for RBC maturation. Antiseizure drugs may contribute to aplastic anemia or folic acid deficiency, but the patient should not stop taking the medications. The health care provider will prescribe changes in medications.

A blood type and cross-match has been ordered for a patient who has an upper gastrointestinal bleed. The results of the blood work indicate that the patient has type A blood. Which description explains this result? a. The patient can be transfused with type AB blood. b. The patient may only receive a type A transfusion. c. The patient has A antigens on his red blood cells (RBCs). d. Antibodies are present on the surface of the patient's RBCs.

c. The patient has A antigens on his red blood cells (RBCs). A person with type A blood has A antigens, not A antibodies, on his RBCs. An AB transfusion would result in agglutination, but he may be transfused with either type A or type O blood.

The perioperative nurse is reviewing the chart of a patient who is being admitted into the operating room for a laminectomy. What information obtained from the chart review should the nurse discuss with the anesthesia care provider? a. The patient's mother has contact dermatitis related to a latex allergy. b. The patient's grandmother developed hypothermia during a craniotomy. c. The patient's father developed a high temperature during a recent surgery. d. The patient's brother developed nausea after surgery with general anesthesia.

c. The patient's father developed a high temperature during a recent surgery. Malignant hyperthermia (MH) is an autosomal dominant disorder characterized by hyperthermia with rigidity of skeletal muscles that can result in death. It may occur if an affected person is exposed to certain general anesthetic agents. To prevent MH, it is important for the nurse to obtain a careful family history. The patient known or suspected to be at risk for MH can be anesthetized with minimal risks if appropriate precautions are taken.

The nurse is caring for a patient with a diagnosis of disseminated intravascular coagulation (DIC). What is the first priority of care? a. Administer heparin. b. Administer whole blood. c. Treat the causative problem. d. Administer fresh frozen plasma.

c. Treat the causative problem. Treating the underlying cause of DIC will interrupt the abnormal response of the clotting cascade and reverse the DIC. Blood product administration occurs based on the specific component deficiencies and is reserved for patients with life-threatening hemorrhage. Heparin will be administered if the manifestations of thrombosis are present and the benefit of reducing clotting outweighs the risk of further bleeding.

A patient is being treated for non-Hodgkin's lymphoma (NHL). What should the nurse first teach the patient about the treatment? a. Skin care that will be needed b. Method of obtaining the treatment c. Treatment type and expected side effects d. Gastrointestinal tract effects of treatment

c. Treatment type and expected side effects The patient should first be taught about the type of treatment and the expected and potential side effects. Nursing care is related to the area affected by the disease and treatment. Skin care will be affected if radiation is used. Not all patients will have gastrointestinal tract effects of NHL or treatment. The method of obtaining treatment will be included in the teaching about the type of treatment.

The nurse assesses a patient with chronic myeloid leukemia receiving chemotherapy using a kinase inhibitor medication. Which question is most important for the nurse to ask? a. "Have you had a fever?" b. "Have you lost any weight?" c. "Has diarrhea been a problem?" d. "Have you noticed any hair loss?"

a. "Have you had a fever?" An adverse effect of kinase inhibitors is neutropenia. Infection is common in neutropenic patients and is the primary cause of death in patients with cancer. Patients should report a temperature of 100.4° F or higher. The other options are possible while undergoing chemotherapy but do not represent the highest priority for assessment.

The nurse is providing discharge teaching to a patient who has had a laparoscopic cholecystectomy at an ambulatory surgery center. Which statement, if made by the patient, indicates an understanding of the discharge instructions? a. "I will have someone stay with me for 24 hours in case I feel dizzy." b. "I should wait for the pain to be severe before taking the medication." c. "Because I did not have general anesthesia, I will be able to drive home." d. "It is expected after this surgery to have a temperature up to 102.4° F."

a. "I will have someone stay with me for 24 hours in case I feel dizzy." The nurse must assess understanding of discharge instructions and the ability of the patient and caregiver to provide for home care needs. A responsible adult caregiver must accompany the patient. The patient may not drive after receiving anesthetics or sedatives. The patient should understand how to manage pain, and pain medication should be taken before the pain becomes severe. The patient should understand symptoms to be reported, such as a fever.

A patient with a recent diagnosis of prostate cancer is scheduled for a radical prostatectomy. Before signing the consent, the patient tells the nurse, "I am not sure if this surgery is safe." Which response by the nurse is the most appropriate? a. "Tell me what you know about your surgery and the risks involved." b. "Any surgery has risks, but we will be here to take good care of you." c. "You seem anxious. After you sign the consent, I can give you a sedative." d. "You do not need to be concerned. Your surgeon has not had any complaints."

a. "Tell me what you know about your surgery and the risks involved." The health care provider performing the surgery is responsible for obtaining the patient's consent. The nurse may witness the patient's signature on the consent form. As a patient advocate, the nurse should verify that the patient understands the surgery and the risks involved. If the nurse determines that the patient is unclear about operative plans, the nurse should contact the health care provider about the patient's need for more information. The other options provide false reassurance or do not respond to the patient's concern.

Which patient is most likely to develop anemia related to an increased destruction of red blood cells? a. A 23-yr-old black man who has sickle cell disease b. A 59-yr-old man whose alcohol use caused folic acid deficiency c. A 13-yr-old child with impaired growth and development due to thalassemia d. A 50-yr-old woman with a history of "heavy periods" accompanied by anemia

a. A 23-yr-old black man who has sickle cell disease A result of a sickling episode in sickle cell anemia involves increased hemolysis of the sickled cells. Thalassemias and folic acid deficiencies cause a decrease in erythropoiesis, whereas the anemia related to menstruation is a direct result of blood loss.

Previous administrations of chemotherapy agents to a patient with cancer have resulted in diarrhea. Which dietary modification should the nurse recommend? a. A bland, low-fiber diet b. A high-protein, high-calorie diet c. A diet high in fresh fruits and vegetables d. A diet emphasizing whole and organic foods

a. A bland, low-fiber diet Patients with diarrhea secondary to chemotherapy or radiation therapy often benefit from a diet low in seasonings and roughage before the treatment. Foods should be easy to digest and low in fat. Fresh fruits and vegetables are high in fiber and should be minimized during treatment. Whole and organic foods do not prevent diarrhea.

The circulating nurse is caring for a patient during a colon resection. What observation made by the nurse is immediately recognized as a violation of aseptic technique? a. A glove contacts the leg of the table that supports the sterile field. b. The cuff of the scrub nurse's sterile gown contacts the sterile field. c. The sterile field was established at 0650, and the current time is 0900. d. A contaminated item is removed from the field and the area is marked off.

a. A glove contacts the leg of the table that supports the sterile field. Tables are sterile only at tabletop level. Areas below this are considered contaminated. The sterile gown below the point 2 inches above the elbow is considered sterile. The passage of time in and of itself does not necessarily render a field contaminated. If the unsterile item is small (e.g., unopened suture), once it is removed, the area is marked off and a wide margin is maintained.

The nurse gave midazolam to a patient during a colonoscopy. What nursing action is appropriate if the patient's respiratory rate changes from 14 to 3 breaths/min? a. Administer flumazenil. b. Give a dose of naloxone. c. Start oxygen at 4 L/min per nasal cannula. d. Place the patient with the head of bed up.

a. Administer flumazenil. Midazolam is a benzodiazepine administered during monitored anesthesia care to patients having procedures such as a colonoscopy. The nurse should monitor the level of consciousness and assess for respiratory depression, hypotension, and tachycardia. To reverse severe benzodiazepine-induced respiratory depression, the nurse would administer flumazenil. Naloxone would reverse opioid-induced respiratory depression. Oxygen should be initiated based on pulse oximetry but at a higher concentration than what is provided with a nasal cannula at 4 L/min. The patient with severe respiratory depression should receive 100% oxygen with a non-rebreather mask. Repositioning the patient will not reverse the effects of sedation and may interfere with the procedure in progress.

In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, the nurse recognizes which action will best enable the patient to achieve the desired outcomes? a. Administering adequate analgesics to promote relief or control of pain b. Asking the patient to demonstrate the postoperative exercises every 1 hour c. Giving the patient positive feedback when the activities are performed correctly d. Warning the patient about possible complications if the activities are not performed

a. Administering adequate analgesics to promote relief or control of pain Even when a patient understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate with the activities.

An alert patient does not want to have a tracheostomy inserted because of extended endotracheal intubation, although family members state that they want it done. What action should the nurse take? a. Advocate for the patient's rights. b. Try to change the patient's mind. c. Call surgery to cancel the procedure. d. Tell the family they cannot interfere.

a. Advocate for the patient's rights. The nurse must act as the patient's advocate and assist the patient with fulfilling his wishes. However, as the patient's advocate, the nurse must be sure he knows the risks and benefits of refusing a tracheostomy. Trying to change the patient's mind is unethical because it is contrary to acting as an advocate. As long as the patient is lucid, he retains the right of self-determination. Canceling the procedure is not indicated until discussion with the patient and surgeon has occurred. Telling the family they cannot interfere can aggravate or escalate the situation.

The nurse is caring for a 36-yr-old patient receiving phenytoin (Dilantin) to treat seizures resulting from a traumatic brain injury as a teenager. It is most important for the nurse to observe for which hematologic adverse effect of this medication? a. Anemia b. Leukemia c. Polycythemia d. Thrombocytosis

a. Anemia Hematologic adverse effects of phenytoin include anemia, thrombocytopenia, leukopenia, granulocytopenia, agranulocytosis, and pancytopenia.

The nurse determines a postoperative patient has a bronchial obstruction from retained secretions and an oxygen saturation of 87%. What condition does the nurse suspect is occurring? a. Atelectasis b. Bronchospasm c. Hypoventilation d. Pulmonary embolism

a. Atelectasis The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.

The nurse is teaching a wellness class to a group of women at their workplace. Which findings represent the highest risk for developing cancer? a. Body mass index of 35 kg/m2 and smoking cigarettes for 20 years b. Family history of colorectal cancer and consumes a high-fiber diet c. Limits fat consumption and has regular mammography and Pap screenings d. Exercises five times every week and does not consume alcoholic beverages

a. Body mass index of 35 kg/m2 and smoking cigarettes for 20 years Cancer prevention and early detection are associated with the following behaviors: limited alcohol use, regular physical activity, maintaining a normal body weight, obtaining regular cancer screenings, avoiding cigarette smoking and other tobacco use, using sunscreen with SPF 15 or higher, and practicing healthy dietary habits (e.g., reduced fat and increased fruits and vegetables).

The laboratory reports that the cells from the patient's tumor biopsy are grade II. What should the nurse know about this histologic grading? a. Cells are abnormal and moderately differentiated. b. Cells are very abnormal and poorly differentiated. c. Cells are immature, primitive, and undifferentiated. d. Cells differ slightly from normal cells and are well-differentiated.

a. Cells are abnormal and moderately differentiated. Grade II cells are more abnormal than grade I and moderately differentiated. Grade I cells differ slightly from normal cells and are well-differentiated. Grade III cells are very abnormal and poorly differentiated. Grade IV cells are immature, primitive, and undifferentiated; the cell origin is difficult to determine.

The patient with leukemia has acute disseminated intravascular coagulation (DIC) and is bleeding. What diagnostic findings should the nurse expect to find? a. Elevated D-dimers b. Elevated fibrinogen c. Reduced prothrombin time (PT) d. Reduced fibrin degradation products (FDPs)

a. Elevated D-dimers The D-dimer is a specific marker for the degree of fibrinolysis and is elevated with DIC. FDP is elevated as the breakdown products from fibrinogen and fibrin are formed. Fibrinogen and platelets are reduced. PT, PTT, aPTT, and thrombin time are all prolonged.

An older adult patient is being prepared for surgery. What assessment data needs to be obtained from the patient? (Select all that apply.) a. Fluid balance history b. Attitude about surgery c. Foods the patient dislikes d. Current mobility problems e. Current cognitive function f. Patient's opinion about the surgeon

a. Fluid balance history d. Current mobility problems e. Current cognitive function Preoperative fluid balance history is especially critical for older adults because they have reduced adaptive capacity that puts them at greater risk for over- and under-hydration. Mobility problems must be assessed to assist with intraoperative and postoperative positioning and ambulation. Preoperative assessment of the older person's baseline cognition function is especially crucial for intraoperative and postoperative evaluation because they are more prone to adverse outcomes during and after surgery from the stressors of the surgery, dehydration, hypothermia, and anesthesia. Attitude about surgery and opinion or faith in the surgeon are important for all patients. Foods the patient dislikes are not important unless the patient is allergic to them, but this is no more important for older patients than it is for all patients.

The patient diagnosed with anemia had laboratory tests done. Which results indicate a lack of nutrients needed to produce new red blood cells (RBCs)? (Select all that apply.) a. Increased homocysteine b. Decreased reticulocyte count c. Decreased cobalamin (vitamin B12) d. Increased methylmalonic acid (MMA) e. Elevated erythrocyte sedimentation rate (ESR)

a. Increased homocysteine c. Decreased cobalamin (vitamin B12) d. Increased methylmalonic acid (MMA) Increased homocysteine and MMA along with decreased cobalamin (vitamin B12) indicate cobalamin deficiency, which is a nutrient needed for RBC production. Decreased reticulocytes indicate low bone marrow activity in producing RBCs, not available nutrients. Elevated ESR is related to an increased inflammatory process, not anemia.

Results of a patient's most recent blood work indicate an elevated neutrophil level. The nurse recognizes that this diagnostic finding suggests which problem? a. Infection b. Hypoxemia c. Acute thrombotic event d. Risk of hypocoagulation

a. Infection An increase in the neutrophil count most commonly occurs in response to infection or inflammation. Hypoxemia and coagulation do not directly affect neutrophil production.

When evaluating a patient's nutritional-metabolic pattern related to hematologic health, what priority assessment should the nurse perform? a. Inspect the skin for petechiae. b. Ask the patient about joint pain. c. Assess for vitamin C deficiency. d. Determine if the patient can perform activities of daily living.

a. Inspect the skin for petechiae. Any changes in the skin's texture or color should be explored when assessing the patient's nutritional-metabolic pattern related to hematologic health. The presence of petechiae or ecchymotic areas could be indicative of hematologic deficiencies related to poor nutritional intake or related causes. The other options are not specific to the nutritional-metabolic pattern related to hematologic health.

The patient is having a mole removed that has changed appearance. What does the nurse teach the patient about the reason for this surgical procedure? a. It will prevent cancer. b. It will alleviate symptoms. c. It will cure the patient's cancer. d. It will provide cosmetic improvement.

a. It will prevent cancer. Removing a mole that is changing is to prevent as well as diagnose cancer. There are no symptoms to alleviate mentioned or cosmetic problems for this patient.

The perioperative nurse needs to monitor the patient for hallucinations and agitation when which anesthetic agent is administered? a. Ketamine b. Halothane c. Thiopental d. Nitrous oxide

a. Ketamine A disadvantage of ketamine is the associated risk of agitation, hallucinations, and nightmares. Ketamine is considered dissociative anesthesia. These unwanted effects are not associated with the use of thiopental, halothane, or nitrous oxide.

A nurse is caring for an unconscious patient who has just been admitted to the postanesthesia care unit (PACU) after an abdominal hysterectomy. How should the nurse position the patient? a. Left lateral position with head supported on a pillow b. Prone position with a pillow supporting the abdomen c. Supine position with head of bed elevated 30 degrees d. Semi-Fowler's position with the head turned to the right

a. Left lateral position with head supported on a pillow An unconscious patient should be placed in the lateral "recovery" position to keep the airway open and reduce the risk of aspiration. When conscious, the patient is usually returned to a supine position with the head of the bed elevated to maximize expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm.

The patient and his family are upset that the patient is going through procedures to diagnose cancer. What nursing actions should the nurse use first to facilitate their coping with this situation? (Select all that apply.) a. Maintain hope. b. Exhibit a caring attitude. c. Plan realistic long-term goals. d. Give them antianxiety medications. e. Be available to listen to fears and concerns. f. Teach them about the type of cancers that could be diagnosed.

a. Maintain hope. b. Exhibit a caring attitude. e. Be available to listen to fears and concerns. Maintaining hope, exhibiting a caring attitude, and being available to actively listen to fears and concerns would be the first nursing interventions to use as well as assessing factors affecting coping during the diagnostic period. Providing relief from distressing symptoms for the patient and teaching them about the diagnostic procedures would also be important. Realistic long-term goals and teaching about the type of cancer cannot be done until the cancer is diagnosed. Giving the family antianxiety medications would not be appropriate.

A surgical patient's premedication regimen includes midazolam. What are the most likely desired effects of this medication? a. Monitored anesthesia care and amnesia b. Potentiates volatile agents to speed induction c. Analgesia and prevention of intraoperative vomiting d. Relaxes skeletal muscles and facilitates endotracheal intubation

a. Monitored anesthesia care and amnesia Midazolam is a benzodiazepine that is widely used for its ability to induce amnesia and provide moderate sedation (conscious sedation). Nitrous oxide is a gaseous agent that potentiates volatile agents to speed induction and reduce total dosage and side effects. Antiemetics prevent intraoperative vomiting. Neuromuscular blocking agents facilitate endotracheal intubation.

The patient is admitted with hypercalcemia, polyuria, and pain in the pelvis, spine, and ribs with movement. Which hematologic problem would most likely cause these manifestations? a. Multiple myeloma b. Thrombocytopenia c. Megaloblastic anemia d. Myelodysplastic syndrome

a. Multiple myeloma Multiple myeloma typically manifests with skeletal pain and osteoporosis that may cause hypercalcemia, which can result in polyuria, confusion, or cardiac problems. Serum hyperviscosity syndrome can cause renal, cerebral, or pulmonary damage. Thrombocytopenia, megaloblastic anemia, and myelodysplastic syndrome are not characterized by these manifestations.

Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks to get up to go to the bathroom to urinate. What is the most appropriate action for the nurse to take? a. Offer the patient to use a urinal or bedpan after explaining the need to maintain safety. b. Assist the patient to the bathroom and stay next to the door to assist patient back to bed when done. c. Allow the patient to go to the bathroom since the onset of the medication will be more than 5 minutes. d. Ask the patient to hold the urine for a short period since a urinary catheter will be placed in the operating room.

a. Offer the patient to use a urinal or bedpan after explaining the need to maintain safety. The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance. The other options would not be safe for the patient.

A patient will receive a hematopoietic stem cell transplant (HSCT). What is the nurse's priority after the patient receives combination chemotherapy before the transplant? a. Prevent patient infection. b. Avoid abnormal bleeding. c. Give pneumococcal vaccine. d. Provide companionship while isolated.

a. Prevent patient infection. After combination chemotherapy for HSCT, the patient's bone marrow is destroyed in preparation to receive the bone marrow graft. Thus, the patient is immunosuppressed and is at risk for a life-threatening infection. The priority is preventing infection. Bleeding is not usually a problem. Giving the pneumococcal vaccine at this time should not be done; it should have been done previously. Providing companionship is not the primary role of the nurse, although the patient will need support during the time of isolation.

Which assessment finding would support the presence of a hemostasis abnormality? a. Purpura b. Pruritus c. Weakness d. Pale conjunctiva

a. Purpura Purpura may occur when platelets or clotting factors are decreased and bleeding into the skin occurs. Pruritus is not related to hemostasis but to hematologic cancers (e.g., lymphomas, leukemias) or increased bilirubin. Weakness and pale conjunctiva are not related to hemostasis unless a lot of bleeding leads to anemia with low hemoglobin level.

Patients may reduce the risk of developing cancer using health promotion strategies. Identify modifiable strategies which can reduce the risk of developing cancer. (Select all that apply.) a. Stop smoking b. Use sunscreen c. Limit alcohol use d. Undergo genetic testing e. Maintain a healthy weight f. Receive appropriate immunizations

a. Stop smoking b. Use sunscreen c. Limit alcohol use e. Maintain a healthy weight f. Receive appropriate immunizations Changing a person's lifestyle can limit cancer promotors, which is key in cancer prevention. Immunizations such as human papilloma virus (HPV) can prevent cervical cancer. Use of sunscreen (SPF 15 or greater) can prevent cell damage and development of skin cancer. Smoking can initiate or promote cancer development. Alcohol use combined with smoking can promote esophageal and bladder cancers. Management of weight can reduce the risk of cancer. Genetic testing (i.e., APC gene) identifies the predisposition to some cancers but is not modifiable.

A patient with cancer is having chemotherapy treatments and has now developed neutropenia. What care should the nurse expect to provide and teach the patient about? (Select all that apply.) a. Strict hand washing. b. Daily nasal swabs for culture. c. Monitor temperature every hour. d. Daily skin care and oral hygiene. e. Encourage the patient to eat all foods to increase nutrients. f. Private room with a high-efficiency particulate air (HEPA) filter

a. Strict hand washing. d. Daily skin care and oral hygiene. f. Private room with a high-efficiency particulate air (HEPA) filter Strict hand washing and daily skin and oral hygiene must be done with neutropenia, because the patient is predisposed to infection from the normal body flora; other people; and uncooked meats, seafood, and eggs; unwashed fruits and vegetables; and fresh flowers or plants. The private room with HEPA filtration reduces the aerosolized pathogens in the patient's room. Blood cultures and antibiotic treatment are used when the patient has a temperature of 100.4° F or more, but temperature is not monitored every hour.

The nurse is preparing to perform an assessment for a newly admitted patient with a potential hematologic disorder and petechiae. What does the nurse anticipate finding when assessing this patient? a. Tiny purple spots on the skin b. Large ecchymotic areas on the skin c. Hyperkeratotic papules and plaques d. Small, raised red areas on the soles of the feet

a. Tiny purple spots on the skin Petechiae present as tiny purple spots on the skin. Large ecchymotic areas are purpura. Hyperkeratotic papules and plaques characterize actinic keratosis. Small, raised red areas on the soles of the feet signify Osler's nodes.

A patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge? (Select all that apply.) a. Vital signs baseline or stable b. Minimal nausea and vomiting c. Wants to wait to void at home d. Responsible adult taking patient home e. Comfortable after IV opioid 15 minutes ago

a. Vital signs baseline or stable b. Minimal nausea and vomiting d. Responsible adult taking patient home Ambulatory surgery discharge criteria include meeting phase I PACU discharge criteria that includes vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria include a responsible adult driving patient, no IV opioid drugs for the past 30 minutes, able to void, able to ambulate if not contraindicated, and received written discharge instruction with patient understanding confirmed.

A patient with thrombocytopenia secondary to sepsis has small, pinpoint deposits of blood visible through the skin on the anterior and posterior chest. The nurse will document this skin abnormality as: a. petechiae. b. erythema. c. ecchymosis. d. telangiectasia.

a. petechiae Petechiae are pinpoint, discrete deposits of blood less than 1 to 2 mm in the extravascular tissues and visible through the skin or mucous membranes. Erythema is redness occurring in patches of variable size and shape. Telangiectasia is visibly dilated, superficial, cutaneous small blood vessels. Ecchymosis is a large, bruise-like lesion caused by a collection of extravascular blood in the dermis and subcutaneous tissue.

During the promotion stage of cancer development, which statement by the nurse most facilitates patient cancer prevention? a. "Exercise every day for 30 minutes." b. "Follow smoking cessation recommendations." c. "Following a vitamin regime is highly recommended." d. "I recommend excision of the cancer as soon as possible."

b. "Follow smoking cessation recommendations." The promotion stage of cancer is characterized by the reversible proliferation of the altered cells. Changing the lifestyle to avoid promoting factors (dietary fat, obesity, cigarette smoking, and alcohol consumption) can reduce the chance of cancer development. Cigarette smoking is a promoting factor and a carcinogen. Daily exercise and vitamins alone will not prevent cancer. Surgery at this stage may not be possible without a critical mass of cells, and this advice would not be consistent with the nurse's role.

A patient asks a student nurse if his family member may accompany him to the surgical area. What is the best response by the nurse? a. "Your family member may not enter the surgical area." b. "Your family can be with you in the preoperative holding area." c. "Your family can't be with you until the postanesthesia care unit." d. "Your family is only allowed in the conference room for preoperative teaching."

b. "Your family can be with you in the preoperative holding area." The perioperative nurse should explain to the student nurse that the family can be in the preoperative holding area before the patient goes to surgery, but this includes talking to the nurse at the nursing station. They are also taken to the conference room for preoperative and postoperative meetings with staff, including teaching.

The nurse notes a provider's order written at 10:00 AM for two units of packed red blood cells to be administered to a patient who is anemic as a result of chronic blood loss. If the transfusion is picked up at 11:30 AM, the nurse should plan to hang the unit no later than what time? a. 11:45 AM b. 12:00 noon c. 12:30 PM d. 3:30 PM

b. 12:00 noon The nurse must hang the unit of packed red blood cells within 30 minutes of signing them out from the blood bank.

Before starting a transfusion of packed red blood cells, the nurse would arrange for a peer to monitor their other assigned patients for how many minutes when the nurse begins the transfusion? a. 5 b. 15 c. 30 d. 60

b. 15 As part of standard procedure, the nurse remains with the patient for the first 15 minutes after starting a blood transfusion. Patients who are likely to have a transfusion reaction will more often exhibit signs within the first 15 minutes that the blood is infusing. Monitoring during the transfusion will be every 30 to 60 minutes.

The nurse is providing preoperative teaching to a group of patients. Which patient should the nurse plan to teach coughing and deep breathing exercises? a. A 20-yr-old man who is scheduled for a tonsillectomy b. A 40-yr-old woman who is scheduled for an open cholecystectomy c. A 30-yr-old woman who is scheduled for a transsphenoidal hypophysectomy d. A 50-yr-old man who is scheduled for an evacuation of a subdural hematoma

b. A 40-yr-old woman who is scheduled for an open cholecystectomy Patients with abdominal surgeries should be taught how to cough and deep breathe to prevent pulmonary complications such as atelectasis and pneumonia. Coughing and deep breathing is contraindicated in cranial surgeries (e.g., subdural hematoma evacuation or transsphenoidal hypophysectomy) and tonsillectomies.

Which patient is statistically and medically at the highest risk of developing cancer? a. A 68-yr-old white woman who has BRCA-1 gene and is obese b. A 56-yr-old black man with hepatitis C who drinks alcohol daily c. An 18-yr-old Hispanic man who eats fast food once per week and drinks alcohol d. An 80-yr-old Asian woman with coronary artery disease on blood pressure medication.

b. A 56-yr-old black man with hepatitis C who drinks alcohol daily The combination of statistically identified risk factors in addition to current liver disease (hepatitis C that is linked to the development of liver cancer) and the added promotor of alcohol makes this patient at the highest risk. Second is the white woman with the gene for breast cancer and the added promotor of obesity. Most cancer cases are diagnosed in people older than 55 years of age. The overall incidence of cancer is higher in men than women. Cancer incidence is higher in blacks, then whites, and then people from other cultures.

Which preoperative patient has the greatest risk of bleeding as a result of prescribed medication? a. A woman who takes metoprolol for the treatment of hypertension. b. A man who is taking clopidogrel after the placement of a coronary artery stent. c. A man whose type 1 diabetes is controlled with insulin injections four times daily. d. A man who recently started taking finasteride for the treatment of benign prostatic hyperplasia.

b. A man who is taking clopidogrel after the placement of a coronary artery stent. Any drug that inhibits platelet aggregation, such as clopidogrel, represents a bleeding risk. Insulin, metoprolol, and finasteride are less likely to contribute to a risk for bleeding.

The nurse is caring for a patient with a diagnosis of immune thrombocytopenic purpura (ITP). What is a priority nursing action in the care of this patient? a. Administration of packed red blood cells b. Administration of oral or IV corticosteroids c. Administration of clotting factors VIII and IX d. Maintenance of reverse isolation and application of standard precautions

b. Administration of oral or IV corticosteroids Common treatment modalities for ITP include corticosteroid therapy to suppress the phagocytic response of splenic macrophages. Blood transfusions, administration of clotting factors, and reverse isolation are not interventions that are indicated in the care of patients with ITP. Standard precautions are used with all patients.

The thrombocytopenic patient has had a bone marrow biopsy taken from the posterior iliac crest. What intervention is the priority for this patient after this procedure? a. Position the patient prone. b. Apply a pressure dressing. c. Administer analgesic for pain. d. Return metal objects to the patient.

b. Apply a pressure dressing. The sterile pressure dressing is applied after a bone marrow biopsy to ensure hemostasis. If bleeding is present, the patient will lie on the site and may need a rolled towel for additional pressure, thus this patient will not be in the prone position. The analgesic should have been administered preprocedure. Metal objects would be removed for an MRI, not a bone marrow biopsy.

The nurse is caring for a patient with polycythemia vera. What is an important action for the nurse to initiate? a. Encourage deep breathing and coughing. b. Assist with or perform phlebotomy at the bedside. c. Teach the patient how to maintain a low-activity lifestyle. d. Perform thorough and regularly scheduled neurologic assessments.

b. Assist with or perform phlebotomy at the bedside. Primary polycythemia vera often requires phlebotomy in order to reduce blood volume. The increased risk of thrombus formation that accompanies the disease requires regular exercises and ambulation. Deep breathing and coughing exercises do not directly address the etiology or common sequelae of polycythemia, and neurologic manifestations are not typical.

A patient has been diagnosed with acute myelogenous leukemia (AML). What should the nurse educate the patient that care will focus on? a. Leukapheresis b. Attaining remission c. One chemotherapy agent d. Waiting with active supportive care

b. Attaining remission Attaining remission is the initial goal of care for leukemia. The methods to do this are decided based on age and cytogenetic analysis. The treatments include leukapheresis or hydroxyurea to reduce the white blood cell count and risk of leukemia-cell-induced thrombosis. A combination of chemotherapy agents will be used for aggressive treatment to destroy leukemic cells in tissues, peripheral blood, and bone marrow and minimize drug toxicity. In nonsymptomatic patients with chronic lymphocytic leukemia, waiting may be done to attain remission, but not with AML.

The nurse is providing care for older adults on a subacute, geriatric medical unit. What effect does aging have on hematologic function of older adults? a. Thrombocytosis b. Decreased hemoglobin c. Decreased WBC count d. Decreased blood volume

b. Decreased hemoglobin Older adults often have decreased hemoglobin levels as a result of changes in erythropoiesis. Decreased blood volume, decreased WBCs, and alterations in platelet number are not considered to be normal, age-related hematologic changes.

A patient has anemia related to inadequate intake of essential nutrients. Which intervention would be appropriate for the nurse to include in the plan of care for this patient? a. Plan for 30 minutes of rest before and after every meal. b. Encourage foods high in protein, iron, vitamin C, and folate. c. Teach the patient to select only soft, bland, and nonacidic foods. d. Give the patient a list of medications that inhibit iron absorption.

b. Encourage foods high in protein, iron, vitamin C, and folate. Increased intake of protein, iron, folate, and vitamin C provides nutrients needed for maximum iron absorption and hemoglobin production. The other interventions do not address the patient's identified problem of inadequate intake of essential nutrients. Selection of foods that are soft, bland, and nonacidic is appropriate if the patient has oral mucosal irritation. Scheduled rest is an appropriate intervention if the patient has fatigue related to anemia. Providing information about medications that may inhibit iron absorption (e.g., antacids, tetracycline, soft drinks, tea, coffee, calcium, phosphorus, and magnesium salts) is important but does not address the patient's problem of inadequate intake of essential nutrients.

Lorazepam (Ativan) 1 mg IV is ordered for a patient before surgery. What is the most appropriate action for the nurse to take before administering the medication? a. Ask the patient about an allergy to iodine or shellfish. b. Encourage or assist the patient to the bathroom to void. c. Explain that the medication is used to prevent postoperative nausea. d. Check the laboratory results for the most recent serum potassium level.

b. Encourage or assist the patient to the bathroom to void. The nurse should have the patient void before administering preoperative medications that may interfere with balance and increase the fall risk when ambulating to the bathroom. Lorazepam is a benzodiazepine that may be used for sedation and amnesia before surgery. Lorazepam does not affect serum potassium, is not contraindicated in patients with allergies to iodine or shellfish and is not indicated to prevent or treat nausea.

The nurse is reviewing the objective data listed below of a patient with suspected allergies. Which assessment finding indicates allergies? *Physical exam:* dry cough, pale skin *Lab results:* neutrophils = 60%; eosinophils = 10%; basophils = 1%; lymphocytes = 20%; monocytes = 6% *Medications:* acetaminophen 1000mg q.12h; levothyroxine (synthroid) 125 mcg daily a. Dry cough b. Eosinophil result c. Lymphocyte result d. Acetaminophen use

b. Eosinophil result Eosinophils are granulocytes that phagocytize antigen-antibody complexes formed during an allergic response. The normal eosinophil count is 2% to 4% of all white blood cells. The dry cough, lymphocyte result, and acetaminophen use do not indicate allergies.

When caring for a patient with metastatic cancer, the nurse notes a hemoglobin level of 8.7 g/dL and hematocrit of 26%. What associated clinical manifestations does the nurse anticipate observing? a. Thirst b. Fatigue c. Headache d. Abdominal pain

b. Fatigue The patient with a low hemoglobin and hematocrit is anemic and would likely have fatigue. Fatigue develops because of the lowered oxygen-carrying capacity that leads to reduced tissue oxygenation to carry out cellular functions. Thirst, headache, and abdominal pain are not related to anemia.

The nurse receives a provider's order to transfuse fresh frozen plasma to a patient with acute blood loss. Which procedure is most appropriate for infusing this blood product? a. Hang the fresh frozen plasma with lactated Ringer's solution. b. Fresh frozen plasma must be given within 24 hours after thawing. c. Infuse the fresh frozen plasma at a rate of 50 mL/hr for the duration. d. Hang the fresh frozen plasma as a piggyback to a primary IV solution without KCl.

b. Fresh frozen plasma must be given within 24 hours after thawing. The fresh frozen plasma should be administered as rapidly as possible and should be used within 24 hours of thawing to avoid a decrease in factors V and VIII. Fresh frozen plasma is infused using any straight-line infusion set. Any existing IV should be interrupted while the fresh frozen plasma is infused, unless a second IV line has been started for the transfusion.

A patient having abdominal surgery had an estimated blood loss of 400 mL and received 300 mL of 0.9% normal saline. Postoperatively, the patient's blood pressure is 70/48 mm Hg. What priority treatment does the nurse anticipate administering? a. Blood administration b. IV fluid administration c. An ECG to check circulatory status d. Return to surgery to check for internal bleeding

b. IV fluid administration The nurse should anticipate restoring circulating volume with IV infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. An ECG may be done if there is no response to the fluid administration, there is a history of cardiac disease, or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if patient's level of consciousness changes or the abdomen becomes firm and distended.

The nurse is caring for a Native American patient 2 days after a thoracotomy for a tumor resection. What would be the most appropriate action if the patient does not report any pain? a. Contact the health care provider. b. Identify possible reasons for denying pain. c. Administer the prescribed pain medication. d. Assess the renal and liver function test results.

b. Identify possible reasons for denying pain. Encourage older adults to report pain, especially those who are reluctant to discuss pain or deny pain when it is likely present, such as after surgery. Older patients may be hesitant to request pain medication, believe pain is an inevitable consequence of surgery, and may not understand how to use patient-controlled machines. Some cultures discourage the expression of pain. The nurse should encourage the use of analgesics, explaining to the patient that untreated pain has a negative effect on recovery. Assessment of pain and administration of medications are within the scope of practice of a nurse. An older patient may have decreased renal and liver function that may lead to drug toxicity. However, this would not be a reason for denial of pain. Administration of pain medication must be based on the patient assessment.

A patient had a splenectomy for injuries sustained in a motor vehicle accident. Which phenomena are likely to result from the absence of the patient's spleen? (Select all that apply.) a. Impaired fibrinolysis b. Increased platelet levels c. Increased eosinophil levels d. Fatigue and cold intolerance e. Impaired immunologic function

b. Increased platelet levels e. Impaired immunologic function Splenectomy can result in increased platelet levels and impaired immunologic function because of the loss of storage and immunologic functions of the spleen. Fibrinolysis, fatigue, and cold intolerance are less likely to result from the loss of the spleen since coagulation and oxygenation are not primary responsibilities of the spleen.

A patient being admitted to the same-day surgery unit informs the nurse they took kava last evening to sleep. Which nursing action would be most appropriate? a. Tell the patient that using kava to help sleep is often helpful. b. Inform the anesthesia care provider of the patient's recent use of kava. c. Tell the patient that the kava should continue to help the patient to relax before surgery. d. Inform the patient about the dangers of taking herbal medicines without consulting a health care provider.

b. Inform the anesthesia care provider of the patient's recent use of kava. Kava may prolong the effects of certain anesthetics. Thus, the anesthesiologist needs to be informed of recent ingestion of this herbal supplement. Patients should not take anything before surgery without the health care provider's knowledge.

The blood bank notifies the nurse that 2 units of blood ordered for a patient is ready for pick up. Which action should the nurse take to prevent an adverse effect during this procedure? a. Immediately pick up both units of blood from the blood bank. b. Infuse the blood slowly for the first 15 minutes of the transfusion. c. Regulate the flowrate so that each unit takes at least 4 hours to transfuse. d. Set up the Y-tubing of the blood set with dextrose in water as the flush solution.

b. Infuse the blood slowly for the first 15 minutes of the transfusion. Because a transfusion reaction is more likely to occur at the beginning of a transfusion, the nurse should initially infuse the blood at a rate no faster than 2 mL/min and remain with the patient for the first 15 minutes after hanging 1 unit of blood. Only 1 unit of blood can be picked up at a time, it must be infused within 4 hours, and it cannot be hung with dextrose.

Which intraoperative nursing responsibilities are performed by the scrub nurse? (Select all that apply.) a. Documenting intraoperative care b. Keeping track of irrigation solutions for monitoring of blood loss c. Passing instruments and supplies to the surgeon by anticipating their needs d. Coordinating the flow and activities of members of the surgical team in the surgical suite e. Performing the count of sponges, needles, and instruments used during the surgical procedure

b. Keeping track of irrigation solutions for monitoring of blood loss c. Passing instruments and supplies to the surgeon by anticipating their needs e. Performing the count of sponges, needles, and instruments used during the surgical procedure Both the scrub nurse and circulating nurse participate in the counting of surgical sponges, needles, and instruments. Passing instruments to the surgeon and other sterile activities are the exclusive responsibility of the scrub nurse. The circulating nurse takes primary responsibility for the coordination of the surgical suite and documentation.

The nurse is positioning a patient after a surgical procedure. What is the best position unless contraindicated, for this patient to be placed in to prevent respiratory complications? a. Supine b. Lateral c. Semi-Fowler's d. High-Fowler's

b. Lateral Unless contraindicated by the surgical procedure, an unconscious patient is positioned in a lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated.

A patient who has sickle cell disease has developed cellulitis above the left ankle. What is the nurse's priority for this patient? a. Start IV fluids. b. Maintain oxygenation. c. Maintain distal warmth. d. Check peripheral pulses.

b. Maintain oxygenation. Maintaining oxygenation is a priority as sickling episodes are frequently triggered by low oxygen tension in the blood which is commonly caused by an infection. Antibiotics to treat cellulitis, pain control, and fluids to reduce blood viscosity will also be used, but oxygenation is the priority.

The nurse is circulating for a surgical procedure. What assessment finding would indicate to the nurse that the patient may be experiencing malignant hyperthermia? a. Hypocapnia b. Muscle rigidity c. Decreased body temperature d. Confusion upon arousal from anesthesia

b. Muscle rigidity Malignant hyperthermia is a metabolic disease characterized by hyperthermia with rigidity of skeletal muscles from altered control of intracellular calcium occurring as a result of exposure to certain anesthetic agents in susceptible patients. Hypoxemia, hypercapnia, and ventricular dysrhythmias may also be seen with this disorder.

A patient informs the nurse prior to the surgical procedure that she is so nervous about the procedure and had to take alprazolam (Xanax) last night, but it did not relieve the anxiety. What is the priority action by the nurse? a. Review the surgery with the patient. b. Notify the anesthesia care provider (ACP). c. Administer another dose of alprazolam (Xanax). d. Tell the patient that everything will be okay with the surgery.

b. Notify the anesthesia care provider (ACP). In determining the psychologic status of the patient, the nurse notes the patient's anxiety. The nurse should notify the ACP after assessing the cause of the anxiety or fear the patient is experiencing. The patient may only need to talk about the surgery related to the situation, concerns with the unknown or body image, or past experiences to relieve the anxiety, but the nurse cannot assume that lack of knowledge is the cause of the anxiety. Medication administration will be prescribed by the ACP if needed, but medications can also be administered during surgery. Reassuring the patient is not taking the patient's needs into account.

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? a. Assess the patient's pain. b. Obtain the patient's vital signs. c. Check the rate of the IV infusion. d. Review the surgeon's postoperative orders.

b. Obtain the patient's vital signs. The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient's vital signs. The other actions can then take place in rapid sequence.

A patient with an acute peptic ulcer and major blood loss requires an immediate transfusion with packed red blood cells. Which task is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? a. Confirm the IV solution is 0.9% saline. b. Obtain the vital signs before the transfusion is initiated. c. Monitor the patient for shortness of breath and back pain. d. Double-check the patient identity and verify the blood product.

b. Obtain the vital signs before the transfusion is initiated. The RN may delegate tasks such as taking vital signs to UAP. Assessments (e.g., monitoring for signs of a blood transfusion reaction [shortness of breath and back pain]) are within the scope of practice of the RN and may not be delegated to UAP. The RN must also assume responsibility for ensuring the correct IV fluid is used with blood products. A licensed nurse must complete verification of the patient's identity and the blood product data.

A 62-yr-old patient with disseminated intravascular coagulation (DIC) after urosepsis has a platelet count of 48,000/μL. The nurse should assess the patient for which abnormality? a. Pallor b. Purpura c. Pruritus d. Palpitation

b. Purpura The normal range for a platelet count is 150,000 to 400,000/μL. Purpura is caused by decreased platelets or clotting factors, resulting in small hemorrhages into the skin or mucous membranes. Pallor is decreased or absent coloration in the conjunctiva or skin. Pruritus is an intense itching sensation. Palpitation is a sensation of feeling the heart beat, flutter, or pound in the chest.

A patient with a diagnosis of hemophilia had a fall down an escalator earlier in the day and now has bleeding in the left knee joint. What should be the emergency nurse's immediate action? a. Immediate transfusion of platelets b. Resting the patient's knee to prevent hemarthroses c. Assistance with intracapsular injection of corticosteroids d. Range-of-motion exercises to prevent thrombus formation

b. Resting the patient's knee to prevent hemarthroses In patients with hemophilia, joint bleeding requires resting of the joint to prevent deformities from hemarthrosis. Clotting factors, not platelets or corticosteroids, are administered. Thrombus formation is not a central concern in a patient with hemophilia.

The nurse is preparing a patient for a surgical procedure. Before admitting the patient into the perioperative suite, what documents must the nurse make sure are in the patient's chart? (Select all that apply.) a. Electrocardiogram b. Signed consent form c. Functional status evaluation d. Renal and liver function tests e. A history and physical examination report

b. Signed consent form e. A history and physical examination report The National Patient Safety Goals (NPSG) require documentation of a history and physical, signed consent form, and nursing and preanesthesia assessment in the chart of a patient going for surgery. The physical examination explains in detail the overall status of the patient before surgery for the surgeon and other members of the surgical team.

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

b. Turn off the chemotherapy infusion. Because extravasation of vesicants may cause severe local tissue breakdown and necrosis, with any sign of extravasation, the infusion should first be stopped. Then the protocol for the drug-specific extravasation procedures should be followed to minimize further tissue damage. The site of extravasation usually hurts, but it may not. It is more important to stop the infusion immediately. The health care provider may be notified by another nurse while the patient's nurse starts the drug-specific extravasation procedures, which may or may not include sterile saline.

A patient has been diagnosed with stage 1A Hodgkin's lymphoma. The nurse knows that which chemotherapy regimen is most likely to be prescribed for this patient? a. Brentuximab vedotin (Adcetris) b. Two to four cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine c. Four to six cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine d. BEACOPP: bleomycin, etoposide, doxorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), procarbazine, and prednisone

b. Two to four cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine The patient with a favorable prognosis early-stage Hodgkin's lymphoma (stage 1A) will receive two to four cycles of ABVD. The unfavorable prognostic featured (stage 1B) Hodgkin's lymphoma would be treated with four to six cycles of chemotherapy. Advanced-stage Hodgkin's lymphoma is treated more aggressively with more cycles or with BEACOPP. Brentuximab vedotin (Adcetris) is a newer agent that will be used to treat patients who have relapsed or refractory disease.Note: Some of acronyms for drug protocols use the brand/trade name of drugs (Adriamycin, Oncovin). These brand/trade names have been discontinued but the drugs are still available as generic drugs.

A 36-yr-old patient suspected of having leukemia is scheduled for a bone marrow aspiration. What statement in the patient's health history requires immediate follow-up by the nurse? a. "I had a bad reaction to iodine before and almost died." b. "I am taking an antibiotic to treat a urinary tract infection." c. "I have rheumatoid arthritis and take aspirin for joint pain." d. "I have dialysis for chronic renal failure three times a week."

c. "I have rheumatoid arthritis and take aspirin for joint pain." Complications of bone marrow aspiration are minimal, but there is a possibility of damaging underlying structures, especially if the sternum site is used. Other complications include hemorrhage, particularly if the patient is thrombocytopenic, and infection if the white blood cell count is low. The risk of hemorrhage is increased if the patient takes aspirin because it promotes bleeding by inhibiting platelet aggregation. Contrast dye is not used during a bone marrow aspiration. A bone marrow aspiration is not contraindicated in patients who have chronic renal failure on dialysis or a urinary tract infection on an antibiotic.

The nurse is caring for an 18-yr-old patient with acute lymphocytic leukemia who is scheduled for hematopoietic stem cell transplantation (HSCT). Which patient statement indicates a correct understanding of the procedure? a. "I understand the transplant procedure has no dangerous side effects." b. "After the transplant, I will feel better and can go home in 5 to 7 days." c. "My brother will be a 100% match for the cells used during the transplant." d. "Before the transplant, I will have chemotherapy and possibly full-body radiation."

d. "Before the transplant, I will have chemotherapy and possibly full-body radiation." Hematopoietic stem cell transplantation (HSCT) requires eradication of diseased or cancer cells. This is accomplished by administering higher-than-usual dosages of chemotherapy with or without radiation therapy. A relative such as a brother would not be a perfect match with human leukocyte antigens; only identical twins are an exact match. HSCT is an intensive procedure with adverse effects and possible death. HSCT recipients can expect a 2- to 4-week hospitalization after the transplant.

Early ambulation is ordered in the postoperative plan of care, but the patient refuses to get up and walk. What teaching should the nurse provide to the patient about the reason for early ambulation? a. "Early walking keeps your legs limber and strong." b. "Early ambulation will help you be ready to go home." c. "Early ambulation will help you get rid of your syncope and pain." d. "Early walking is the best way to prevent postoperative complications."

d. "Early walking is the best way to prevent postoperative complications." The best reason is that early ambulation will prevent postoperative complications that can then be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and venous thromboembolism, speeds wound healing, and increases vital capacity and maintains normal respiratory function. These things help the patient be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management should always occur before walking.

A patient with leukemia is admitted for severe hypovolemia after prolonged diarrhea. The platelet count is 43,000/µL. It is most important for the nurse to take which action? a. Insert two 18-gauge IV catheters. b. Administer prescribed enoxaparin. c. Monitor the patient's temperature every 2 hours. d. Check stools for presence of frank or occult blood.

d. Check stools for presence of frank or occult blood. A platelet count below 150,000/µL indicates thrombocytopenia. Prolonged bleeding from trauma or injury does not usually occur until the platelet counts are below 50,000/µL. Bleeding precautions (e.g., check all secretions for frank and occult blood) are indicated for patients with thrombocytopenia. Injections (including IVs) should be avoided; however, when needed for critical fluids and medications, IV access should be provided through the smallest bore devices that are feasible. Enoxaparin, an anticoagulant administered subcutaneously, is contraindicated in patients with thrombocytopenia. Monitoring temperature would be indicated in a patient with leukopenia.

An older adult patient who had surgery has signs of delirium. What priority action would benefit this patient? a. Review the chart for intraoperative complications. b. Check which medications were used for anesthesia. c. Assess the effectiveness of the analgesics received. d. Check the preoperative assessment for previous delirium or dementia.

d. Check the preoperative assessment for previous delirium or dementia. If the patient's ABCs are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications and pain will be assessed as these can all contribute to delirium.

The nurse is planning health promotion teaching for a group of healthy older adults in a residential community. Which statement accurately describes expected hematologic effects of aging? a. "Platelet production increases with age and leads to easy bruising." b. "Anemia is common with aging because iron absorption is impaired." c. "Older adults with infections may have only a mild white blood cell count elevation." d. "Older adults often have poor immune function with a decreased number of lymphocytes."

c. "Older adults with infections may have only a mild white blood cell count elevation." During an infection, the older adult may have only a minimal elevation in the total white blood cell count and may not have a fever. Presentation of infection can initially be nonspecific with disorientation, anorexia, and weakness. Platelets are unaffected by the aging process. However, changes in vascular integrity from aging can manifest as easy bruising. Iron absorption is not impaired in the older patient, but adequate nutritional intake of iron may be decreased. The total white blood cell count and differential are generally not affected by aging. However, a decrease in humoral antibody response and decrease in T-cell function may occur.

The patient has osteosarcoma of the right leg. The unlicensed assistive personnel (UAP) reports that the patient's vital signs are normal, but the patient says he still has pain in his leg, and it is getting worse. Which question would best determine treatment measures for the patient's pain? a. "Where is the pain?" b. "Is the pain getting worse?" c. "What does the pain feel like?" d. "Do you use medications to relieve the pain?"

c. "What does the pain feel like?" The UAP told the nurse the location of the patient's pain and the patient reports worsening of pain (pattern). Asking about the quality of the pain will help in planning further treatment. The nurse should already know if the patient is using medication to relieve the pain or can check the patient's medication administration record to see if analgesics have been administered. The intensity of pain using a pain scale should also be assessed.

A female patient is having chemotherapy for brain metastasis. She is concerned about how she will look when she loses her hair. What is the best response by the nurse to this patient? a. "When your hair grows back, it will be patchy." b. "Use your curling iron since that will slow down the loss." c. "You can get a wig now to match your hair so you will not look different." d. "You should contact "Look Good, Feel Better" to figure out what to do about this."

c. "You can get a wig now to match your hair so you will not look different." The best response by the nurse is to suggest getting a wig before she loses her hair so she will not look or feel so different. Although hair loss with chemotherapy is usually reversible, hair loss with radiation is usually permanent in the areas radiation was administered. When hair grows back, it could be a different color or texture. Avoiding use of electric hair dryers, curlers, and curling irons may slow the hair loss but will not answer the patient's concern. The American Cancer Society's "Look Good, Feel Better" program will be helpful, but this response is avoiding the patient's immediate concern.

While performing preoperative teaching, the patient asks when he is no longer able to eat or drink. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, what is the best response by the nurse? a. "Stay NPO after midnight." b. "Maintain NPO status until after breakfast." c. "You may drink clear liquids up to 2 hours before surgery." d. "You may drink clear liquids up until she is moved to the OR."

c. "You may drink clear liquids up to 2 hours before surgery." Practice guidelines for preoperative fasting state the minimum fasting period for clear liquids is 2 hours. Evidence-based practice no longer supports the long-standing practice of requiring patients to be NPO after midnight.

When preparing to administer an ordered blood transfusion, which IV solution does the nurse use when priming the blood tubing? a. Lactated Ringer's b. 5% dextrose in water c. 0.9% sodium chloride d. 0.45% sodium chloride

c. 0.9% sodium chloride The blood set should be primed before the transfusion with 0.9% sodium chloride, also known as normal saline. It is also used to flush the blood tubing after the infusion is complete to ensure the patient receives blood that is left in the tubing when the bag is empty. Dextrose and lactated Ringer's solutions cannot be used with blood because they will cause RBC hemolysis.

The nurse is assigned to care for several patients on a medical unit. Which patient should the nurse assess first? a. A 60-yr-old patient with a blood pressure of 92/64 mm Hg and hemoglobin of 9.8 g/dL b. A 50-yr-old patient with a respiratory rate of 26 breaths/minute and an elevated D-dimer c. A 40-yr-old patient with a temperature of 100.8°F (38.2°C) and a neutrophil count of 256/µL d. A 30-yr-old patient with a pulse of 112 beats/min and a white blood cell count of 14,000/µL

c. A 40-yr-old patient with a temperature of 100.8°F (38.2°C) and a neutrophil count of 256/µL A low-grade fever greater than 100.4° F (38° C) in a patient with a neutrophil count below 500/µL is a medical emergency and may indicate an infection. An infection in a neutropenic patient could lead to septic shock and possible death if not treated immediately.

The patient was told that he would have intraperitoneal chemotherapy. He asks the nurse when the IV will be started for the chemotherapy. What should the nurse teach the patient about this type of chemotherapy delivery? a. It is delivered via an Ommaya reservoir and extension catheter. b. It is instilled in the bladder via a urinary catheter and retained for 1 to 3 hours. c. A Silastic catheter will be percutaneously placed in the abdomen for chemotherapy administration. d. The arteries supplying the tumor are accessed with surgical placement of a catheter connected to an infusion pump.

c. A Silastic catheter will be percutaneously placed in the abdomen for chemotherapy administration. Intraperitoneal chemotherapy is delivered to the peritoneal cavity via a temporary percutaneously inserted Silastic catheter and drained from this catheter after the dwell time in the peritoneum. The Ommaya reservoir is used for intraventricular chemotherapy. Intravesical bladder chemotherapy is delivered via a urinary catheter. Intraarterial chemotherapy is delivered via a surgically placed catheter that delivers chemotherapy via an external or internal infusion pump.

The nurse is doing a preoperative assessment on a male patient who has type 2 diabetes; weighs 146 kg; and is 5 feet 8, inches tall. Which patient assessment is a priority related to anesthesia? a. Hemoglobin A1C of 8.5% b. Several seasonal allergies c. A body mass index of 48.8 kg/m2 d. A history of postoperative vomiting

c. A body mass index of 48.8 kg/m2 The patient's body mass index is the priority because it indicates the patient is severely obese. The patient's size may impair the anesthesiologist's ability to ventilate and medicate the patient properly, as well as the surgery room staff's ability to position the patient safely. The other factors are not the priority.

While the perioperative nurse is transporting a patient to the operating room for general surgery, the patient states, "I am a Jehovah's Witness, and I am worried about blood transfusions." What would be the best response by the nurse to this patient's statement? a. "I will make sure that you do not receive a blood transfusion during this surgery." b. "Would you like to sign the consent form just in case you need blood during surgery?" c. "Do you have someone I can contact in an emergency if you need a blood transfusion?" d. "Tell me what you would like done if it is determined that you need blood replacement during surgery."

d. "Tell me what you would like done if it is determined that you need blood replacement during surgery." The perioperative nurse should identify what the patient's concern is related to a blood transfusion. In addition, the nurse should clarify whether the patient wants a blood transfusion. The Jehovah's Witness community member may refuse blood transfusions, but each patient should be consulted to determine an individualized plan related to receiving or refusing blood transfusions.

The nurse teaches a black man with sickle cell disease about symptom management and prevention of sickle cell crisis. The nurse determines further teaching is necessary if the patient makes which statement? a. "When I take a vacation, I should not go to the mountains." b. "I should avoid being with anyone who has a respiratory infection." c. "I may have severe pain during a crisis and need opioid analgesics." d. "When my vision is blurred, I will close my eyes and rest for an hour."

d. "When my vision is blurred, I will close my eyes and rest for an hour." Blurred vision should be reported immediately and may indicate a detached retina or retinopathy. Hypoxia (at high altitudes) and infection are common causes of a sickle cell crisis. Severe pain may occur during a sickle cell crisis, and narcotic analgesics are indicated for pain management.

A patient has recently been diagnosed with stage II cervical cancer. Which statement by the nurse best explains the diagnosis? a. "The cancer is found at the point of origin only." b. "Tumor cells have been identified in the cervical region." c. "The cancer has been identified in the cervix and the liver." d. "Your cancer was identified in the cervix and has limited local spread."

d. "Your cancer was identified in the cervix and has limited local spread." Stage II cancer is associated with limited local spread. Stage 0 denotes cancer in situ or at the point of origin only; stage I denotes tumor limited to the tissue of origin with localized tumor growth. Stage III denotes extensive local and regional spread. Stage IV denotes metastasis such as to the liver.

When providing oral care to a patient with metastatic cancer who is at risk for oral tissue injury secondary to chemotherapy, what would be most beneficial to teach the patient to use? a. Firm-bristle toothbrush b. Hydrogen peroxide rinse c. Alcohol-based mouthwash d. 1 tsp salt in 1 L water mouth rinse

d. 1 tsp salt in 1 L water mouth rinse A salt-water mouth rinse will not cause further irritation to oral tissue that is fragile because of mucositis, which is a side effect of chemotherapy. A soft-bristle toothbrush will be used. One teaspoon of sodium bicarbonate may be added to the salt-water solution to decrease odor, alleviate pain, and dissolve mucin. Hydrogen peroxide and alcohol-based mouthwash are not used because they would damage the oral tissue.

Which patient would be at highest risk for hypothermia after surgery? a. A 42-yr-old patient who had a laparoscopic appendectomy b. A 38-yr-old patient who had a lumpectomy for breast cancer c. A 20-yr-old patient with an open reduction of a fractured radius. d. A 75-yr-old patient with repair of a femoral neck fracture after a fall.

d. A 75-yr-old patient with repair of a femoral neck fracture after a fall. Patients at highest risk for hypothermia are those who are older, debilitated, or intoxicated. Also, long surgical procedures and prolonged anesthetic administration increase the patient's risk for hypothermia.

The patient is receiving immunotherapy and targeted therapy for ovarian cancer. What medication should the nurse expect to administer before therapy to combat the most common side effects of these medications? a. Morphine sulfate b. Ibuprofen (Advil) c. Ondansetron (Zofran) d. Acetaminophen (Tylenol)

d. Acetaminophen (Tylenol) Acetaminophen is administered before therapy and every 4 hours to prevent or decrease the intensity of the severe flu-like symptoms, especially with interferon which is frequently used for ovarian cancer. Morphine sulfate and ibuprofen will not decrease flu-like symptoms. Ondansetron is an antiemetic but is not used first to combat flu-like symptoms such as headache, fever, chills, and myalgias.

The nurse is caring for a patient with anorexia secondary to chemotherapy. Which strategy would be most appropriate to increase the patient's nutritional intake? a. Increase intake of liquids at mealtime to stimulate the appetite. b. Serve three large meals per day plus snacks between each meal. c. Avoid the use of liquid protein supplements to encourage eating at mealtimes. d. Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods.

d. Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods. The nurse can increase the nutritional density of foods by adding items high in protein and/or calories (e.g., peanut butter, skim milk powder, cheese, honey, brown sugar) to foods the patient will eat. Increasing fluid intake at mealtime fills the stomach with fluid and decreases the desire to eat. Small frequent meals are best tolerated. Supplements can be helpful.

The perioperative nurse is supervising the surgical technologist before the arrival of the patient in the operating room for an exploratory laparotomy. Which action, if taken by the surgical technologist, would require the nurse to intervene? a. The surgical technologist always holds hands away from the body and above the elbows. b. The surgical technologist scrubs the fingers and hands first followed by the forearms and elbows. c. After a surgical scrub, the surgical technologist puts on a sterile gown and one pair of sterile gloves. d. When wearing a sterile gown and gloves, the surgical technologist organizes the equipment on the sterile field.

c. After a surgical scrub, the surgical technologist puts on a sterile gown and one pair of sterile gloves. After a surgical hand scrub is completed, the surgical technologist should put on a sterile surgical gown and two pairs of gloves to prevent the transmission of microorganisms. Surgical hand antisepsis is completed by scrubbing fingers and hands first followed by progression to forearms and elbows. The hands always should be held away from surgical attire and higher than the elbows to prevent contamination. After performing a surgical hand scrub and applying a sterile gown and two pairs of sterile gloves, the person may manipulate and organize all sterile items for use during the procedure.

The nurse is caring for a patient who is to receive a transfusion of two units of packed red blood cells. After obtaining the first unit from the blood bank, the nurse would ask which health team member in the nurses' station to assist in checking the unit before administration? a. Unit secretary b. A physician's assistant c. Another registered nurse d. An unlicensed assistive personnel

c. Another registered nurse Before hanging a transfusion, the registered nurse must check the unit with another RN or with a licensed practical (vocational) nurse, depending on agency policy. The unit secretary, physician's assistant, or unlicensed assistive personnel should not be asked.

When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. What is the priority action by the nurse? a. Recheck in 1 hour for increased drainage. b. Notify the surgeon of a potential hemorrhage. c. Assess the patient's blood pressure and heart rate. d. Remove the dressing and assess the surgical incision.

c. Assess the patient's blood pressure and heart rate. The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.

In caring for the postoperative patient on the clinical unit after transfer from the postanesthesia care unit (PACU), which care can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Monitor the patient's pain. b. Obtain the admission vital signs. c. Assist the patient to take deep breaths and cough. d. Change the dressing when there is excess drainage.

c. Assist the patient to take deep breaths and cough. The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report pain to the nurse caring for the patient. The RN should do the admission vital signs for the patient transferring to the clinical unit from the postanesthesia care unit (PACU). The RN will monitor and treat the patient's pain and change the dressings.

A patient with breast cancer is having teletherapy radiation treatments after surgery. What should the nurse teach the patient about skin care? a. Use Dial soap to feel clean and fresh. b. Scented lotion can be used on the area. c. Avoid heat and cold to the treatment area. d. Wear the new bra to comfort and support the area.

c. Avoid heat and cold to the treatment area. Avoiding heat and cold in the treatment area will protect it. Only mild soap and unscented, non-medicated lotions may be used to prevent skin damage. The patient will want to avoid wearing tight-fitting clothing such as a bra over the treatment field and will want to expose the area to air as often as possible.

When reviewing the preoperative forms, the nurse notices that the informed consent form is not present or signed. What action should the nurse take? a. Have the patient sign the consent form. b. Have the family sign the form for the patient. c. Call the surgeon to obtain consent for surgery. d. Teach the patient about the surgery and get verbal permission.

c. Call the surgeon to obtain consent for surgery. The informed consent for the surgery must be obtained by the physician. The nurse can witness the signature on the consent form and verify that the patient (or caregiver if patient is a minor, unconscious, or mentally incompetent to sign) understands the informed consent. Verbal consents are not enough. The state's nurse practice act and agency policies must be followed.

Before beginning a transfusion of packed red blood cells (PRBCs), which action by the nurse would be of highest priority to avoid an error during this procedure? a. Add the blood transfusion as a secondary line to the existing IV. b. Stay with the patient for 60 minutes after starting the transfusion. c. Check the identifying information on the unit of blood against the patient's ID bracelet. d. Prime new primary IV tubing with lactated Ringer's solution to use for the transfusion.

c. Check the identifying information on the unit of blood against the patient's ID bracelet. The patient's identifying information (name, date of birth, medical record number) on the ID bracelet should exactly match the information on the blood bank tag that has been placed on the unit of blood. If any information does not match, the transfusions should not be hung because of possible error and risk to the patient. The transfusion is hung on blood transfusion tubing, not a secondary line, and cannot be hung with lactated Ringer's solution because it will cause RBC hemolysis. Usually, the patient will need continuous monitoring for 15 minutes after the transfusion is started, as this is the time most transfusion reactions occur. Then the patient should be monitored every 30 to 60 minutes during the administration.

A patient requests that the nurse give his hearing aid to a family member so it will not be lost in surgery. What is the appropriate action by the nurse? a. Give the hearing aid to the wife as he wishes. b. Tape the hearing aid to his ear to prevent loss. c. Encourage the patient to wear it for the surgery. d. Tell the surgery nurse that he has his hearing aid out.

c. Encourage the patient to wear it for the surgery. Although jewelry is removed before surgery, hearing aids should be left in place to allow the patient to better follow instructions given in the surgical suite and the postanesthesia care unit (PACU), as well as the dismissal instructions that will be given before he returns home for recovery.

The nurse is caring for a patient receiving an initial dose of chemotherapy to treat a rapidly growing metastatic colon cancer. The nurse is aware that the patient is at risk for tumor lysis syndrome (TLS) and will monitor for which abnormality associated with this oncologic emergency? a. Hypokalemia b. Hypercalcemia c. Hyperuricemia d. Hypophosphatemia

c. Hyperuricemia TLS is a metabolic complication characterized by rapid release of intracellular components in response to chemotherapy. This can rapidly lead to acute renal injury. The hallmark signs of TLS are hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcemia.

A patient is admitted to the postanesthesia care unit (PACU) after abdominal surgery. Which assessment, if made by the nurse, is the best indicator of respiratory depression? a. Increased respiratory rate b. Decreased oxygen saturation c. Increased carbon dioxide pressure d. Frequent premature ventricular contractions (PVCs)

c. Increased carbon dioxide pressure Transcutaneous carbon dioxide pressure (PtcCO2) monitoring is a sensitive indicator of respiratory depression. Increased CO2 pressures would indicate respiratory depression. Clinical manifestations of inadequate oxygenation include increased respiratory rate, dysrhythmias (e.g., premature ventricular contractions), and decreased oxygen saturation.

The patient is told that an adenoma tumor is not encapsulated but has normally differentiated cells and surgery will be needed. The patient asks the nurse what this means. What should the nurse's response be to the patient? a. It will recur. b. It has metastasized. c. It is probably benign. d. It is probably malignant.

c. It is probably benign. Benign tumors are usually encapsulated, have normally differentiated cells, and do not metastasize. Malignant tumors are rarely encapsulated, have poorly differentiated cells, and are capable of metastasis.

The nurse knows that hemolytic anemia can be caused by which extrinsic factors? a. Trauma or splenic sequestration crisis b. Abnormal hemoglobin or enzyme deficiency c. Macroangiopathic or microangiopathic factors d. Chronic diseases or medications and chemicals

c. Macroangiopathic or microangiopathic factors Macroangiopathic or microangiopathic extrinsic factors lead to acquired hemolytic anemias. Trauma or splenic sequestration crisis can lead to anemia from acute blood loss. Abnormal hemoglobin or enzyme deficiency are intrinsic factors that lead to hereditary hemolytic anemias. Chronic diseases or medications and chemicals can decrease the number of red blood cell (RBC) precursors which reduce RBC production.

The nurse is performing a preoperative assessment for a patient scheduled for a surgical procedure. What is the rationale for the nurse's careful documentation of the patient's current medication list? a. Some medications may alter the patient's perceptions about surgery. b. Many anesthetics alter renal and hepatic function, causing toxicity of other drugs. c. Some medications may interact with anesthetics, altering the potency and effect of the drugs. d. Routine medications are withheld the day of surgery, requiring dosage and schedule adjustments after surgery.

c. Some medications may interact with anesthetics, altering the potency and effect of the drugs. Drug interactions may occur between prescribed medications and anesthetic agents used during surgery. For this reason, it is important to take a careful medication history and check that it has been communicated to the anesthesia care provider. Routine medications may or may not be prescribed for use the day of surgery.

The nurse collects a nutritional history from a 22-yr-old woman who is planning to conceive a child in the next year. Which foods reported by the woman would indicate that her diet is high in folate and iron? a. Crab, fish, and tuna b. Milk, cheese, and yogurt c. Spinach, beans, and liver d. White rice, potatoes, and pasta

c. Spinach, beans, and liver Normal intake of iron and folic acid is necessary for the development of red blood cells, and normal levels before conception and in early pregnancy are particularly important for normal fetal development. Foods high in both folic acid and iron include liver, red meat, egg yolks, turkey or chicken giblets, beans, lentils, chickpeas, soybeans, spinach, and collard greens. In addition, enriched cereals, pasta, and breads are also high in both folic acid and iron (check the labels).

The nurse in an ambulatory surgery center has administered the following preoperative medications to a patient scheduled for general surgery: diazepam, cefazolin, and famotidine. What mode of transportation to the operating room (OR) would be the most appropriate for the nurse to arrange for this patient? a. Seated in a wheelchair accompanied by a responsible family member. b. Ambulatory and accompanied by a hospital escort and a family member. c. Stretcher with side rails up and accompanied by OR transportation personnel. d. Ambulatory accompanied by an OR staff member or transportation personnel.

c. Stretcher with side rails up and accompanied by OR transportation personnel. The patient has received a sedative (diazepam) and should be transported either by stretcher (with side rails raised) or wheelchair and accompanied by either OR staff, OR transport personnel, or the nurse.

A patient having an open reduction internal fixation (ORIF) of a left lower leg fracture will receive regional anesthesia during the procedure. As the patient is prepared in the operating room, what should the nurse implement to maintain patient safety during surgery that is directly related to the type of anesthesia being used? a. Apply grounding pad to unaffected leg. b. Assess peripheral pulses and skin color. c. Verify the last oral intake before surgery. d. Ensure a smooth surface under the patient.

d. Ensure a smooth surface under the patient. Regional anesthesia decreases sensation to the anesthetized area without impairing level of consciousness, which means the affected leg will be without sensation while the anesthetic is effective. A double tourniquet on the affected leg is used to restrict blood flow. This increases the patient's risk of impaired skin integrity because the patient does not have sensation and cannot identify discomfort or foreign objects and will not be moving during surgery. The nurse's role includes positioning the patient for correct alignment, exposure of the surgical site, and preventing injury. The other options will be occurring but are not directly related to the regional anesthesia.

A patient has been diagnosed with Burkitt's lymphoma. In the initiation stage of cancer, the cells genetic structure is mutated. Exposure to what may have functioned as a carcinogen for this patient? a. Bacteria b. Sun exposure c. Most chemicals d. Epstein-Barr virus

d. Epstein-Barr virus Burkitt's lymphoma consistently shows evidence of the presence of Epstein-Barr virus in vitro. Bacteria do not initiate cancer. Sun exposure causes cell alterations leading to melanoma and squamous and basal cell skin carcinoma. Long-term exposure to certain chemicals (e.g., ethylene oxide, chloroform, benzene) is known to initiate cancer.

A nurse is assigned to provide preoperative teaching to a patient scheduled for coronary artery bypass surgery who only speaks Spanish. What is the best method for the nurse to teach the patient how to use an incentive spirometer? a. Give the patient a pamphlet written in Spanish with directions on the use of the incentive spirometer. b. Ask another Spanish-speaking patient in the preoperative area to translate as the nurse describes the procedure. c. Notify the postoperative unit to have a Spanish-speaking nurse provide teaching on the incentive spirometer after surgery. d. Have the hospital interpreter available while the nurse demonstrates the procedure and the patient returns the demonstration.

d. Have the hospital interpreter available while the nurse demonstrates the procedure and the patient returns the demonstration. If the patient does not speak English, it is essential that the services of a competent interpreter be obtained. Hospitals are required to provide interpreters for common languages other than English. Demonstration and return demonstration is the most effective teaching method for use of equipment such as the incentive spirometer and should be done in the preoperative period if possible.

The surgical team in the operating room performs a surgical time-out just before starting hip replacement surgery. Which action would be part of the surgical time-out? a. Check the chart for a signed consent form for the procedure. b. Assess the patient's vital signs and oxygen saturation level. c. Determine if the patient has any questions about the procedure. d. Have the patient verify the procedure and the location of the surgery.

d. Have the patient verify the procedure and the location of the surgery. During a surgical time-out, the surgery team will stop all activities right before the procedure to verify the patient identification, surgical procedure, and surgical site. Proper identification will be accomplished by asking the patient to state name, birth date, and operative procedure and location. In addition, the surgical team will compare the hospital ID number with the patient's own ID band and chart.

When caring for the patient with cancer, what does the nurse understand is the response of the immune system to antigens of the malignant cells? a. Metastasis b. Tumor angiogenesis c. Immunologic escape d. Immunologic surveillance

d. Immunologic surveillance Immunologic surveillance is the process in which lymphocytes check cell surface antigens and detect and destroy cells with abnormal or altered antigenic determinants to prevent these cells from developing into clinically detectable tumors. Metastasis is increased growth rate of the tumor, increased invasiveness, and spread of the cancer to a distant site in the progression stage of cancer development. Tumor angiogenesis is the process of blood vessels forming within the tumor itself. Immunologic escape is the cancer cells' evasion of immunologic surveillance that allows the cancer cells to reproduce.

When assessing laboratory values on a patient admitted with septicemia, what does the nurse expect to find? a. Increased platelets b. Increased red blood cells c. Decreased erythrocyte sedimentation rate (ESR) d. Increased bands in the white blood cell (WBC) differential

d. Increased bands in the white blood cell (WBC) differential When infections are severe, such as in septicemia, more granulocytes are released from the bone marrow as a compensatory mechanism. To meet the increased demand, many young, immature polymorphonuclear neutrophils (bands) are released into circulation. WBCs are usually reported in order of maturity (initially with the less mature forms on the left side of a written report). Hence, the term "shift to the left" is used to denote an increase in the number of bands. Thrombocytosis occurs with inflammation and some malignant disorders. Increased red blood cells or decreased ESR is not indicative of septicemia.

A patient is having elective facial cosmetic surgery and will be staying in the facility for 24 hours after surgery. What is the nurse's postoperative priority for this patient? a. Manage patient pain. b. Control the bleeding. c. Maintain fluid balance. d. Manage oxygenation status.

d. Manage oxygenation status. The nurse's priority is to manage the patient's oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise her ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase her risk for upper airway edema causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority.

The patient is going to have a colonoscopy. Which type of anesthesia should the nurse expect to be used? a. Local anesthesia b. Moderate sedation c. General anesthesia d. Monitored anesthesia care (MAC)

d. Monitored anesthesia care (MAC) The nurse should expect MAC to be used for the patient having a colonoscopy because it can match the sedation level to the patient needs and procedural requirements. Local anesthesia would not be used because the area affected by a colonoscopy is larger than loss of sensation could be provided for with topical, intracutaneous, or subcutaneous application. Moderate sedation is used for procedures performed outside the operating room, and the patient remains responsive. General anesthesia is not needed for a colonoscopy, and it requires advanced airway management.

An older adult patient undergoing coronary artery bypass graft (CABG) surgery has just experienced intraoperative vomiting. The nurse should consequently anticipate the use of which drug? a. Fentanyl b. Midazolam c. Meperidine d. Ondansetron

d. Ondansetron Ondansetron is an antiemetic, midazolam is a benzodiazepine, and fentanyl and meperidine are opioid analgesics.

In which surgical area will the patient's surgical skin scrub prep be performed for surgery, and what clothing is appropriate for the nurse performing the scrub to wear? a. Surgical suite wearing a lab coat b. Postanesthesia care unit (PACU) wearing scrubs c. Preoperative holding area wearing street clothes d. Operating room wearing surgical attire and masks

d. Operating room wearing surgical attire and masks Surgical attire includes pants and shirts (or scrubs), a cap or hood, masks, and protective eyewear. All surgical attire is worn when the patient's skin is being prepped in the operating room to avoid contamination of the site. The surgical suite includes all unrestricted, semi-restricted, and restricted areas of the controlled surgical environment. The staff usually wears a lab coat over their scrubs when they leave the surgical area. The staff will not wear street clothes in the preoperative holding area, although the family may. The holding area and PACU will not include prepping the patient for surgery.

A patient is being prepared for a surgical procedure. What is the priority intervention by the nurse prior to the start of the procedure according to the National Patient Safety Goal (NPSG)? a. Prevention of infection b. Improved staff communication c. Identify patients at risk for suicide d. Patient, surgical procedure, and site are checked

d. Patient, surgical procedure, and site are checked During the surgical time-out, the Universal Protocol is used to verify the patient's identity, surgical procedure, and site to prevent mistakes in surgery. Prevention of infection is to be done at all times. Improved staff communication relates to getting important test results to the right staff on time. Identifying patient's safety risks for suicide is not usually vital before surgery and does not occur during the time-out.

A patient who is receiving radiation to the head and neck as treatment for an invasive cancer reports mouth sores and pain. Which intervention should the nurse add to the plan of care? a. Provide ice chips to soothe the irritation. b. Weigh the patient every month to monitor for weight loss. c. Cleanse the mouth every 2 to 4 hours with hydrogen peroxide. d. Provide high-protein and high-calorie, soft foods every 2 hours.

d. Provide high-protein and high-calorie, soft foods every 2 hours. A patient with stomatitis should have soft, non-irritating foods offered frequently. The diet should be high in protein and high in calories to aid healing. Extremes of temperature are to be avoided. Saline or water should be used to cleanse the mouth (not hydrogen peroxide). Patients should be weighed at least twice each week to monitor for weight loss.

Which problem is of most concern for a patient with myelosuppression secondary to chemotherapy for cancer treatment? a. Acute pain b. Hypothermia c. Powerlessness d. Risk for infection

d. Risk for infection Myelosuppression is accompanied by a high risk of infection and sepsis. Hypothermia, powerlessness, and acute pain are also possible when patients undergo chemotherapy, but the threat of infection is paramount.

At 0600, the anesthesiologist prescribes preoperative medications for a patient who is scheduled for surgery at 0730: cefazolin IV to be infused 30 minutes before surgery; midazolam before surgery, and scopolamine patch behind the ear. Which medication should the nurse administer first? a. Cefazolin b. Fentanyl c. Midazolam d. Scopolamine

d. Scopolamine The scopolamine patch will be administered first to allow enough time for the serum level to become therapeutic. The cefazolin will be given at 0700 to allow infusion 30 minutes before surgery. Fentanyl is an opioid and was not ordered preoperatively. Midazolam, a short-acting benzodiazepine, is used as a sedative.

An older adult female patient has come to the ambulatory surgery center for surgery. When reviewing the assessment record, what test should the nurse seek an order for before this patient has surgery? *Past Health History:* Smoker for past 25 years; last cigarette yesterday; Has hypertension *Lab and Diagnostic Results:* CBC within normal limits; Chest x-ray clear; UA within normal limits; No other lab work drawn *Medications*: Takes hydrochlorothiazide 50 mg every morning a. Blood glucose b. Pregnancy test c. Serum albumin d. Serum potassium

d. Serum potassium The nurse should seek a serum potassium level because the patient takes hydrochlorothiazide. An ECG would also be appropriate to seek with the history of hypertension and cigarette smoking. There are not indications for the need of a blood glucose, pregnancy, or serum albumin test.

A 70-yr-old man who has end-stage lung cancer is admitted to the hospital with confusion and oliguria for 2 days. Which finding would the nurse report immediately to the health care provider? a. Weight gain of 6 lb b. Nausea and vomiting c. Urine specific gravity of 1.004 d. Serum sodium level of 118 mEq/L

d. Serum sodium level of 118 mEq/L Lung cancer cells are able to manufacture and release antidiuretic hormone (ADH) with resultant water retention and hyponatremia. Hyponatremia (serum sodium levels less than 135 mEq/L) may lead to central nervous system symptoms such as confusion, seizures, coma, and death. The other options listed are also symptoms of hyponatremia but are not as critical to report to the health care provider.

An older adult patient is having surgery. What risk area will the nurse need to be especially aware of for this patient during surgery? a. Sterility b. Paralysis c. Urine output d. Skin integrity

d. Skin integrity Skin of older adults has lost elasticity and is at increased risk for injury from tape, electrodes, warming or cooling blankets, and dressings. Pooling cleansing solution may create skin burns or abrasions. The nurse is responsible for monitoring patient safety and adjusting patient position as necessary to prevent pressure or misalignment. Sterility and urine output would be monitored for all patients. Paralysis would not be unusual during some types of surgery but would have an impact on any patient's skin integrity.

The patient is being treated with brachytherapy for cervical cancer. What factors must the nurse be aware of to protect herself when caring for this patient? a. The medications the patient is taking b. The nutritional supplements that will help the patient c. How much time is needed to provide the patient's care d. The time the nurse spends at what distance from the patient

d. The time the nurse spends at what distance from the patient The principles of ALARA (as low as reasonably achievable) and time, distance, and shielding are essential to maintain the nurse's safety when the patient is a source of internal radiation. The patient's medications, nutritional supplements, and time needed to complete care will not protect the nurse caring for a patient with brachytherapy for cervical cancer.

An older adult patient has been admitted before having surgery for a bilateral mastectomy and breast reconstruction. What information should the nurse include in the patient's preoperative teaching? (Select all that apply.) a. Various options for reconstructive surgery b. The risks and benefits of her particular surgery c. Risk factors for breast cancer and the role of screening d. Where in the hospital she will be taken after surgery is over e. How to perform postoperative deep-breathing and coughing exercises

d. Where in the hospital she will be taken after surgery is over e. How to perform postoperative deep-breathing and coughing exercises During preoperative teaching, it is important to introduce the role of deep-breathing and coughing exercises and to inform the patient about the different locations involved in her hospital stay. The surgeon would address specific risks and benefits of surgery and reconstruction options. Teaching about breast cancer screening would be inappropriate, and insensitive at this point in her disease trajectory.