Adult Nursing 5 Test 7
An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to
alternate periods of rest and activity
A patient who has acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to
ask whether there are questions or concerns about HSCT.
The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the
bilirubin level.
A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the
bleeding time.
A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding
White blood cell (WBC) count of 2800/μL
The nurse reviews the laboratory test results of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider?
White blood cell (WBC) count 15,500/μL
The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient
Do you take medication containing salicylates
A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to support the patient's self-esteem
Encourage the patient to purchase a wig or hat to wear when hair loss begins
A patient with Hodgkin's lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." Which intervention should the nurse add to the plan of care?
Establish time to take a short walk almost every day
The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect
Hematuria
The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered
Hemoglobin level
The nurse is reviewing laboratory results and notes a patient's activated partial thromboplastin time (aPTT) level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication
Heparin
A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). The nurse will include which information in the patient's teaching plan?
Hospitalization is required for several weeks after the stem cell transplant.
The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective?
I will need follow-up examinations for many years after treatment before I can be considered cured
A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct?
Malignant tumors may spread to other tissues or organs
When caring for a patient who is pancytopenic, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene
The UAP assists the patient to use dental floss after eating.
After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first?
A 33-yr-old with a fever of 100.8° F (38.2° C)
The nurse assesses a patient with non-Hodgkin's lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse
Shortness of breath
The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement, if made by the patient, indicates that teaching was effective
The biopsy will help decide the treatment for my enlarged prostate
Which patient requires the most rapid assessment and care by the emergency department nurse?
The patient with neutropenia who has a temperature of 101.8° F
The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider?
White blood cells (WBC) 2700/μL
Which patient information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis
Serum iron level
A routine complete blood count for an active older man indicates possible myelodysplastic syndrome. The nurse will plan to teach the patient about
bone marrow biopsy.
Which instruction will the nurse plan to include in discharge teaching for a patient admitted with a sickle cell crisis
Avoid exposure to crowds when possible
A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect?
Elevated reticulocyte count
The health care provider's progress note for a patient states that the CBC shows a "shift to the left." Which assessment finding will the nurse expect
Elevated temperature
Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the health care provider
. Tarry stools
Which action will the nurse include in the plan of care for a patient who has thalassemia major?
Administer iron chelation therapy as needed.
The nurse examines the lymph nodes of a patient during a physical assessment. Which assessment finding would be of most concern to the nurse
A 2-cm nontender supraclavicular node
A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan (select all that apply)?
-Cook food thoroughly before eating -Avoid public transportation such as buses -Talk to the oncologist before having any dental work
The CBC indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care
Avoid intramuscular injections
During the teaching session for a patient who has a new diagnosis of acute leukemia, the patient is restless and looks away without making eye contact. The patient asks the nurse to repeat the information about the complications associated with chemotherapy. Based on this assessment, which nursing diagnosis is appropriate for the patient?
Risk for ineffective health maintenance related to possible anxiety about leukemia diagnosis
An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/μL during chemotherapy is to
check all stools for occult blood
Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy
Absolute neutrophil count
Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)?
Activated partial thromboplastin time
A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take?
Administer PRN acetaminophen (Tylenol).
A patient with metastatic cancer of the colon experiences severe vomiting after each administration of chemotherapy. Which action, if taken by the nurse, is appropriate
Administer prescribed antiemetics 1 hour before the treatments
A patient has been assigned the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers. Which nursing action will be most effective in improving oral intake?
Apply prescribed anesthetic gel to oral lesions before meals.
External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation?
Clean the perianal area carefully after every bowel movement.
The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider
Crackles heard at the lung bases
A patient with a large stomach tumor attached to the liver is scheduled for a debulking procedure. Which information should the nurse teach the patient about the outcome of this procedure?
Decreasing the tumor size will improve the effects of other therapy
A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/μL. Which action will the nurse include in the plan of care?
Discontinue the heparin infusion.
The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in cancer therapy with the health care provider?
Increased carcinoembryonic antigen (CEA)
Which action will the nurse include in the plan of care for a patient admitted with multiple myeloma
Monitor fluid intake and output
Following successful treatment of Hodgkin's lymphoma for a 55-yr-old woman, which topic will the nurse include in patient teaching
Need for follow-up appointments to screen for malignancy
A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take?
Notify the health care provider.
An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hr in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider?
Patient has crackles up to the midline posterior chest.
A patient with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets?
Platelet count is 42,000/µL.
Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia
Potential complication: infection
A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient
Rinse the mouth before and after each meal and at bedtime with a saline solution.
Which statement by a patient indicates good understanding of the nurse's teaching about prevention of sickle cell crisis?
Risk for a crisis is decreased by having an annual influenza vaccination
When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care
Schedule immunization with the pneumococcal vaccine (e.g., Pneumovax).
The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take
Stop the infusion if swelling is observed at the site
Which action should the nurse take when caring for a patient who is receiving chemotherapy and complains of problems with concentration?
Suggest use of a daily planner and encourage adequate rest and sleep
The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by UAP, if observed by the nurse, would require an intervention?
The UAP stands by the patient's bed for 30 minutes talking with the patient.
A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching
The patient's visitors bring in fresh peaches
A patient who has acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate?
The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy
A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient
Transfuse only leukocyte-reduced PRBCs.
The nurse should suggest which food choice when providing dietary teaching for a patient scheduled to receive external-beam radiation for abdominal cancer?
Baked chicken
A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test
Bone marrow biopsy
Which action will the admitting nurse include in the care plan for a patient who has neutropenia?
Check temperature every 4 hours.
It is important for the nurse providing care for a patient with sickle cell crisis to
evaluate the effectiveness of opioid analgesics.
Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first?
. A 23-yr-old with no previous health problems who has a nontender lump in the axilla
A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of
. folic acid.
The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first?
A 24-yr-old patient who received neck radiation and has blood oozing from the neck
Which menu choice indicates that the patient understands the nurse's teaching about recommended dietary choices for iron-deficiency anemia?
Omelet and whole wheat toast
The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect
Numbness of the extremities
An expected action by the nurse caring for a patient who has an acute exacerbation of polycythemia vera is to
monitor fluid intake and output.
A patient who is diagnosed with cervical cancer classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is accurate
The cancer involves only the cervix
A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature of 102° F (38.9° C), and severe back pain. Which prescribed action will the nurse implement first
Infuse normal saline 500 mL over 30 minutes
During a routine health examination, a 40-yr-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next
Obtain more information about the family history
Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient?
IL-2 enhances the body's immunologic response to tumor cells.
Which patient should the nurse assign as the roommate for a patient who has aplastic anemia
A patient with chronic heart failure
Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate
I will call my health care provider if my stools turn black
A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first
Assess for sensation and strength in the legs.
The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take before this procedure
Assist the patient to a flat position.
Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura
Avoid IM injections
A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action would address the cause of the patient problem
Avoid giving the patient foods that are strongly disliked
The nurse is caring for a patient who smokes two packs/day. Which action by the nurse could help reduce the patient's risk of lung cancer?
Discuss risks associated with cigarette smoking during each patient encounter
A patient's complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding
Do you have any history of lung disease
A patient who has ovarian cancer is crying and tells the nurse, "My husband rarely visits. He just doesn't care." The husband indicates to the nurse that he does not know what to say to his wife. Which nursing diagnosis is appropriate for the nurse to add to the plan of care?
Dysfunctional family processes related to effect of illness on family members
A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure?
Have the patient lie on the left side for 1 hour.
A 52-yr-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states
I could choose nasal spray rather than injections of vitamin B12
A widowed mother of four school-age children is hospitalized with metastatic ovarian cancer. The patient is crying and tells the nurse that she does not know what will happen to her children when she dies. Which response by the nurse is most appropriate
Would you like to talk about options for the care of your children?
A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory test findings to include
hemoglobin (Hgb) of 8.6 g/dL (86 g/L).
The nurse is caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee. The nurse should
immobilize the knee joint.
Which action for a patient with neutropenia is appropriate for the RN to delegate to a LPN?
Administering subcutaneous filgrastim (Neupogen) injection
The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate UAP?
Obtain the temperature, blood pressure, and pulse before the transfusion.
After change-of-shift report on the oncology unit, which patient should the nurse assess first?
Patient who is neutropenic and has a temperature of 100.5° F (38.1° C)
Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider?
Serum calcium level is 15 mg/dL.
The nurse is caring for a patient with left-sided lung cancer. Which finding would be most important for the nurse to report to the health care provider
Serum sodium of 126 mEq/L
A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to
disconnect the transfusion and infuse normal saline.
The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective
Blueberry yogurt
Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider
Calf swelling and pain
The nurse is caring for a patient diagnosed with stage I colon cancer. When assessing the need for psychologic support, which question by the nurse will provide the most information?
Can you tell me what has been helpful to you in the past when coping with stressful events
A patient who has acute myelogenous leukemia develops an absolute neutrophil count of 850/μL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate
Teach the patient to administer filgrastim (Neupogen) injections
The nurse at the clinic is interviewing a 64-yr-old woman who is 5 feet, 3 inches tall and weighs 125 lb (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine two or three times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk (select all that apply)?
-Pap testing -Sunscreen use -Mammography -Colorectal screening
The nurse is caring for a patient with colon cancer who is scheduled for external radiation therapy to the abdomen. Which information obtained by the nurse would indicate a need for patient teaching?
The patient swims several days each week
A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about the management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective?
I can buy aloe vera gel to use on my skin
The home health nurse is caring for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment?
I rarely have the energy to get out of bed
A patient who has non-Hodgkin's lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse?
Lip swelling
Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider
The patient is difficult to arouse.
A patient who has severe pain associated with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective?
The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs.
The nurse is caring for a patient who is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching
Wash hands and avoid persons who are ill.