ATI A&C II: Cancer/Immunity/Emergency Triage
a school-age child is being seen in the oncology clinic for possible Hodgkin disease. During the course of the nursing assessment, which findings would be expected? Select all that apply. a) fever b) painless cervical nodes c) painful cervical nodes d) poor appetite e) complaints of night sweats
"Answers: b and d (complaints of night sweats, painless cervical nodes.)Painless cervical nodes are a hallmark sign of HD. In addition to this, night sweats also are characteristic. Fever, poor appetite, and painful cervical nodes are more characteristic of infection."
a two-year-old female has recently has diagnosed with a Wilms tumor. Her presenting signs and symptoms likely included
*an abdominal mass, hematuria, hypertension and fever* *not enlarged abdomen detected by her parents, decreased ambulation, fatigue, and hyperglycemia
what are examples of Type I or IgE-mediated hypersensitivity reactions? select all that apply.
*atopic dermatitis* *allergic rhinitis* *anaphylaxis (anaphylactic shock)* wheal-and-flare reactions
a nurse is planning care for a client who has acute leukemia and received aggressive chemotherapy treatment 10 years ago. which of the following hematologic laboratory abnormalities should the nurse expect to see?
- decreased platelet count - decreased WBC count - decreased RBC count
an occupational health nurse is instructing workers at an industrial facility in emergency procedures in the event of an amputation. which of the following guidelines should the nurse include for preserving the amputated part of surgical reattachment?
-wrap the part in dry sterile gauze - put the severed part in a dry, waterproof plastic bag - prevent contact of the severed part with water
A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?
A dry, red rash across the bridge of the nose and on the cheeks. A "butterfly" rash that is dry, red, and raised is characteristic of SLE.
a nurse is caring for a client who has a cardiopulmonary arrest. the nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?
Atropine the team administers atropine during CPR if the client has symptomatic bradycardia or is hemodynamically unstable
A triage nurse in an emergency department (ED) is caring for a client who has a gunshot wound to the right side of her chest. the dressing on the chest and a sucking noise coming from the wound. the client has a blood pressure of 100/60 mm Hg and a weak pulse rate of 118/min and a respiratory rate of 40/min. which of the following actions should the nurse take
Administer oxygen via nasal cannula
A nurse approaches a client who has just arrived at the ED with possible multiple facial fractures. what is the nurse's initial assessment priority for this client?
Altered respirations possible airway obstruction
a nurse on an oncology unit is preparing to administer doxorubicin to a client who has breast cancer. prior to beginning the infusion, the nurse verifies the client's current cumulative lifetime dose of the medication. for which of the following reasons is the verification necessary?
An excess amount of doxorubicin can lead to cardiomyopathy Doxorubicin is an antineoplastic antibiotic used in the treatment of various cancers. Irreversible cardiomyopathy with congestive heart failure can result from repeated doses of doxorubicin, and prolonged use can also cause severe heart damage, even years after the client has stopped taking it. The maximum cumulative dose a client should receive is 550 mg/m2 or 450 mg/m2with a history of radiation to the mediastinum.
a nurse in the emergency department is caring for a client who is bleeding profusely from a deep laceration on his forearm. after observing precautions, which of the following should the nurse plan to do first?
Apply pressure directly over the wound risk for hemorrhage
A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE?
Exercise SLE is a chronic autoimmune disease that develops when the immune system becomes hyperactive and attacks healthy body tissue. This attack results in generalized inflammation and the manifestations associated with the specific involved tissues.Most clients who have SLE can follow an exercise program to increase the aerobic capacity of cells and improve immune function, and the client should develop such a program with her provider's assistance.
a nurse is caring for a client who has received a blood transfusion and has an anaphylaxis reaction. the nurse understands this is a humoral immune response against invading antigens. which of the following would further the nurse's understanding?
Humoral immune response is mediated by antibodies produced by B lymphocytes
A nurse in the emergency department is admitting a client with extensive burn injury who has no know medical problems. Which of the following is an expected laboratory finding in this client?
Hyperkalemia direct result of tissue injury due to burns which releases large amounts of cellular potassium into circulation
A nurse on a pediatric unit is caring for a client who has a brain tumor. To help ensure the client's safety which of the following actions should the nurse take?
Initiate seizure precautions for the child A client who has a brain tumor is at risk for seizures. It is imperative for the nurse to implement seizure precautions for this client.
a group of college students was attending a weekend football rally when one of the students stumbled and fell into the bonfire. Although several friends quickly intervened, the client sustained partial-thickness burns to both lower legs, chest, and both forearms. Which of the following is the priority nursing action when the client is brought into the emergency room?
Inspect mouth for signs of inhalation injuries
a nurse is caring for a client who is receiving cisplatin for treatment of small cell lung cancer. the clients most recent complete blood count is shown below. which of the following should be considered? WBC 1,400/mm3 RBC 4.3 x 10^12 Hgb 12.1g/dL Hct 36.5% Platelets 170,000/mm^3 Albumin 4.5g/dL
The client has an increased risk of infection the low WBC count (expected range is 5,000-10,000/mm3) places the client at risk for infection. The nurse should assess the client's skin and mucous membranes, lung sounds, and venous access sites every 8 hours for signs of infection
A 12 year old boy seen in the clinic, and a diagnosis of Hodgkin's disease is suspected. Which diagnostic test results confirms the diagnosis of Hodgkin's disease?
The presence of Reed-Sternberg cells in lymph nodes *Hodgkin's disease is a neoplasm of lymphatic tissue.* The presence of gaint multinucleated cells *(Reed-Sternbergs cells) is the hallmark of this disease* the presence of blast cells in bone marrow indicates leukemia. The epstein-barr virus is associated with infectious mononucleosis. elevated levels of vanillylmandelic acid in the urine may be found in children with neuroblastoma.
A patient has received a bone marrow transplant. Soon after the transplant, there is a rash on the patient's skin is itchy and she has severe abdominal pain. What best summarizes what is happening to this patient and how she will be treated?
Transplanted bone marrow is rejecting her tissue; prevent with immunosuppressive agents.
a nurse is reviewing the CBC finding for a female client who is receiving combination chemotherapy for breast cancer. which of the following findings should the nurse report to the provider?
WBC finding of 2300/mm3
A child who has leukemia is being admitted. Several rooms are available on the pediatric floor. Which of the following clients should the nurse place in the same room with this child?
a child who has nephrotic syndrome not an infectious disorder, and therefore, no posed risk to a child with leukemia.
a nurse is caring for a client admitted to the ED with extensive partial and full-thickness burns of the head, neck, and chest. while planning the client's care, the nurse should be aware that initially the client is at greatest risk for
airway obstruction burns of the head, neck, and chest may involve damage to the pulmonary tree due to heat and soot inhalation. this can result in severe respiratory difficulty.
A nurse is caring for an adult client who has atopic dermatitis. which of the following findings should the nurse expect?
chronic rash with thick skin lichenification (thick, "leather" skin)
a patient was given an IM injection of penicillin in the gluteus maximus and developed dyspnea and weakness within minutes following the injection. which additional assessment findings indicate that the patient is having anaphylactoid reaction?
d. wheezing e. feeling of impending doom
a nurse is caring for a client in the emergency department who, 2 hr earlier, severed the tip of a finger during a farming accident. during the assessment, the nurse detects a strong smell of alcohol from the client. which of the following should the nurse assess first?
date of last tetanus immunization
a nurse is caring for a client who has systemic lupus erythematosus and is about to start taking hydroxychloroquine (Plaquenil) to reduce skin inflammation. The nurse should instruct the client to report which of the following as an indication of a toxic reaction to this medication?
decreased visual acuity
a nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. the nurse suspects the client is developing cardiac tamponade. The nurse suspects the client is developing cardiac tamponade. Which of the following findings supports this suspicion?
distant heart sounds with low voltage QRS complexes on the EKG
a nurse is caring for a 17-year-old who is experiencing a relapse of leukemia and is refusing treatment
notify the charge nurse of the situation
the nurse is assessing a patient who comes to the clinic with an itching, red rash on his hands. after gathering a history, the nurse determines that the patient has developed contact dermatitis from wearing latex gloves while painting. which of the description about this patient's condition is accurate?
this demonstrates a type IV allergic reaction to chemicals used in the manufacture of latex gloves
A nurse is caring for a client admitted to the hospital for continued treatment of cancer. The client previously experienced peripheral neuropathy secondary to chemotherapy. The nurse should expect the client to report which of the following symptoms?
tingling feeling in the extremities
a nurse is caring for a client who has delayed hypersensitivity reaction. the nurse should expect which of the following manifestations?
tissue damage at the site
a nurse is providing discharge teaching to a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include?
wash the hair with a mild protein shampoo *Clients who have SLE are prone to hair loss" they should use a mild protein shampoo and avoid treatments that can damage the hair
a client who has chronic lymphocytic leukemia is starting chemotherapy treatments and asks if she needs to make any dietary changes. Which of the following statements by the nurse is appropriate?
"you should avoid drinking liquids an hour before treatments"
a nurse is providing teaching to a client about carbon monoxide poisoning. which of the following statements by the client indicates a need for further teaching?
"i can detect the presence of carbon monoxide by a metallic odor."
a nurse is teaching a newly licensed nurse about reporting suspected child abuse. which of the following statements indicates an understanding by the newly licensed nurse?
"if suspicion of abuse exists then reporting is mandatory." healthcare workers are legally required to report any suspicions of child abuse even if evidence does not exist.
a nurse is admitting a client who has multiple trauma following a motor vehicle crash. shortly after admission, the client's husband arrives. he is distraught and blames himself for the accident. which of the following is appropriate response?
"tell me more about your feelings about what happened to your wife."
a nurse is teaching a client who has a new diagnosis of atopic dermatitis. which of the following statements should the nurse include in the teaching?
"your provider may recommend a daily antihistamine to help control your symptoms"
a nurse is teaching a client about seven warning signs of cancer. which of the following signs should the nurse include as manifestations of cancer?
a non-healing sore change in bowel pattern changes in moles nagging cough
a nurse is assisting with disaster triage following a bomb explosion in a bus station. which of the following clients should the nurse identify as being the highest priority?
a conscious adult with second degree burns on both lower legs; respiratory rate is >30/min, capillary refill is <2 seconds
a charge nurse is expecting four new admissions from the ED and must assign each to a room. which of the following clients should the nurse admit to the room closest to the nurse's station?
a client who has a concussion and is having periods of confusion
a nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local faculty. Which of the following clients should the nurse tag to be the *highest priority of care?*
a client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the puncture wound site *according to urgent vs non-urgent priority framework, the nurse should suspect air leaking from the lung and tag the client for priority and immediate care, a client with pneumothorax can be stabilized and have a high probability of survival.
a nurse is triaging clients in the emergency department ED. which client should the nurse see first?
a client who is 28 weeks gestation and reports slight amount of painless bleeding
The nurse is triaging clients as they present to the emergency room. which of the following clients should the provider see first?
a school-age child who has acute epiglottis; is drooling, and an absence of spontaneous cough requires immediate medical attention
a nurse in emergency department is preparing care for a client who received multiple injuries during a gang riot. the nurse should plan to base his primary survey on which of the following? a. airway b..cervical spine c. disability d. exposure e. urinary output f. pain management
a. airway b. cervical spine c. disability d. exposure
a nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. which of the following is the priority focus of care?
airway protection
a nurse is the triage officer in the emergency department when four clients arrive at the same time by ambulance following a factory explosion. which of the following clients should the nurse care for first?
an unconscious adult with a sucking chest wound; respirations are 38/min, capillary refill is <2 seconds
a nurse in the emergency department is implementing a plan of care for conscious client who has a suspected cervical cord injury. which of the following immediate interventions should the nurse implement?
assess adequacy of respirations obtain a set of vital signs stabilize the head and neck assess for visceral damage
a nurse is caring for a pediatric client who is about to receive chemotherapy to treat leukemia. the nurse reviewing the lab results notes that her platelet count is low. which of the following precautions should be added to clients care plan?
bleeding precautions specific measures for decreasing bleeding risk -soft-bristle toothbrushes -avoiding Im injections -prevent constipation
a nurse is admitting an adolescent following a blunt trauma to the adolescents abdomen. which of the following findings should concern the nurse?
blood pressure 92/50 mmHg a decrease in blood pressure may be in response to internal hemorrhage from the abdominal trauma. trauma to an internal organ such as the liver or spleen may cause internal bleeding resulting in hypotension
Following a suicide bombing at a shopping mall, an unidentified, unconscious client is admitted to the emergency department with an acute intra-abdominal hemorrhage. The nurse should recognize that consent for the surgery
can be inferred since the client is in critical condition
a 3-year-old is scheduled to remove a Wilm's tumor from one kidney. the parents ask the nurse about what treatments, if any, will be necessary after recovery from surgery. The nurse's explanation should be based on knowledge that
chemotherapy with or without radiotherapy is indicated
A nurse is caring for a client has a new diagnosis of systemic lupus erythematosus (SLE) and asks where the disease originated within the body. the nurse should tell the client that SLE originates in which of the following locations in the body?
connective tissues SLE originates in the connective tissues of the body and affects all organ systems
A nurse in the emergency department is preparing to care for a client who has an altered level of consciousness and signs of alcohol intoxication. which of the following should the nurse plan to include in the client's care?
contact the laboratory to obtain a blood sample prepare the client for a CT scan check the client's pupil reactivity obtain a urine specimen
a nurse is providing teaching to a client who has cancer about foods that prevent protein-energy malnutrition. which of the following foods should the nurse include in the teaching?
cottage cheese milkshakes tuna fish egg and ham omelet strawberries and bananas - incorrect
a nurse is caring for a client who has learned that she has lung cancer. the nurse should expect that the provider might prescribe which of the following medications for this client?
cyclophosphamide (cytoxan) treats leukemia, multiple myelonoma, lymphomas, and head, ovary, breast , and lung cancer
a nurse is caring for a client who has myasthenia gravis. the nurse should recognize that this disease is caused by which of the following types of hypersensitivities?
cytotoxic hypersensitivity
a nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. which of the following manifestations should the nurse identify as possible organ rejection?
oliguria The nurse should identify little to no urine output as possible manifestations of kidney rejection.
a nurse in an emergency department is caring for a client who collapsed after playing football on a hot, sunny day. after reviewing the admission laboratory values below, the nurse should recognize that these results are consistent with which of the following? serum electrolyte panel sodium 152 mEg/L potassium 3.0 mEq/L chloride 15 mEq/L CO2 24 mEq/L glucose 102 mg/dl BUN 25mg/dL creatinine 0.5mg/dL
dehydration hypernatremic (hypertonic) dehydration occurs when lost fluid contains less sodium than the blood volume. the client's history collapsing after activity on a hot, sunny, day (elevated BUN and sodium) are consistent with dehydration
a nurse is caring for a client in an urgent care center who has traumatic injuries following an assault. she sits quietly and calmly in the examination room. the nurse should recognize this behavior as which of the following reactions?
denial
A child is admitted with a possible diagnosis of Wilms' tumor (nephroblastoma). The nurse should obtain a sign with which of the following warnings to be placed over the child's bed?
do not palpate abdomen
a nurse is assessing a client who is newly transferred from the ED. While in the emergency dept, the client had a chest tube inserted in the right pleural space and attached to a chamber drainage system for a spontaneous pnemothorax. which of the followings observations should concern the nurse?
drainage of 250mL of bright red blood in the past 2 hours
a nurse in the emergency department is assessing a client who has multiple injuries of the abdomen. which of the followings require further investigation by the nurse
ecchymosis an abnormal finding of the abdomen and may indicate internal injury
a nurse is caring for a client who has been diagnosed with cancer of the colon. the client asks the nurse several questions about what the provider might be planning to do. which of the following nursing responsibilities is appropriate?
encourage the client to write down questions to ask the provider
The nurse in a trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?
evaluate chest expansion
in the emergency department is caring for a client who was injured in motor-vehicle crash. the client reports dyspnea and severe pain
flail chest results from multiple rib fractures that cause instability during inspiration, the thorax moves inward, and during expiration is bulges out this paradoxic chest movement prevents adequate ventilation of the injured lung
a nurse is planning care for a client who has metastatic breast cancer and is being treated with chemotherapy and radiation. admission laboratory results indicate that the client has neutopenia. What's the restriction indicated in the client's plan of care?
fresh fruits and vegetables in the diet
A nurse is teaching a client with an estrogen-receptor (ER) positive breast cancer tumor who has a new prescription for tamoxifen citrate (Nolvadex). Which of the following should be included in the teaching for this medication?
hot flashes are a common adverse effect
A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?
hypovolemia
a nurse is performing a neurological assessment for a client who is receiving treatment for head trauma. which of the following will give the nurse information about the function of the third cranial nerve?
instruct the client to look up and down without moving his head the nurse should observe extraocular eye movements as part of evaluation of oculomotor nerve.
a client arrives at the ED following an explosion at a chemical plant. he has deep partial- and full thickness chemical burns over more than 25% of his body surface area. What is the nurse's priority intervention?
maintain a patent airway
a nurse is assessing a client who has a pneumothorax with a chest tube in place. for which of the following findings should the nurse notify the provider?
movement of the trachea toward the unaffected side A chest tube inserted for a spontaneous pneumothorax may result in the development of a tension pneumothorax, a medical emergency. This results from air in the pleural space compressing the blood vessels of the thorax and limiting blood return to the heart. An assessment of tracheal deviation, or movement of the trachea toward the unaffected side, is indicative of tension pneumothorax and should be reported to the provider immediately.
a nurse is discussing emergency response with a newly licensed nurse. the nurse should identify which of the following as a triage officer during the time of disaster?
nurses and other emergency medical personnel (physicians, EMTs, and paramedics are responsible for performing triage duties)
a nurse is assessing an older client who has received radiation therapy to treat lung cancer. based on the understanding of the side effects of radiation therapy, the nurse should focus the assessment on
observing for signs of infection
a nurse is caring for a postmenopausal client who has advanced breast cancer and has a new prescription for an aromatase inhibitor, lectrozole (femara). the nurse advises the client to report which of the following to the provider?
pain in the calf
A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings is the highest priority for the nurse to report to the provider?
presence of peripheral edema
A child is undergoing induction therapy to treat leukopenia. Allopurinol is included in the regimen. the main reason for administering allopurinol as part of the client's chemotherapy regimen is to:
prevent metabolic breakdown of xanthine to uric acid
a nurse is monitoring a client who received epinephrine for angioedema after a first dose of losartan. which of the following data indicates a therapeutic response to the epinephrine?
respirations are unlabored Losartan is an angiotensin receptor blocker (ARB). Both ARBs and angiotensin converting enzyme (ACE) inhibitors have the adverse effect of angioedema. The primary symptom of angioedema is swelling of the tongue, glottis, and pharynx. This results in limitation or blockage of the airway.
a client is admitted to the emergency room with a respiratory rate of seven per min. arterial blood gases are following values pH 7.22 paCO2 68 mmHg bicarbonate 28mEq/L base excess -2 paO2 78 mmHg saturation 80%
respiratory acidosis the pH is decreased while PCO2 is elevated
a nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function?
serum creatinine
a nurse monitors a client who has a traumatic head injured. which of the following manifestations should the nurse report immediately to the provider?
sudden sleepiness the nurse should report immediately to the provider the client's sudden sleepiness which is a sign of increased intracranial pressure
