MSII Exam4

ANS: C The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis

42. Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? a. Hematocrit 55% b. Presence of plethora c. Calf swelling and pain d. Platelet count 450,000/m

ANS: A The Centers for Disease Control and Prevention recommends testing for Chlamydia for all sexually active women younger than age 25 years. HPV infection does not cause infertility. There is no vaccine available for herpes simplex, and herpes simplex infection does not cause cervical cancer

A 20-yr-old female patient who is being seen in the family medicine clinic for an annual physical examination reports being sexually active. What topic should the nurse plan to teach the patient? a. Testing for Chlamydia infection b. Immunization for herpes simplex c. Infertility associated with the human papillomavirus (HPV) d. The relationship between the herpes virus and cervical cancer

ANS: C Some antihypertensives may cause ED, and the nurse should anticipate a change in antihypertensive therapy. The other medications will not affect erectile function

A 49-year-old man who has type 2 diabetes, high blood pressure, hyperlipidemia, and gastroesophageal reflux tells the nurse that he has had recent difficulty in achieving an erection. Which of the following drugs from his current medications list may cause erectile dysfunction (ED)? a. Ranitidine (Zantac) b. Atorvastatin (Lipitor) c. Propranolol (Inderal) d. Metformin (Glucophage

ANS: B The initial response by the nurse should be further assessment of the problem. The other statements by the nurse are accurate but may not respond to the patient's concerns.

A 68-year-old male patient tells the nurse that he is worried because he does not respond to sexual stimulation the same way he did when he was younger. Which is the nurse's best response to the patient's concern? a. "You may need additional stimulation with aging." b. "Tell me more about how your reaction has changed." c. "Interest in sex frequently decreases as men get older." d. "Erectile dysfunction is common problem in older men."

ANS: A The patient is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats. Limiting social contacts is not appropriate at a time when the patient is likely to need a good social support system. The damage occurs at the hair follicles and will occur regardless of gentle washing or use of a mild shampoo. The information that the hair will grow back is not immediately helpful in maintaining the patient's self-esteem.

A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to support the patient's self-esteem? a. Encourage the patient to purchase a wig or hat to wear when hair loss begins. b. Suggest that the patient limit social contacts until regrowth of the hair occurs. c. Teach the patient to wash hair gently with mild shampoo to minimize hair loss. d. Inform the patient that hair usually grows back once chemotherapy is complete.

ANS: B For the Huhner test, the couple should have intercourse at the estimated time of ovulation and then arrive for the test 2 to 8 hours after intercourse. The other instructions would be used for other types of fertility testing.

A couple is scheduled to have a Huhner test for infertility. What will the nurse instruct the couple about in preparation for the test? a. Being sedated during the procedure b. Determining the estimated time of ovulation c. Experiencing shoulder pain after the procedure d. Refraining from intercourse before the appointme

ANS: B Fresh, thinned-skin fruits are not permitted in a neutropenic diet because of the risk of bacteria being present. The patient should ambulate in the room rather than the hospital hallway to avoid exposure to other patients or visitors. Because overuse of soap can dry the skin and increase infection risk, showering every other day is acceptable. Careful cleaning after having a bowel movement will help prevent skin breakdown and infection

A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching? a. The patient ambulates several times a day in the room. b. The patients visitors bring in some fresh peaches from home. c. The patient cleans with a warm washcloth after having a stool. d. The patient uses soap and shampoo to shower every other da

ANS: C Information about sexual contacts is needed to help establish whether the patient has been exposed to a sexually transmitted infection and because sexual contacts also will need treatment. The other information is not pertinent in determining the plan of care for the patient's current symptoms.

A male patient who has a profuse, purulent urethral discharge with painful urination is seen at the clinic. Which information should the nurse obtain as a basis for planning focused care? a. Sexual orientation b. Immunization history c. Recent sexual contacts d. Contraceptive preference

ANS: C Many women with gonorrhea are asymptomatic or have minor symptoms that are overlooked. The disease may affect both the genitals and the other reproductive organs and cause complications such as pelvic inflammatory disease. Women who can transmit the disease have active infections, not subclinical cases or carrier status

A male patient who has been diagnosed with gonococcal urethritis tells the nurse he had recent sexual contact with a woman but says she did not appear to have any disease. What information should the nurse explain to the patient? a. Women develop subclinical cases of gonorrhea that are not true gonorrheal infections. b. Women do not develop gonorrhea infections but can serve as carriers to spread the disease to men. c. Women may not be aware they have gonorrhea because they often do not have symptoms of infection. d. When gonorrhea infections occur in women, the disease affects only the ovaries and not the genital organs.

ANS: D Because the total white blood cell (WBC) count is not usually affected by aging, the low WBC count in this patient would indicate that the patient's immune function may be compromised, and the underlying cause of the problem needs to be investigated. The platelet count is normal. The slight decrease in hemoglobin and hematocrit are not unusual for an older patient.

A nurse reviews the laboratory data for an older adult. The nurse would be most concerned about which finding? a. Hematocrit of 35% b. Hemoglobin of 11.8 g/dL c. Platelet count of 400,000/µL d. White blood cell count of 2800/µ

ANS: B Exudate from any lesions with syphilis is highly contagious. Systemic antibiotics, rather than local treatment of lesions, are used to treat syphilis. The patient does not require a private room because the disease is spread through contact with the lesions. This patient has clinical manifestations of secondary syphilis and does not need to be monitored for manifestations of tertiary syphilis.

A patient admitted with chest pain is found to have positive rapid plasma reagin (RPR) and fluorescent treponemal antibody absorption (FTA-Abs) tests, rashes on the palms and the soles of the feet, and moist papules in the anal and vulvar area. Which action will the nurse include in the plan of care? a. Assess for arterial aneurysms. b. Wear gloves for patient contact. c. Place the patient in a private room. d. Apply antibiotic ointment to the perineum

ANS: A, C, E Eating only cooked food and avoiding public transportation will decrease infection risk. A high-fiber diet is recommended for neutropenic patients to decrease constipation. Because bacteria may enter the circulation during dental work or oral surgery, the patient may need to postpone dental work or take antibiotics

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) a. Cook food thoroughly before eating. b. Choose low fiber, low residue foods. c. Avoid public transportation such as buses. d. Use rectal suppositories if needed for constipation. e. Talk to the oncologist before having any dental work don

ANS: D Because the etiology of the patients poor nutrition is the painful oral ulcers, the best intervention is to apply anesthetic gel to the lesions before the patient eats. The other actions might be helpful for other patients with impaired nutrition, but would not be as helpful for this patient

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? a. Offer the patient frequent small snacks between meals. b. Assist the patient to choose favorite foods from the menu. c. Provide teaching about the importance of nutritional intake. d. Apply the ordered anesthetic gel to oral lesions before meals

ANS: D Because false positives are common with VDRL and RPR testing, FTA-Abs testing is recommended to confirm a diagnosis of syphilis. Gram staining is used for other sexually transmitted infections (STIs) such as gonorrhea and Chlamydia and cytologic studies are used to detect abnormal cells (e.g., neoplastic cells).

A patient in the sexually transmitted infection clinic has a positive Rapid Plasma Reagin (RPR) test, but no chancre is visible on assessment. For what test should the nurse expect to send specimens? a. Cytologic studies b. Culture and Gram stain c. Herpes Simplex Antibody Test d. Fluorescent treponemal antibody absorption (FTA-Abs)

ANS: D Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after a person has a splenectomy

A patient is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching? a. Check often for swollen lymph nodes. b. Watch for excess bleeding or bruising. c. Take iron supplements to prevent anemia. d. Wash hands and avoid persons who are ill.

ANS: D The patient should rinse the mouth with a saline solution frequently. A soft toothbrush is used for oral care. Hydrogen peroxide may damage tissues. Antiseptic mouthwashes may irritate the oral mucosa and are not recommended

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? a. Remove food debris from the teeth and oral mucosa with a stiff toothbrush. b. Use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth. c. Gargle and rinse the mouth several times a day with an antiseptic mouthwash. d. Rinse the mouth before and after each meal and at bedtime with a saline solution

ANS: B The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count <500/µL), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient's home environment.

A patient receiving outpatient chemotherapy for myelogenous leukemia develops an absolute neutrophil count of 850/µL. Which collaborative action should the outpatient clinic nurse anticipate?? a. Discuss the need for hospital admission to treat the neutropenia. b. Teach the patient to administer filgrastim (Neupogen) injections. c. Plan to discontinue the chemotherapy until the neutropenia resolves. d. Order a high-efficiency particulate air (HEPA) filter for the patient's home.

ANS: C Aloe vera gel and cream may be used on the radiated skin area. Ice and sunlamps may injure the skin. Treatment areas should be cleaned gently to avoid further injury.

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? a. "I can use ice packs to relieve itching." b. "I will scrub the area with warm water." c. "I can buy aloe vera gel to use on my skin." d. "I will expose my skin to a sun lamp each day."

ANS: C Hemorrhage causes the release of reticulocytes (immature red blood cells) from the bone marrow into circulation. The hematocrit and hemoglobin levels are normal. Bleeding does not affect the white blood cell count.

A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect? a. Hematocrit of 46% b. Hemoglobin of 13.8 g/dL c. Elevated reticulocyte count d. Decreased white blood cell count

ANS: B TRALI pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI.

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? a. Infuse PRBCs slowly over 4 hours. b. Transfuse leukocyte-reduced PRBCs. c. Administer the prescribed diuretic before the transfusion. d. Give the PRN dose of antihistamine before the transfusion.

ANS: B This response uses therapeutic communication by addressing the patient's question and giving accurate information. The other responses either give inaccurate information or fail to address the patient's question, which will discourage the patient from asking the nurse for information

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? a. "If you do not want to have chemotherapy, other treatment options include stem cell transplantation." b. "The side effects of chemotherapy are difficult, but AML often goes into remission with chemotherapy." c. "The decision about treatment is one that you and the doctor need to make rather than asking what I would do." d. "You don't need to make a decision about treatment right now because leukemias in adults tend to progress slowly.

ANS: B Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision

A patient who has acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). What is the best approach for the nurse to assist the patient with this treatment decision? a. Discuss the need for insurance to cover post-HSCT care. b. Inquire whether there are questions or concerns about HSCT. c. Emphasize the positive outcomes of a bone marrow transplant. d. Explain that a cure is not possible with any treatment except HSCT

ANS: A When antibody testing is positive for syphilis, the antibodies remain present for an indefinite period even after successful treatment, so the nurse should inquire about previous treatment before doing other assessments or testing. Culture, FTA-Abs testing, and assessment for symptoms may be appropriate based on whether the patient has been previously treated for syphilis.

A patient who has had blood drawn for an insurance screening has a positive Rapid Plasma Reagin (RPR) test. Which action should the nurse take first? a. Ask the patient about past treatment for syphilis. b. Explain the need for blood and spinal fluid cultures. c. Schedule fluorescent treponemal antibody absorption (FTA-Abs) testing. d. Assess for the presence of chancres, flulike symptoms, or a rash on the trunk

Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The nurse should stop the infusion and further assess for anaphylaxis. The other findings may occur with chemotherapy but are not immediately life threatening

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? a. Anorexia b. Vomiting c. Oral ulcers d. Lip swelling

ANS: D The data indicate that this diagnosis is most appropriate because poor communication among the family members is affecting family processes. No data suggest a change in lifestyle or its role as an etiology. The data do not support impairment in home maintenance or a burden caused by caregiving responsibilities

A patient who has ovarian cancer is crying and tells the nurse, My husband rarely visits. He just doesnt care. The husband indicates to the nurse that he never knows what to say to help his wife. Which nursing diagnosis is most appropriate for the nurse to add to the plan of care? a. Compromised family coping related to disruption in lifestyle b. Impaired home maintenance related to perceived role changes c. Risk for caregiver role strain related to burdens of caregiving responsibilities d. Dysfunctional family processes related to effect of illness on family member

ANS: C For chronic cancer pain, analgesics should be taken on a scheduled basis, with additional doses as needed for breakthrough pain. Taking the medications only when pain reaches a certain level does not provide effective pain control. Although nonopioid analgesics also may be used, there is no maximum dose of opioid. Opioids are given until pain control is achieved. The IV route is not more effective than the oral route, and usually the oral route is preferred

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? a. The patient uses the ordered opioid pain medication whenever the pain is greater than 5 (0 to 10 scale). b. The patient agrees to take the medications by the IV route in order to improve analgesic effectiveness. c. The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs. d. The patient states that nonopioid analgesics may be used when the maximal dose of the opioid is reached without adequate pain relief

ANS: B Spinal cord compression, an oncologic emergency, can occur with invasion of tumor into the epidural space. The nurse will need to assess the patient further for symptoms such as decreased leg sensation and strength and then notify the health care provider. Administration of opioids or use of relaxation may be appropriate but only after the nurse has assessed for possible spinal cord compression

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? a. Give the patient the prescribed PRN opioid. b. Assess for sensation and strength in the legs. c. Notify the health care provider about the symptoms. d. Teach the patient how to use relaxation to reduce pain

ANS: A Cancer in situ indicates that the cancer is localized to the cervix and is not invasive at this time. Cell differentiation is not indicated by clinical staging. Because the cancer is in situ, the origin is the cervix. Further testing is not indicated given that the cancer has not spread

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? a. "The cancer involves only the cervix." b. "The cancer cells look like normal cells." c. "Further testing is needed to determine the spread of the cancer." d. "It is difficult to determine the original site of the cervical cancer."

ANS: B Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. Which nutrient supplement should the nurse plan to explain to the patient? a. Iron b. Folic acid c. Cobalamin (vitamin B12) d. Ascorbic acid (vitamin C)

ANS: C The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors do not metastasize. The other statements are inaccurate. Both types of tumors may cause damage to adjacent tissues. Malignant cells do not reproduce more rapidly than normal cells. Benign tumors do not usually recur

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? a. "Benign tumors do not cause damage to other tissues." b. "Benign tumors are likely to recur in the same location." c. "Malignant tumors may spread to other tissues or organs." d. "Malignant cells reproduce more rapidly than normal cells

ANS: B Walking programs are used to keep the patient active without excessive fatigue. Having a hospital bed does not necessarily address the fatigue. The better option is to stay as active as possible while combating fatigue. Fatigue is expected during treatment and is not an indication of depression. Minimizing activity may lead to weakness and other complications of immobility.

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? a. Minimize activity until the treatment is completed. b. Establish time to take a short walk almost every day. c. Consult with a psychiatrist for treatment of depression. d. Arrange for delivery of a hospital bed to the patient's home.

ANS: C A debulking surgery reduces the size of the tumor and makes radiation and chemo therapy more effective. Debulking surgeries do not control tumor growth. The tumor is debulked because it is attached to the liver, a vital organ (not to relieve pressure on the stomach).Debulking does not sever the sensory nerves, although pain may be lessened by the reduction in pressure on the abdominal organs.

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? a. Pain will be relieved by cutting sensory nerves in the stomach. b. Relief of pressure in the stomach will promote better nutrition. c. Decreasing the tumor size will improve the effects of other therapy. d. Tumor growth will be controlled by the removal of malignant tissue.

ANS: C The patient will eat more if disliked foods are avoided and foods that the patient likes are included instead. Additional spice is not usually an effective way to enhance taste. Adding baby meats to foods will increase calorie and protein levels, but does not address the issue of taste. The patients poor intake is not caused by a lack of information about nutrition

A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action is most appropriate? a. Add strained baby meats to foods such as casseroles. b. Teach the patient about foods that are high in nutrition. c. Avoid giving the patient foods that are strongly disliked. d. Add extra spice to enhance the flavor of foods that are served.

ANS: C Because there is a high incidence of co-infection with gonorrhea and Chlamydia, patients are usually treated for both. The other explanations about the purpose of the antibiotic combination are not accurate

A patient with gonorrhea is treated with a single IM dose of ceftriaxone and is given a prescription for azithromycin (Zithromax) 1000 mg ´ 1 dose. What rationale should the nurse provide to the patient for this combination? a. Prevent reinfection during treatment. b. Treat any coexisting syphilis infection. c. Provides coverage for possible chlamydia infection. d. Provides coverage for possible trichomonas infection

ANS: D The patient requires strict protective isolation to prevent infection for 2 to 4 weeks after HSCT while waiting for the transplanted marrow to start producing cells. The transplanted cells are infused through an IV line, so the transplant is not painful, nor is an operating room or incision require

A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). The nurse will include which information in the patients teaching plan a. Transplant of the donated cells is painful because of the nerves in the tissue lining the bone. b. Donor bone marrow cells are transplanted through an incision into the sternum or hip bone. c. The transplant procedure takes place in a sterile operating room to minimize the risk for infection. d. Hospitalization will be required for several weeks after the stem cell transplant procedure is performed

ANS: C Treatment with antiemetics before chemotherapy may help prevent nausea. The patient should eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea. The acidity of citrus fruits may be further irritating to the stomach.

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? a. Have the patient eat large meals when nausea is not present. b. Offer dry crackers and carbonated fluids during chemotherapy. c. Administer prescribed antiemetics 1 hour before the treatments. d. Give the patient a glass of a citrus fruit beverage during treatments.

ANS: A A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. The other procedures do not require a signed consent.

A patient with pancytopenia of unknown origin is scheduled for diagnostic tests. The nurse will ensure a consent form was signed before which test? a. Bone marrow biopsy b. Abdominal ultrasound c. Complete blood count (CBC) d. Activated partial thromboplastin time (aPTT

ANS: C To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60 minutes. After a bone marrow biopsy, the wound is small and will not be packed with gauze. A pressure dressing is used to cover the aspiration site. There is no indication to elevate the patient's head

A patient with pancytopenia will have a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure? a. Elevate the head of the bed to 45 degrees. b. Use a -in sterile gauze to pack the wound. c. Have the patient lie on the left side for 1 hour. d. Apply a sterile 2-in gauze dressing to the site

ANS: B The hemoglobin and hematocrit results indicate polycythemia, which can be associated with chronic obstructive pulmonary disease. The other questions would be appropriate for patients who are anemic

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? a. "Have you had a recent weight loss?" b. "Do you have any history of lung disease?" c. "Have you noticed any dark or bloody stools?" d. "What is your dietary intake of meat and protein?"

ANS: B Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary later if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy.

A routine complete blood count for an active older man indicates possible myelodysplastic syndrome. What should the nurse plan to explain to the patient? a. Blood transfusion b. Bone marrow biopsy c. Filgrastim administration d. Erythropoietin administration

ANS: A This response expresses the nurses willingness to listen and recognizes the patients concern. The responses beginning Many patients with cancer live for a long time and For now you need to concentrate on getting well close off discussion of the topic and indicate that the nurse is uncomfortable with the topic. In addition, the patient with metastatic ovarian cancer may not have a long time to plan. Although it is possible that the patients friends will take the children, more assessment information is needed before making plans

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? a. Why don't we talk about the options you have for the care of your children? b. I'm sure you have friends that will take the children when you cant care for them. c. For now you need to concentrate on getting well and not worrying about your children. d. Many patients with cancer live for a long time, so there is still time to plan for your children

ANS: B The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease.

A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery. Which laboratory value should the nurse monitor? a. Platelet count b. Bleeding time c. Thrombin time d. Prothrombin time

ANS: C Temperature elevation is an emergency in neutropenic patients because of the risk for rapid progression to severe infections and sepsis. The other patients also require assessments or interventions, but do not need to be assessed as urgently. Patients with thrombocytopenia do not have spontaneous bleeding until the platelets are 20,000/L. Xerostomia does not require immediate intervention. Although breakthrough pain needs to be addressed rapidly, the patient does not appear to have breakthrough pain

After change-of-shift report on the oncology unit, which patient should the nurse assess first? a. Patient who has a platelet count of 82,000/L after chemotherapy b. Patient who has xerostomia after receiving head and neck radiation c. Patient who is neutropenic and has a temperature of 100.5 F (38.1 C) d. Patient who is worried about getting the prescribed long-acting opioid on time

ANS: D The patient's symptoms indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal.

An adult male with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. Which laboratory data would the nurse identify as consistent with these symptoms? a. RBC count of 4,500,000/mL b. Hematocrit (Hct) value of 38% c. Normal red blood cell (RBC) indices d. Hemoglobin (Hgb) of 8.6 g/dL (86 g/L)

ANS: D Rapid fluid infusions may cause heart failure, especially in older patients. The other findings are common in patients who have cancer and/or are receiving chemotherapy

An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hour in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the HCP? a. Patient complains of severe fatigue. b. Patient needs to void every hour during the day. c. Patient takes only 50% of meals and refuses snacks. d. Patient has audible crackles to the midline posterior ches

ANS: C Radiation to the abdomen will affect organs in the radiation path, such as the bowel, and cause frequent diarrhea. Careful cleaning of this area will help decrease the risk for skin breakdown and infection. Stools are likely to have occult blood from the inflammation associated with radiation, so routine testing of stools for blood is not indicated. Radiation to the abdomen will not cause stomatitis. A low-residue diet is recommended to avoid irritation of the bowel when patients receive abdominal radiation.

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? a. Test all stools for the presence of blood. b. Maintain a high-residue, high-fiber diet. c. Clean the perianal area carefully after every bowel movement. d. Inspect the mouth and throat daily for the appearance of thrush.

ANS: A The patient may be at increased risk for colon cancer, but the nurse's first action should be further assessment. The other actions may be appropriate, depending on the information that is obtained from the patient with further questioning

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? a. Obtain more information about the family history. b. Schedule a sigmoidoscopy to provide baseline data. c. Teach the patient about the need for a colonoscopy at age 50. d. Teach the patient how to do home testing for fecal occult blood.

ANS: C The patient who has a new cancer diagnosis is likely to have high anxiety, which may impact learning and require that the nurse repeat and reinforce information. The patients history of a recent diagnosis suggests that infiltration of the leukemia is not a likely cause of the confusion. The patient asks for the information to be repeated, indicating that lack of interest in learning and denial are not etiologic factors

During the teaching session for a patient who has a new diagnosis of acute leukemia the patient is restless and is looking away, never making eye contact. After teaching about the complications associated with chemotherapy, the patient asks the nurse to repeat all of the information. Based on this assessment, which nursing diagnosis is most appropriate for the patient? a. Risk for ineffective adherence to treatment related to denial of need for chemotherapy b. Acute confusion related to infiltration of leukemia cells into the central nervous system c. Risk for ineffective health maintenance related to anxiety about new leukemia diagnosis d. Deficient knowledge: chemotherapy related to a lack of interest in learning about treatment

ANS: D The chemotherapy used in treating Hodgkin's lymphoma results in a high incidence of secondary malignancies; follow-up screening is needed. Chemotherapy will not impact the fertility of a 55-yr-old woman. Maintenance chemotherapy is not used for Hodgkin's lymphoma. Pruritus is a clinical manifestation of lymphoma but should not be a concern after treatment

Following successful treatment of Hodgkin's lymphoma for a 55-yr-old woman, which topic will the nurse include in patient teaching? a. Potential impact of chemo therapy treatment on fertility b. Application of soothing lotions to treat residual pruritus c. Use of maintenance chemotherapy to maintain remission d. Need for follow-up appointments to screen for malignanc

ANS: A IL-2 enhances the ability of the patients own immune response to suppress tumor cells. IL-2 does not protect normal cells from damage caused by chemotherapy, stimulate malignant cells to enter mitosis, or prevent bone marrow depression.

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? a. IL-2 enhances the immunologic response to tumor cells. b. IL-2 stimulates malignant cells in the resting phase to enter mitosis. c. IL-2 prevents the bone marrow depression caused by chemotherapy. d. IL-2 protects normal cells from the harmful effects of chemotherapy

ANS: B The patient's age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently

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. A 44-yr-old with sickle cell anemia who says his eyes always look yellow b. A 23-yr-old with no previous health problems who has a nontender axillary lump c. A 50-yr-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue d. A 19-yr-old with hemophilia who wants to learn to self-administer factor VII replacement

ANS: A Thrombocytopenia is a decreased number of platelets, which places the patient at high risk for bleeding. Neutropenic patients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. Encouraging fluid intake and iron-rich food intake is not indicated in a patient with thrombocytopenia

The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care? a. Avoid intramuscular injections. b. Encourage increased oral fluids. c. Check temperature every 4 hours. d. Increase intake of iron-rich foods.

ANS: D During a liver and spleen scan, a radioactive isotope is injected IV, and images from the radioactive emission are used to evaluate the structure of the spleen and liver. An indwelling IV catheter and sedation are not needed. The patient is placed in a flat position before the scan

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 to prepare the patient for this procedure? a. Check for any iodine allergy. b. Insert a large-bore IV catheter. c. Administer prescribed sedatives. d. Assist the patient to a flat position

ANS: C The term "shift to the left" indicates that the number of immature polymorphonuclear neutrophils (bands) is elevated and that finding is a sign of infection. There is no indication that the patient is at risk for hypoxemia, pallor or weakness, or cool extremities.

The health care provider's progress note for a patient states that the complete blood count (CBC) shows a "shift to the left." Which assessment finding should the nurse expect? a. Cool extremities b. Pallor and weakness c. Elevated temperature d. Low oxygen saturation

ANS: B Fatigue can be a dose-limiting toxicity for use of biologic therapies. Flulike symptoms, such as muscle aches and chills, are common side effects with interferon use. Patients are advised to use acetaminophen every 4 hours

The home health nurse cares for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment? a. I have frequent muscle aches and pains. b. I rarely have the energy to get out of bed. c. I experience chills after I inject the interferon. d. I take acetaminophen (Tylenol) every 4 hour

ANS: B Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication generally should be given slowly to avoid irritation of the vein. The size of the catheter is not as important as administration of vesicants into a running IV line to allow dilution of the chemotherapy drug. These medications can be given through peripheral lines, although central vascular access devices are preferred.

The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? a. Infuse the medication over a short period of time. b. Stop the infusion if swelling is observed at the site. c. Administer the chemotherapy through a small-bore catheter. d. Hold the medication unless a central venous line is available

ANS: C Salicylates interfere with platelet function and can lead to petechiae and ecchymoses. Antiseizure drugs may cause anemia but not clotting disorders or bleeding. Oral contraceptives increase a person's clotting risk. Antihypertensives do not usually cause problems with decreased clotting

The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient? a. "Are you taking any oral contraceptives?" b. "Have you been prescribed antiseizure drugs?" c. "Do you take medication containing salicylates?" d. "How long have you taken antihypertensive drugs?"

ANS: D Capillary leak syndrome and acute pulmonary edema are possible toxic effects of interleukin-2. The patient may need oxygen and the nurse should rapidly notify the health care provider. The other findings are common side effects of interleukin-2.

The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider? a. Generalized muscle aches b. Complaints of nausea and anorexia c. Oral temperature of 100.6 F (38.1 C) d. Crackles heard at the lower scapular border

ANS: A Rituximab (Rituxan) is a monoclonal antibody. Shortness of breath should be investigated rapidly because anaphylaxis is a possible reaction to monoclonal antibody administration. The nurse will need to rapidly take actions such as stopping the infusion, assessing the patient further, and notifying the health care provider. The other findings will also require action by the nurse, but are not indicative of life-threatening complication

The nurse assesses a patient with non-Hodgkins lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse? a. Shortness of breath b. Temperature 100.2 F (37.9 C) c. Shivering and complaint of chills d. Generalized muscle aches and pain

ANS: C Extremity numbness is associated with cobalamin (vitamin B12) deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia.

The nurse assesses a patient with pernicious anemia. Which finding would the nurse expect? a. Yellow-tinged sclerae b. Shiny, smooth tongue c. Tender, bleeding gums d. Numbness of extremities

ANS: A, C, D, E The patients age, gender, and history indicate a need for screening and/or teaching about colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use excessive alcohol or tobacco, she is physically active, and her body weight is health

The nurse at the clinic is interviewing a 64-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (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 2 or 3 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)? a. Pap testing b. Tobacco use c. Sunscreen use d. Mammography e. Colorectal screening

ANS: A Enlarged and nontender nodes are suggestive of malignancies such as lymphoma. Firm nodes are an expected finding in a known area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5 to 1 cm and nontender.

The nurse examines the lymph nodes of a patient during a physical assessment. Which finding would be of most concern to the nurse? a. A 2-cm nontender supraclavicular node A 1-cm mobile and nontender axillary node c. An inability to palpate any superficial lymph nodes d. Firm inguinal nodes in a patient with an infected foot

ANS: C The adverse effects of intravesical chemotherapy are confined to the bladder. The other adverse effects are associated with systemic chemotherapy

The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect? a. Nausea b. Alopecia c. Hematuria d. Xerostomia

ANS: C Information about how the patient has coped with past stressful situations helps the nurse determine usual coping mechanisms and their effectiveness. The length of time since the diagnosis will not provide much information about the patients need for support. The patients knowledge of typical stages in adjustment to a critical diagnosis does not provide insight into patient needs for assistance. Because surgical interventions for stage I cancer of the colon may not cause any body image changes, this question is not appropriate at this time

The nurse is caring for a patient who has been diagnosed with stage I cancer of the colon. When assessing the need for psychologic support, which question by the nurse will provide the most information? a. How long ago were you diagnosed with this cancer? b. Do you have any concerns about body image changes? c. Can you tell me what has been helpful to you in the past when coping with stressful events? d. Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon

ANS: D Teaching about the risks associated with cigarette smoking is recommended at every patient encounter because cigarette smoking is associated with multiple health problems. The other options may detect lung cancer that is already present but do not reduce the risk

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? a. Teach the patient about the seven warning signs of cancer. b. Plan to monitor the patient's carcinoembryonic antigen (CEA) level. c. Teach the patient about annual chest x-rays for lung cancer screening. d. Discuss risks associated with cigarette smoking during each patient encounter.

ANS: B The patient is instructed to avoid swimming in salt water or chlorinated pools during the treatment period. The patient does not need to change habits of eating frequently or showering with a mild soap. A history of dental caries will not impact the patient who is scheduled for abdominal radiation

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? a. The patient has a history of dental caries. b. The patient swims several days each week. c. The patient snacks frequently during the day. d. The patient showers each day with mild soap.

ANS: C Syndrome of inappropriate antidiuretic hormone (and the resulting hyponatremia) is an oncologic metabolic emergency and will require rapid treatment in order to prevent complications such as seizures and coma. The other findings also require intervention, but are common in patients with lung cancer and not immediately life threatening

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? a. Hematocrit 32% b. Pain with deep inspiration c. Serum sodium 126 mEq/L d. Decreased breath sounds on left side

ANS: B The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started

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. Which action should the nurse take? a. Apply heat to the knee. b. Immobilize the knee joint. c. Assist the patient with light weight bearing. d. Perform passive range of motion to the knee.

ANS: B The aPTT level is increased (prolonged) in heparin administration. aPTT is used to monitor whether heparin is at a therapeutic level (needs to be greater than the normal range of 25 to 35sec). Prothrombin time (PT) and international normalized ratio (INR) are most commonly used to test for therapeutic levels of warfarin (Coumadin). Aspirin affects platelet function. Erythropoietin is used to stimulate red blood cell production

The nurse is reviewing laboratory results and notes a patient's activated partial thromboplastin time (aPTT) level is 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication? a. Aspirin b. Heparin c. Warfarin d. Erythropoietin

ANS: C Pallor of the skin or nail beds is indicative of anemia, which would be indicated by a low Hgb level. Platelet counts indicate a person's clotting ability. A neutrophil is a type of white blood cell that helps to fight infection.

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? a. Platelet count b. Neutrophil count c. Hemoglobin level d. White blood cell count

ANS: D An increase in CEA indicates that the chemotherapy is not effective for the patients cancer and may need to be modified. The other patient findings are common adverse effects of chemotherapy. The nurse may need to address these, but they would not necessarily indicate a need for a change in therapy

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 therapy with the HCP? a. Poor oral intake b. Frequent loose stools c. Complaints of nausea and vomiting d. Increase in carcinoembryonic antigen (CEA)

ANS: C Because neck bleeding may indicate possible carotid artery rupture in a patient who is receiving radiation the neck, this patient should be seen first. The diagnoses and clinical manifestations for the other patients are not immediately life threatening

The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first? a. 35-year-old patient who has wet desquamation associated with abdominal radiation b. 42-year-old patient who is sobbing after receiving a new diagnosis of ovarian cancer c. 24-year-old patient who received neck radiation and has blood oozing from the neck d. 56-year-old patient who developed a new pericardial friction rub after chest radiation

ANS: D The low WBC count places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that WBC growth factors such as filgrastim (Neupogen) are needed. Although the other laboratory data indicate decreased levels, they do not indicate any immediate life-threatening adverse effects of the chemotherapy.

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? a. Hematocrit of 30% b. Platelets of 95,000/L c. Hemoglobin of 10 g/L d. White blood cell (WBC) count of 2700/

ANS: D The elevation in white blood cells indicates that the patient has an inflammatory or infectious process ongoing, which may be the cause of the patient's pain, and that further diagnostic testing is needed. The monocytes are at a normal level. The hemoglobin and platelet counts are normal.

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? a. Monocytes 4% b. Hemoglobin 13.6 g/dL c. Platelet count 168,000/µL d. White blood cell count 15,500/µL

ANS: B Protein is needed for wound healing. To minimize the diarrhea that is commonly associated with bowel radiation, the patient should avoid foods high in roughage, such as fruits and whole grains. Lactose intolerance may develop secondary to radiation, so dairy products should also be avoided

The nurse should suggest which food choice when providing dietary teaching for a patient scheduled to receive external-beam radiation for abdominal cancer? a. Fruit salad c. Creamed broccoli b. Baked chicken d. Toasted wheat bread

ANS: B Because patients with temporary implants emit radioactivity while the implants are in place, exposure to the patient is limited. Laundry and urine/feces do not have any radioactivity and do not require special precautions. Cervical radiation will not affect the oral mucosa, and alcohol-based mouthwash is not contraindicated

The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention? a. The UAP flushes the toilet once after emptying the patients bedpan. b. The UAP stands by the patients bed for 30 minutes talking with the patient. c. The UAP places the patients bedding in the laundry container in the hallway. d. The UAP gives the patient an alcohol-containing mouthwash to use for oral care

ANS: C A biopsy is used to determine whether the prostate enlargement is benign or malignant and determines the type of treatment that will be needed. A biopsy does not give information about metastasis, life expectancy, or the impact of cancer on the patient's life.

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? a. "The biopsy will remove the cancer in my prostate gland." b. "The biopsy will determine how much longer I have to live." c. "The biopsy will help decide the treatment for my enlarged prostate." d. "The biopsy will indicate whether the cancer has spread to other organs."

ANS: B Yogurt has high biologic value because of the protein and fat content. Fruit salad does not have high amounts of protein or fat. Lime sherbet is lower in fat and protein than yogurt. Cream cheese is low in protein

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? a. Lime sherbet b. Blueberry yogurt c. Cream cheese bagel d. Fresh strawberries and bananas

ANS: C The risk of recurrence varies by the type of cancer. Some cancers are considered cured after a shorter time span or after surgery, but stage III breast cancer will require additional therapies and ongoing follow-up.

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? a. "After cancer has not recurred for 5 years, it is considered cured." b. "The cancer will be cured if the entire tumor is surgically removed." c. "I will need follow-up examinations for many years after treatment before I can be considered cured." d. "Cancer is never cured, but the tumor can be controlled with surgery, chemotherapy, and radiation

ANS: D Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis. Iron is contraindicated in patients with polycythemia vera

What action is expected by the nurse caring for a patient who has an acute exacerbation of polycythemia vera? a. Place the patient on bed rest. b. Administer iron supplements. c. Avoid use of aspirin products. d. Monitor fluid intake and output

ANS: D PSA testing may be recommended annually for men, starting at age 50 based on the person's risk history and discussion with their HCP. There is no indication that the other patient teaching topics are appropriate for this patient.

What should the nurse plan to teach a 57-year-old man who is scheduled for an annual physical examination? a. Increased risk for testicular cancer b. Possible changes in erectile function c. Normal decreases in testosterone level d. Prostate-specific antigen (PSA) testing

ANS: B Pelvic inflammatory disease may cause scarring of the fallopian tubes and result in difficulty in fertilization or implantation of the fertilized egg. Because ovarian function is not affected, the patient will not require HT, have irregular menstrual cycles, or experience changes in secondary sex characteristics.

What topic should the nurse plan to teach a 26-year-old patient who has been treated for pelvic inflammatory disease? a. Use of hormone therapy (HT) b. Potential complication of infertility c. Irregularities in the menstrual cycle d. Changes in secondary sex characteristics O

ANS: A Use of dental floss is avoided in patients with pancytopenia because of the risk for infection and bleeding. The other actions are appropriate for oral care of a pancytopenic patient

When caring for a patient who is pancytopenic, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene? a. The UAP assists the patient to use dental floss after eating. b. The UAP adds baking soda to the patients saline oral rinses. c. The UAP puts fluoride toothpaste on the patients toothbrush. d. The UAP has the patient rinse after meals with a saline solution

ANS: D Use of tools to enhance memory and concentration such as a daily planner and adequate rest are helpful for patients who develop chemo-brain while receiving chemotherapy. Patients should be encouraged to exercise the brain through new activities. Chemo-brain may be short- or long-term. There is no urgent need to report common chemotherapy side effects to the provide

Which action should the nurse take when caring for a patient who is receiving chemotherapy and complains of problems with concentration? a. Teach the patient to rest the brain by avoiding new activities. b. Teach that chemo-brain is a short-term effect of chemotherapy. c. Report patient symptoms immediately to the health care provider. d. Suggest use of a daily planner and encourage adequate rest and sleep

ANS: A The frequent transfusions used to treat thalassemia major lead to iron toxicity in patients unless iron chelation therapy is consistently used. Iron supplementation is avoided in patients with thalassemia. There is no need to avoid intramuscular injections. The goal for patients with thalassemia major is to maintain a hemoglobin of 10 g/dL or greater.

Which action will the nurse include in planning of care for a patient who has thalassemia major? a. Administer chelation therapy as needed. b. Teach the patient to use iron supplements. c. Avoid the use of intramuscular injections. d. Notify health care provider of hemoglobin 11 g/dL

ANS: A A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient's calcium level and are not used

Which action will the nurse include in the plan of care for a patient admitted with multiple myeloma? a. Monitor fluid intake and output. b. Administer calcium supplements. c. Assess lymph nodes for enlargement. d. Limit weight bearing and ambulation.

ANS: C Clear penile discharge may be indicative of a sexually transmitted infection (STI). The other findings are normal and do not need to be reported.

Which finding from the nurse's physical assessment of a 42-year-old male patient should be reported to the health care provider? a. One testis hangs lower than the other. b. Genital hair distribution is diamond shaped. c. Clear discharge is present at the penile meatus. d. Inguinal lymph nodes are nonpalpable bilaterally

ANS: D Because iron chelating agents are used to lower serum iron levels, the most useful information will be the patient's iron level. The other parameters will also be monitored but are not the most important to monitor when determining the effectiveness of deferoxamine.

Which information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis? a. Skin color b. Hematocrit c. Liver function d. Serum iron level

ANS: B Many medications used for hypertension can cause erectile dysfunction. More information is needed regarding the specific medications. The other assessment data will not impact erectile function (recent knee surgery) or are normal for a 70-year-old man (physical examination data).

Which information obtained by the nurse and shown in the accompanying figure about a 72-year-old man who is complaining of erectile dysfunction is most important to communicate to the health care provider? a. Recent knee surgery b. Use of antihypertensives c. Low position of left testis d. Pulse and blood pressure level

ANS: B Hypercalcemia may lead to complications such as dysrhythmias or seizures and should be addressed quickly. The other patient findings will also be discussed with the health care provider but are not life threatening

Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider? a. Patient reports severe back pain. b. Serum calcium level is 15 mg/dL. c. Patient reports no stool for 5 days. d. Urine sample has Bence-Jones protein

ANS: B Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended

Which instruction will the nurse plan to include in discharge teaching for a patient admitted with a sickle cell crisis? a. Limit fluids to 2 to 3 quarts per day. b. Avoid exposure to crowds when possible. c. Take a daily multivitamin supplement with iron. d. Drink no more than two caffeinated beverages daily.

ANS: D Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts are also important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim

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? a. Platelet count b. Reticulocyte count c. Total lymphocyte count d. Absolute neutrophil count

ANS: A Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.

Which menu choice indicates that the patient understands the nurse's recommendations about dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast b. Cantaloupe and cottage cheese c. Strawberry and banana fruit plate d. Cornmeal muffin and orange juice

ANS: A Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated

Which nursing intervention is a priority for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/µL during chemotherapy? a. Test all stools for occult blood. b. Encourage fluids to 3000 mL/day. c. Provide oral hygiene every 2 hours. d. Check the temperature every 4 hours.

ANS: B Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized

Which nursing intervention is important when providing care for a patient with sickle cell crisis? a. Limiting the patient's intake of oral and IV fluids b. Evaluating the effectiveness of opioid analgesics c. Encouraging the patient to ambulate as much as tolerated d. Teaching the patient about high-protein, high-calorie foods

ANS: B A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient.

Which patient requires the most rapid assessment and care by the emergency department nurse? a. The patient with hemochromatosis who reports abdominal pain. b. The patient with neutropenia who has a temperature of 101.8° F. c. The patient with thrombocytopenia who has oozing gums after a tooth extraction. d. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours.

ANS: C It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the health care provider about this. The other patient statements are correct

Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? a. "I could take a stool softener if I feel constipated." b. "I can take the iron with orange juice before eating." c. "I should notify my health care provider if my stools turn black." d. "I will increase my fluid and fiber intake while I am taking iron."

ANS: C Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin

Which patient statement to the nurse indicates that the patient understands self-care for pernicious anemia? a. "I need to start eating more red meat and liver." b. "I will stop having a glass of wine with dinner." c. "I could choose nasal spray rather than injections of vitamin B12." d. "I will need to take a proton pump inhibitor such as omeprazole (Prilosec).

ANS: B Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury but are not indicators of possible serious blood loss.

Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the health care provider? a. Leg bruises b. Tarry stools c. Skin abrasions d. Bleeding gums

ANS: D Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises.

Which statement by a patient indicates good understanding of the nurse's teaching about preventing sickle cell crisis? a. "Home oxygen therapy is frequently used to decrease sickling." b. "There are no effective medications that can help prevent sickling." c. "Routine continuous dosage opioids are prescribed to prevent a crisis." d. "Risk for a crisis is decreased by having an annual influenza vaccination."