NCLEX ?'s test 2

A client with colorectal cancer was started on 5-fluorouracil (5-FU) and is experiencing fatigue, diarrhea, and mouth ulcers. A relatively new chemotherapeutic agent, oxaliplatin (Eloxatin), has been added to the treatment regimen. What does the nurse tell the client about the diarrhea and mouth ulcers? "A combination of chemotherapeutic agents has caused them." "GI problems are symptoms of the advanced stage of your disease." "5-FU cannot discriminate between your cancer and your healthy cells." "You have these as a result of the radiation treatment."

"5-FU cannot discriminate between your cancer and your healthy cells."

A male client with a long history of ulcerative colitis experienced massive bleeding and had emergency surgery for creation of an ileostomy. He is very concerned that sexual intercourse with his wife will be impossible because of his new ileostomy pouch. How does the nurse respond? "A change in position may be what is needed for you to have intercourse with your wife." "Have you considered going to see a marriage counselor with your wife?" "What has your wife said about your pouch system?" "You must get clearance from your health care provider before you attempt to have intercourse."

"A change in position may be what is needed for you to have intercourse with your wife."

A nurse is teaching a client with Crohn's disease about managing the disease with the drug adalimumab (Humira). Which instruction does the nurse emphasize to the client? "Avoid large crowds and anyone who is sick." "Do not take the medication if you are allergic to foods with fatty acids." "Expect difficulty with wound healing while you are taking this drug." "Monitor your blood pressure and report any significant decrease in it.

"Avoid large crowds and anyone who is sick."

A client diagnosed with ulcerative colitis is to be discharged on loperamide (Imodium) for symptomatic management of diarrhea. What does the nurse include in the teaching about this medication? "Be aware of the symptoms of toxic megacolon that we discussed." "If diarrhea increases, you should let your health care provider know." "Pregnancy should be avoided." "You will need to decrease your dose of sulfasalazine (Azulfidine)."

"Be aware of the symptoms of toxic megacolon that we discussed."

A certified Wound, Ostomy, and Continence Nurse is teaching a client about caring for a new ileostomy. What information is most important to include? "After surgery, output from your ileostomy may be a loose, dark-green liquid with some blood present." "Call the health care provider if your stoma has a bluish or pale look." "Notify the health care provider if output from your stoma has a sweetish odor." "Remember that you must wear a pouch system at all times."

"Call the health care provider if your stoma has a bluish or pale look."

A nurse is teaching a client about dietary methods to help manage exacerbations ("flare-ups") of diverticulitis. What does the nurse advise the client? "Be sure to maintain an exclusively low-fiber diet to prevent pain on defecation." "Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet." "Maintain a high-fiber diet to prevent the development of hemorrhoids that frequently accompany this condition." "Make sure you consume a high-fiber diet while diverticulitis is active. When inflammation resolves, consume a low-fiber diet."

"Consume a low-fiber diet while your diverticulitis is active. When inflammation resolves, consume a high-fiber diet."

Ben, a 31-year-old nursing student, is caring for Maria, a 45-year-old Latina woman who is receiving chemotherapy following surgery for breast cancer. Based on the evidence about cultural influences on cancer patients, Ben knows that which factor will likely influence this patient's ability to cope with her cancer? 1Transportation resources to the oncology clinic 2Whether the patient's physician is male or female 3The stigma family members place on cancer 4The level of social support available to the patient

4)The level of social support available to the patient

A cleansing enema is ordered for a 55-year-old patient before intestinal surgery. The nurse understands that the maximum amount of fluid given is: 150 to 200 mL. 200 to 400 mL. 400 to 750 mL. 750 to 1000 mL.

750 to 1000 mL.

Elimination changes that result from inability of the bladder to empty properly may cause which of the following? (Select all that apply.) Incontinence Frequency Urgency Urinary retention Urinary tract infection

ALL OF THE ABOVE...

The nurse teaches a client that intraperitoneal chemotherapy will be delivered to which part of the body? Veins of the legs Lung Heart Abdominal cavity

Abdominal cavity

Before collecting a stool sample for occult blood, the nurse instructs the nursing assistive personnel to: Ask the patient to void. Wash the patient's perineum. Secure a sterile, specimen container. Plan to collect the first specimen of the day.

Ask the patient to void.

What does the nurse advise a client diagnosed with irritable bowel syndrome (IBS) to take during periods of constipation? Bulk-forming laxatives Saline laxatives Stimulant laxatives Stool-softening agents

Bulk-forming laxatives

A patient states that she has been experiencing a high level of stress lately. Which hormone level is most likely increased due to stress? Cortisol Calcitonin Oxytocin Prolactin

Cortisol

The nurse is discharging a hospitalized patient to the home care setting. Place the following actions in order of priority. (Separate letters by a comma and space as follows: A, B, C, D.) a. Arrange a physical therapy visit before the patient is discharged from the hospital. b. Assess the patient's ability to perform activities of daily living before discharge. c. Have the patient demonstrate the learned skills at the end of the teaching session. d. Determine if the patient has had home visits before and if the experience was positive.

DBCA

The nurse is caring for a client receiving chemotherapy who reports anorexia. Which measure does the nurse use to best monitor for cachexia?

Monitor weight

A patient is admitted for lower gastrointestinal (GI) bleeding. What color of stool does the nurse anticipate the patient to have? Red Black Green Orange

Red

A patient exhibiting exophthalmos most likely suffers from dysfunction of which gland? Pancreas Cerebellum Thyroid Gonads

Thyroid

When the nurse is counseling a 60-year-old African-American male client with all of these risk factors for lung cancer, teaching should focus most on which risk factor? Tobacco use Ethnicity Gender Increased age

Tobacco use

A client has a glioblastoma. The nurse begins to plan care for this client with which type of cancer?

brain cancer

A client who developed viral gastroenteritis with vomiting and diarrhea is scheduled to be seen in the clinic the following day. What will the nurse teach the client to do in the meantime? "Avoid all solid foods to allow complete bowel rest." "Consume extra fluids to replace fluid losses." "Take an over-the-counter antidiarrheal medication." "Contact your provider for an antibiotic medication."

"Consume extra fluids to replace fluid losses."

A 52-year-old client relates to the nurse that she has never had a mammogram because she is terrified that she will have cancer. Which response by the nurse is therapeutic? "Don't worry, most lumps are discovered by women during breast self-examination." "Does anyone in your family have breast cancer?" "Finding a cancer in the early stages increases the chance for cure." "Have you noticed a lump or thickening in your breast?"

"Finding a cancer in the early stages increases the chance for cure."

The nurse is caring for a client who is to be discharged after a bowel resection and the creation of a colostomy. Which client statement demonstrates that additional instruction from the nurse is needed? "I can drive my car in about 2 weeks." "I should avoid drinking carbonated sodas." "It may take 6 weeks to see the effects of some foods on my bowel patterns." "Stool softeners will help me avoid straining.

"I can drive my car in about 2 weeks."

The patient states that she "loses urine" every time she laughs or coughs. The nurse teaches the patient measures to regain urinary control. The nurse recognizes the need for further teaching when the patient states: "I will perform my Kegel exercises every day." "I joined weight watchers." "I drink two glasses of wine with dinner." "I have tried urinating every 3 hours."

"I drink two glasses of wine with dinner."

The home health nurse is teaching a client about the care of a new colostomy. Which client statement demonstrates a correct understanding of the instructions? "A dark or purplish-looking stoma is normal and should not concern me." "If the skin around the stoma is red or scratched, it will heal soon." "I need to check for leakage underneath my colostomy." Correct "I should strive for a very tight fit when applying the barrier around the stoma."

"I need to check for leakage underneath my colostomy." Correct

A client with irritable bowel syndrome (IBS) is constipated. The nurse instructs the client about a management plan. Which client statement shows an accurate understanding of the nurse's teaching? "A drink of diet soda with dinner is OK for me." "I need to go for a walk every evening." "Maintaining a low-fiber diet will manage my constipation." "Watching the amount of fluid that I drink with meals is very important."

"I need to go for a walk every evening."

The nurse is giving a group presentation on cancer prevention and recognition. Which statement by an older adult client indicates understanding of the nurse's instructions? "Cigarette smoking always causes lung cancer." "Taking multivitamins will prevent me from developing cancer." "If I have only one shot of whiskey a day, I probably will not develop cancer." "I need to report the pain going down my legs to my health care provider."

"I need to report the pain going down my legs to my health care provider."

Which statement made by a client allows the nurse to recognize whether the client receiving brachytherapy for ovarian cancer understands the treatment plan? "I may lose my hair during this treatment." "I must be positioned in the same way during each treatment." "I will have a radioactive device in my body for a short time." "I will be placed in a semiprivate room for company."

"I will have a radioactive device in my body for a short time." Brachytherapy refers to short-term insertion of a radiation source. Side effects of radiation therapy are site-specific; this client is unlikely to experience hair loss from treating ovarian cancer with radiation. The client undergoing teletherapy (external beam radiation), not brachytherapy, must be positioned precisely in the same position each time. The client who is receiving brachytherapy must be in a private room.

The Certified Wound, Ostomy, and Continence Nurse is teaching a client with colorectal cancer how to care for a newly created colostomy. Which client statement reflects a correct understanding of the necessary self-management skills? "I will have my spouse change the bag for me." "If I have any leakage, I'll put a towel over it." "I need to call my home health nurse to come out if I have any problems." "I will make certain that I always have an extra bag available."

"I will make certain that I always have an extra bag available."

A 24-year-old male is scheduled for a minimally invasive inguinal hernia repair (MIIHR). Which client statement indicates a need for further teaching about this procedure? "I may have trouble urinating immediately after the surgery." "I will need to stay in the hospital overnight." "I should not eat after midnight the day of the surgery." "My chances of having complications after this procedure are slim."

"I will need to stay in the hospital overnight."

A client suspected of having irritable bowel syndrome (IBS) is scheduled for a hydrogen breath test. What does the nurse tell the client about this test? "During the test, you will drink small amounts of an antacid as directed by the technician." "If you have IBS, hydrogen levels may be increased in your breath samples." "The test will take between 30 and 45 minutes to complete." "You must have nothing to drink (except water) for 24 hours before the test."

"If you have IBS, hydrogen levels may be increased in your breath samples."

A postoperative client is requesting medication for pain every 4 hours. In planning effective pain management, what assessment question does the nurse ask the client before administering the medication? "Are you bleeding?" "Are you really hurting every 4 hours?" "Is your pain controlled between doses?" "What do you do for pain when you're at home?"

"Is your pain controlled between doses?"

A client with an exacerbation of ulcerative colitis has been prescribed Vivonex PLUS. The client asks the nurse how this is helpful for improving symptoms. How does the nurse reply? "It is absorbed quickly and allows the affected part of the GI tract to rest and heal." "It provides key nutrients and extra calories to promote healing." "It is bland and reduces the secretion of gastric acids." "It does not contain caffeine or other GI tract stimulants."

"It is absorbed quickly and allows the affected part of the GI tract to rest and heal."

Katie, a child in remission for leukemia, and her mother come to the pediatrician's office for a routine physical examination. The nurse asks Katie about whether she is having continued symptoms. Her mom says," I don't know why you want all of this information about Katie's cancer treatment. The leukemia is gone." The best response from the nurse in support of the child and mother would be: 1"The doctor likes to keep the records complete on all of her patients." 2"Just because Katie is in remission does not mean that it will stay that way." 3"It is common for children to have delayed effects from treatment, so we need to know this to plan Katie's care properly." 4"I understand your concern. If you don't want to provide the information, sign this release form."

"It is common for children to have delayed effects from treatment, so we need to know this to plan Katie's care properly."

A client with ulcerative colitis (UC) has stage 1 of a restorative proctocolectomy with ileo-anal anastomosis (RPC-IPAA) procedure performed. The client asks the nurse, "How long do people with this procedure usually have a temporary ileostomy?" How does the nurse respond? "It is usually ready to be closed in about 1 to 2 months." "This is something that you will have to discuss with your health care provider." "The period of time is indefinite—I am sorry that I cannot say." "You will probably have it for 6 months or longer, until things heal.

"It is usually ready to be closed in about 1 to 2 months."

A client has been newly diagnosed with ulcerative colitis (UC). What does the nurse teach the client about diet and lifestyle choices? "Drinking carbonated beverages will help with your abdominal distress." Incorrect "It's OK to smoke cigarettes, but you should limit them to ½ pack per day." "Lactose-containing foods should be reduced or eliminated from your diet." "Raw vegetables and high-fiber foods may help to diminish your symptoms."

"Lactose-containing foods should be reduced or eliminated from your diet."

The family of a client with chronic cancer pain says to the nurse, "Can you please reduce Dad's pain medication so that we can spend more quality time with him?" How does the nurse respond? "I will ask his oncologist about your question." "Let's ask your father about your request." "No, his pain relief is more important than your concerns." "Yes, this is a valuable way for all of you to make needed adjustments."

"Let's ask your father about your request."

Mr. Stewart is a 62-year-old patient diagnosed with prostate cancer who underwent surgical removal of the prostate 3 days ago. He lives with his wife at home. The nurse is planning to provide discharge instructions for the patient. What would be the most effective initial question to ask of the patient and family in determining the approach to discharge instructions? 1"Mr. Stewart, have you had surgery in the past?" 2"The doctor has ordered you to go home with a urinary catheter. Tell me how you think you can manage this." 3"Mrs. Stewart, do you find it difficult to look at your husband's incision? If so, tell me how you feel." 4"Mr. Stewart, describe for me how much your wife normally helps you at home and what you can do on your own."

"Mr. Stewart, describe for me how much your wife normally helps you at home and what you can do on your own."

A client who is scheduled to undergo radiation for prostate cancer is admitted to the hospital by the nurse. Which statement by the client is most important to communicate to the health care provider? "I am allergic to iodine." "My urinary stream is very weak." "My legs are numb and weak." "I am incontinent when I cough."

"My legs are numb and weak." Numbness and weakness should be reported to the physician because paralysis caused by spinal cord compression can occur. Prostate cancer may frequently metastasize to the bone, specifically the spine. Allergy to iodine should be reported when contrast media will be used, but dye is not used in radiation therapy.

The nurse is teaching a 47-year-old woman about recommended screening practices for breast cancer. Which statement by the client indicates understanding of the nurse's instructions? "My mother and grandmother had breast cancer, so I am at risk." "I get a mammogram every 2 years since I turned 30." "A clinical breast examination is performed every month since I turned 40." "A computed tomography (CT) scan will be done every year after I turn 50."

"My mother and grandmother had breast cancer, so I am at risk."

A client who is using patient-controlled analgesia (PCA) is asleep. The nurse observes a family member pushing the PCA button for the sleeping client. What does the nurse say to the visitor?

"Please allow the client to push the button when needed."

The nurse is reviewing skin care of an immobilized patient with an unlicensed assistive employee. The nurse knows the employee understands the importance of skin care when making which statement? "Proper care of the skin is important because the immobilized patient does not want to smell bad." "Proper care of the skin is important because the immobilized patient is at high risk for breakdown." "Proper care of the skin is important because the immobilized patient will have many visitors." "Proper care of the skin is important because the immobilized patient will be incontinent."

"Proper care of the skin is important because the immobilized patient is at high risk for breakdown."

Which information must the organ transplant nurse emphasize before a client is discharged? "Taking immunosuppressant medications increases your risk for cancer and the need for screenings." "You are at increased risk for cancer when you reach 60 years of age." "Immunosuppressant medications will decrease your risk for developing cancers." "After 6 months, you may stop immunosuppressant medications, and your risk for cancer will be the same as that of the general population."

"Taking immunosuppressant medications increases your risk for cancer and the need for screenings."

A client with colorectal cancer is scheduled for colostomy surgery. Which comment from the nurse is most therapeutic for this client? "Are you afraid of what your spouse will think of the colostomy?" "Don't worry. You will get used to the colostomy eventually." "Tell me what worries you the most about this procedure." "Why are you so afraid of having this procedure done?"

"Tell me what worries you the most about this procedure."

A client being discharged after hip replacement says, "I am going to use hypnosis instead of medication to manage my pain. I believe in mind over body." How does the nurse respond? "I will cancel your medication order." "That sounds like a great plan; can you tell me more about it?" "That sounds like a wonderful idea; and I think it will definitely work!" "Your plan will not work; people with your type of pain need narcotics.

"That sounds like a great plan; can you tell me more about it?"

The nurse reviews the chart of a client admitted with a diagnosis of glioblastoma with a T1NXM0 classification. Which explanation does the nurse offer when the client asks what the terminology means? "Two lymph nodes are involved in this tumor of the glial cells, and another tumor is present." "The brain tumor measures about 1 to 2 cm and shows no regional lymph nodes and no distant metastasis." "This type of tumor in the brain is small with some lymph node involvement; another tumor is present somewhere else in your body." "Glioma means this tumor is benign, so I will have to ask your health care provider the reason for the chemotherapy and radiation."

"The brain tumor measures about 1 to 2 cm and shows no regional lymph nodes and no distant metastasis." T1 means that the tumor is increasing in size to about 2 cm, and that no regional lymph nodes are present in the brain. M0 means that no distant metastasis has occurred. NX means that no regional lymph nodes can be assessed. A glioma is a benign tumor of the brain, but the client is diagnosed with a glioblastoma, which means a malignant tumor of the glial cells of the brain.

A male client's sister was recently diagnosed with colorectal cancer (CRC), and his brother died of CRC 5 years ago. He asks the nurse whether he will inherit the disease too. How does the nurse respond? "Have you asked your health care provider what he or she thinks your chances are?" "It is hard to know what can predispose a person to develop a certain disease." "No. Just because they both had CRC doesn't mean that you will have it, too." "The only way to know whether you are predisposed to CRC is by genetic testing

"The only way to know whether you are predisposed to CRC is by genetic testing

When assessing a client for pain, acute or chronic, what question does the nurse ask the client to obtain the most data? "Did someone do this to you?" "Does it hurt badly?" "Is the pain really that bad?" "When does it hurt?"

"When does it hurt?"

The nurse is assessing learning needs for a patient who has coronary heart disease. The nurse finds that the patient has recently made dietary changes to decrease fat intake and has stopped smoking. The best initial response by the nurse at this time is "You did an excellent job of changing your eating habits and quitting smoking. This is so important for your heart health. Nice work!'' "Although the changes you made are important, it is essential that you make other changes, too." "Which additional changes in your lifestyle would you like to implement at this time?" "Are you having any difficulty in maintaining the changes you have already made?"

"You did an excellent job of changing your eating habits and quitting smoking. This is so important for your heart health. Nice work!''

A client is admitted with severe viral gastroenteritis caused by norovirus. The client asks the nurse, "How did I get this disease?" Which answer by the nurse is correct? "You may have contracted it from an infected infant." Incorrect "You may have consumed contaminated food or water." "You may have come into contact with an infected animal." "You may have had contact with the blood of an infected person."

"You may have consumed contaminated food or water."

client with osteoarthritis pain tells the nurse, "I take two arthritis-strength Tylenol (650 mg) every 8 hours." How does the nurse respond? "Aspirin would be a better, more effective choice for your pain relief." "More Tylenol is needed to provide effective pain relief for you." "That is the appropriate dose of Tylenol for your pain." "You will need to have routine liver and kidney function laboratory tests.

"You will need to have routine liver and kidney function laboratory tests.

A client newly diagnosed with ulcerative colitis (UC) is started on sulfasalazine (Azulfidine). What does the nurse tell the client about why this therapy has been prescribed? "It is to stop the diarrhea and bloody stools." "This will minimize your GI discomfort." "With this medication, your cramping will be relieved." "Your intestinal inflammation will be reduced.

"Your intestinal inflammation will be reduced.

A patient is admitted to the long-term care setting. The nurse notes that the patient does not read or write well. Which nursing actions are priority while developing a teaching plan to increase adherence? (Select all that apply.) -Determine the patient's motivation and readiness to learn. - Assess what the patient knows about their health issues. -Include the family in the orientation to the unit and include them in the teaching process. - Assess what grade level the patient can read and write -and tailor teaching strategies accordingly. Give the patient brochures with more pictures and explanations with short sentences.

-Determine the patient's motivation and readiness to learn. - Assess what the patient knows about their health issues. -Include the family in the orientation to the unit and include them in the teaching process. - Assess what grade level the patient can read and write -and tailor teaching strategies accordingly.

List the correct order in which to apply an ostomy pouch: -Remove the used pouch and skin barrier. -Perform hand hygiene and apply clean gloves. -Assess the stoma for color, swelling, and healing. -Gently cleanse the peristomal skin with warm tap water. -Apply nonallergenic tape around the pectin skin barrier. -Cut an opening on the pouch 0.15-0.3 cm ( to inch)larger than the stoma. -Press the adhesive backing of the pouch smoothly against the skin.

-Perform hand hygiene and apply clean gloves. -Remove the used pouch and skin barrier. -Gently cleanse the peristomal skin with warm tap water. -Perform hand hygiene and apply clean gloves. -Cut an opening on the pouch 0.15-0.3 cm ( to inch)larger than the stoma. -Press the adhesive backing of the pouch smoothly against the skin. -Apply nonallergenic tape around the pectin skin barrier.

Caring for a patient with cancer is unique because of the effects of the disease and associated treatment. An understanding of a patient's symptom experience is critical and best revealed by a nurse asking which of the following questions? (Select all that apply.) 1"What symptoms do you think you are having as a result of your cancer?" 2"Describe for me how the symptoms affect you in your daily life." 3"Let's focus on your pain. Tell me how it affects you." 4"Can you describe for me how your family provides care for your symptoms?"

1"What symptoms do you think you are having as a result of your cancer?" 2"Describe for me how the symptoms affect you in your daily life." 3"Let's focus on your pain. Tell me how it affects you."

After a transurethral prostatectomy a patient returns to his room with a triple-lumen indwelling catheter and continuous bladder irrigation. The irrigation is normal saline at 150 mL/hr. The nurse empties the drainage bag for a total of 2520 mL after an 8-hour period. How much of the total is urine output? __________________________________

1320 ml

The nurse is planning to remove a Foley catheter at 1300. The nurse would check if the patient has voided by: 1400. 1600 1700. 2300.

1700.

Cancer survivors are at risk for treatment-related problems. Which of the patients listed below has the greatest risk for developing such a problem? 1. An 80-year-old woman undergoing surgery for removal of a basal cell carcinoma on the face 2. A 71-year-old man receiving high-dose chemotherapy and radiation for an advanced-stage lymphoma 3. A 26-year-old man receiving chemotherapy for testicular cancer that is localized to the testicle 4. A 48-year-old woman receiving radiation for Hodgkin's disease that involves lymph nodes extending above and below the diaphragm

2. A 71-year-old man receiving high-dose chemotherapy and radiation for an advanced-stage lymphoma

A nurse in an oncology outpatient clinic has been seeing a woman and her husband since the woman was diagnosed with breast cancer. Sometimes the husband appears supportive, asking questions about his wife's care. At other times the husband seems easily distracted and uninterested. The nurse decides to reassess the psychosocial condition of the patient and her husband. Which of the following questions best elicits needed psychosocial information? 1"In what way does the pain you have affect you on a daily basis?" 2"Describe to me what you eat in a typical day." 3"Tell me how you think you and your husband are dealing with your cancer." 4"Are the two of you having any relational difficulties because of your cancer?"

3"Tell me how you think you and your husband are dealing with your cancer."

A nurse reviews the medical record of a 40-year-old patient newly admitted to the medical nursing unit for evaluation of diabetes. As the nurse reviews the patient's medical history, she notices that the patient had bladder surgery 3 years ago. Which of the following assessment questions is most appropriate for the nurse to ask to determine if the patient is a cancer survivor? 1. Determining if the patient had additional surgeries recently 2.Assessing the patient's medication history 3.Determining if the surgery was cancer related 4.Assessing if the patient's parents had cancer

3. Determining if the surgery was cancer related

The nurse is planning a dressing change on a postoperative mastectomy client. The client is receiving acetaminophen and oxycodone (Percocet) orally for pain every 4 hours and is due to receive them at 4:00 p.m. When will the nurse change the dressing? 3:30 p.m. 4:00 p.m. 4:30 p.m. 7:00 p.m.

4:30 p.m.

A nurse working in a medicine clinic knows that it is important to recognize cancer survivors who are most at risk for posttreatment symptoms. Which of the following patients will likely be at greatest risk for posttreatment symptoms? 1) A 50-year-old mother of three who was diagnosed with late-stage breast cancer and has hypertension 2) A 20-year-old male college student diagnosed with leukemia whose father had lung cancer 3) A 32-year-old Hispanic woman who has been diagnosed with local cervical cancer and receives Medicaid 4) A 72-year-old African American male who had colorectal cancer with surgery, radiation, and a second round of chemotherapy because of failure of initial treatment and has diabetes

72 YR. OLD

The RN receives a change-of-shift report about four clients. Which client does the nurse assess first? A 20-year-old with ulcerative colitis (UC) who had six liquid stools during the previous shift A 25-year-old who has just been admitted with possible appendicitis and has a temperature of 102° F A 56-year-old who had a colon resection earlier in the day and whose colostomy bag does not have any stool in it A 60-year-old admitted with acute gastroenteritis who is reporting severe cramping and nausea

A 25-year-old who has just been admitted with possible appendicitis and has a temperature of 102° F

Which client does the charge nurse assign to an experienced LPN/LVN? A 28-year-old who requires teaching about how to catheterize a Kock ileostomy A 30-year-old who must receive neomycin sulfate (Mycifradin) before a colectomy A 34-year-old with ulcerative colitis (UC) who has a white blood cell count of 23,000/mm3 A 38-year-old with gastroenteritis who is receiving IV fluids at 250 mL/hr

A 30-year-old who must receive neomycin sulfate (Mycifradin) before a colectomy

The RN on the medical-surgical unit receives a shift report about four clients. Which client does the nurse assess first? A 34-year-old who has returned to the unit after a colon resection with a new colostomy stoma, which is dark pink A 36-year-old admitted after a motor vehicle crash with areas of ecchymoses on the abdomen in a "lap-belt" pattern A 40-year-old with pneumonia who has abdominal distention and decreased bowel sounds in all quadrants A 51-year-old with familial adenomatous polyposis (FAP) who is scheduled for a colonoscopy

A 36-year-old admitted after a motor vehicle crash with areas of ecchymoses on the abdomen in a "lap-belt" pattern Ecchymoses in the abdominal area may indicate intraperitoneal or intra-abdominal bleeding; this client requires rapid assessment and interventions.

An intensive care unit (ICU) RN is "floated" to the medical-surgical unit. Which client does the charge nurse assign to the float nurse? A 28-year-old with an exacerbation of Crohn's disease (CD) who has a draining enterocutaneous fistula A 32-year-old with ulcerative colitis (UC) who needs discharge teaching about the use of hydrocortisone enemas A 34-year-old who has questions about how to care for a newly created ileo-anal reservoir A 36-year-old with peritonitis who just returned from surgery with multiple drains in place

A 36-year-old with peritonitis who just returned from surgery with multiple drains in place

A newly graduated RN has just finished a 6-week orientation to the oncology unit. Which client is most appropriate to assign to the new graduate? A 30-year-old with acute lymphocytic leukemia who will receive combination chemotherapy today A 40-year-old with chemotherapy-induced nausea and vomiting who has had no urine output for 16 hours A 45-year-old with pancytopenia who will require IV administration of erythropoietin (Procrit) A 72-year-old with tumor lysis syndrome who is receiving normal saline IV at a rate of 250 mL/hr

A 45-year-old with pancytopenia who will require IV administration of erythropoietin (Procrit)

Which client does the medical-surgical unit charge nurse assign to an LPN/LVN? A 41-year-old who needs assistance with choosing a site for a colostomy stoma A 47-year-old who needs to receive "whole gut" lavage before a colon resection A 51-year-old who has recently arrived on the unit after having an open herniorrhaphy A 56-year-old who has obstipation and a recent emesis of foul-smelling liquid

A 47-year-old who needs to receive "whole gut" lavage before a colon resection

Which client does the RN arriving for duty assess first? A 27-year-old who has chronic severe back pain with movement A 51-year-old with lung cancer who reports pain "whenever I cough" A 56-year-old with acute pancreatitis who reports increasing abdominal pain A 63-year-old who reports ongoing pain associated with rheumatoid arthritis

A 56-year-old with acute pancreatitis who reports increasing abdominal pain

The nurse recognizes which patient needs to use a fracture pan for a bowel movement? The patient who is obese The patient experiencing confusion The patient on bed rest A patient recovering from hip surgery

A patient recovering from hip surgery

The nurse is instructing a client with recently diagnosed diverticular disease about diet. What food does the nurse suggest the client include? A slice of 5-grain bread Chuck steak patty (6 ounces) Strawberries (1 cup) Tomato (1 medium)

A slice of 5-grain bread

A client is scheduled for discharge after surgery for inflammatory bowel disease. The client's spouse will be assisting home health services with the client's care. What is most important for the home health nurse to assess in the client and the spouse with regard to the client's home care? Ability of the client and spouse to perform incision care and dressing changes Effective coping mechanisms for the client and spouse after the surgical experience Knowledge about the client's requested pain medications Incorrect Understanding of the importance of keeping scheduled follow-up appointments

Ability of the client and spouse to perform incision care and dressing changes

A postoperative client reports, "I have pain from a mild headache." Which PRN medication does the nurse administer? Acetaminophen (Tylenol) Hydromorphone (Dilaudid) Midazolam (Versed) Oxycodone hydrochloride/acetaminophen (Tylox)

Acetaminophen (Tylenol)

The nurse is teaching a group of clients with irritable bowel syndrome (IBS) about complementary and alternative therapies. What does the nurse suggest as possible treatment modalities? (Select all that apply.) Acupuncture Decreasing physical activities Herbs (moxibustion) Meditation Peppermint oil capsules Yoga

Acupuncture Herbs (moxibustion) Meditation Peppermint oil capsules Yoga

A client with chronic pain feels no relief with high-dose opioids and says, "I just can't manage living right now." What intervention does the nurse anticipate the health care provider will order for this client? Adding acetaminophen (Tylenol) Adding duloxetine (Cymbalta) as adjuvant therapy Increasing the opioid dose to control the pain Replacing the opioid with duloxetine (Cymbalta) for depression

Adding duloxetine (Cymbalta) as adjuvant therapy Both tricyclic and other antidepressants such as duloxetine (Cymbalta) help treat the depression that can accompany chronic pain. They also stimulate the activity of endogenous opiates (endorphins and enkephalins) by increasing levels of the neurotransmitter serotonin.

A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the hypothalamic region of the brain. The nurse manager should intervene immediately when observing the child's nurse perform which action? Places a hypothermia blanket at the bedside Adjusts the bed to the Trendelenburg position Obtains electronic equipment for monitoring the vital signs Secures a pump to administer the ordered intravenous fluids

Adjusts the bed to the Trendelenburg position

A client with cancer is receiving low-dose oral morphine but is reporting both "breakthrough" pain and constipation. What intervention does the nurse implement first? Administers ordered docusate sodium (Colace) and gabapentin (Neurontin) Decreases the morphine (morphine sulfate) dosage for the client Gives the client a Fleet's (sodium biphosphate) enema Records the client's bowel movements

Administers ordered docusate sodium (Colace) and gabapentin (Neurontin)

A 72-year-old client recovering from lung cancer surgery asks the nurse to explain how she developed cancer when she has never smoked. Which factor may explain the possible cause? A diagnosis of diabetes treated with insulin and diet An exercise regimen of jogging 3 miles four times a week A history of cardiac disease Advancing age

Advancing age

The nurse is caring for a client who is receiving rituximab (Rituxan) for treatment of lymphoma. During the infusion, it is essential for the nurse to observe for which side effect? Alopecia Allergy Fever Chills

Allergy is the most common side effect of monoclonal antibody therapy (rituximab) there are also side effects of fever and chills but allergy is priority

When caring for the client with hyperuricemia associated with tumor lysis syndrome (TLS), for which medication does the nurse anticipate an order? Recombinant erythropoietin (Procrit) Allopurinol (Zyloprim) Potassium chloride Radioactive iodine-131 (131I)

Allopurinol (Zyloprim) TLS results in hyperuricemia (elevation of uric acid in the blood), hyperkalemia, and other electrolyte imbalances; allopurinol decreases uric acid production and is indicated in TLS.

A client who is undergoing chemotherapy for breast cancer reports problems with concentration and memory. Which nursing intervention is indicated at this time? -Explain that this occurs in some clients and is usually permanent. - Inform the client that a small glass of wine may help her relax. -Protect the client from infection. - Allow the client an opportunity to express her feelings.

Allow the client an opportunity to express her feelings.

Aside from chemotherapeutic agents, what other medications does the nurse expect to administer to a client with advanced colorectal cancer for relief of symptoms? Analgesics and antiemetics Analgesics and benzodiazepines Steroids and analgesics Steroids and anti-inflammatory medications

Analgesics and antiemetics

The nurse is teaching a client who recently began taking sulfasalazine (Azulfidine) about the drug. What side effects does the nurse tell the client to report to the health care provider? (Select all that apply.) Anorexia Depression Drowsiness Frequent urination Headache Vomiting

Anorexia Headache Vomiting

When using ice massage for pain relief, which of the following are correct? (Select all that apply.) Apply ice using firm pressure over skin. Apply ice until numbness occurs and remove the ice for 5 to 10 minutes. Apply ice until numbness occurs and discontinue application. Apply ice for no longer than 10 minutes.

Apply ice using firm pressure over skin. Apply ice until numbness occurs and remove the ice for 5 to 10 minutes.

When assessing a 55-year-old patient who is in the clinic for a routine physical, the nurse instructs the patient about the need to obtain a stool specimen for guaiac fecal occult blood testing (gFOBT): If patient reports rectal bleeding. When there is a family history of polyps. As part of a routine examination for colon cancer. If a palpable mass is detected on digital examination.

As part of a routine examination for colon cancer.

Which of the following medications listed in a patient's medication history possibly causes gastrointestinal bleeding? (Select all that apply.) Aspirin Cathartics Antidiarrheal opiate agents Nonsteroidal antiinflammatory drugs (NSAIDs)

Aspirin Nonsteroidal antiinflammatory drugs (NSAIDs)

The nurse has received in report that a client receiving chemotherapy has severe neutropenia. Which interventions does the nurse plan to implement? (Select all that apply.) Assess for fever. Observe for bleeding. Administer pegfilgrastim (Neulasta). Do not permit fresh flowers or plants in the room. Do not allow the client's 16-year-old son to visit. Teach the client to omit raw fruits and vegetables from the diet.

Assess for fever. Administer pegfilgrastim (Neulasta). Do not permit fresh flowers or plants in the room . Teach the client to omit raw fruits and vegetables from the diet.

After having received 0.2 mg of naloxone (Narcan) intravenous push (IVP), a patient's respiratory rate and depth are within normal limits. The nurse now plans to implement the following action: Discontinue all ordered opioids Close the room door to allow the patient to recover Administer the remaining naloxone over 4 minutes Assess patient's vital signs every 15 minutes for 2 hours

Assess patient's vital signs every 15 minutes for 2 hours

A patient returning to the nursing unit after knee surgery is verbalizing pain at the surgical site. The nurse's first action is to: Call the patient's health care provider. Administer pain medication as ordered. Check the patient's vital signs. Assess the characteristics of the pain.

Assess the characteristics of the pain.

The patient is incontinent, and a condom catheter is placed. The nurse should take which action? Secure the condom with adhesive tape Change the condom every 48 hours Assess the patient for skin irritation Use sterile technique for placement

Assess the patient for skin irritation

A patient is being treated for tuberculosis (TB) with a standard four-drug regimen but continues to have positive sputum smears for acid-fast bacilli. Which actions should the nurse implement? (Select all that apply.) - Assist the patient with short-term goals and plan teaching according to these goals. - Provide the patient with all the educational materials about drug-resistant TB. - Refer the patient to a pulmonary specialist, who can assist the patient with the treatment regimen. - Ask the patient about any barriers to obtaining medications. - Ask the patient whether medications have been taken as directed.

Assist the patient with short-term goals and plan teaching according to these goals. Provide the patient with all the educational materials about drug-resistant TB. Ask the patient whether medications have been taken as directed.

A male client in a long-term care facility is 2 days postoperative after an open repair of an indirect inguinal hernia. Which nursing action does the RN delegate to unlicensed assistive personnel (UAP)? Assessing the client's incision for signs of infection Assisting the client to stand to void Instructing the client in how to deep-breathe Monitoring the client's pain level

Assisting the client to stand to void

The nurse is conducting a community health education class on diet and cancer risk reduction. What should be included in the discussion? (Select all that apply.) Limit sodium intake. Avoid beef and processed meats. Increase consumption of whole grains. Eat "colorful fruits and vegetables," including greens. Avoid gas-producing vegetables such as cabbage.

Avoid beef and processed meats. Increase consumption of whole grains. Eat "colorful fruits and vegetables," including greens.

A 41-year-old man who underwent a craniotomy for the removal of a brain tumor 6 months ago comes to the clinic for his monthly follow-up visit. In planning your assessment, you anticipate that the patient may possibly experience which of the following late effects of surgery? (Select all that apply.) 1 Pain 2 Fatigue 3 Blurred vision 4 Difficulty breathing 5 Poor attention span

BLURRED VISION POOR ATTENTION SPAN

The nurse suspects metastasis from left breast cancer to the thoracic spine when the client has which symptom? Vomiting Back pain Frequent urination Cyanosis of the toes

Back pain Typical sites of breast cancer metastasis include bone (manifested by back pain), lung, liver, and brain. Signs of metastasis to the spine may include numbness, pain, paresthesias and tingling, and loss of bowel and bladder control, but not vomiting. Although frequent urination may be a sign of bladder cancer, incontinence is more indicative of spinal metastasis. Cyanosis of the toes indicates decreased tissue perfusion, often related to atherosclerotic disease.

In the role of client advocate, what does the nurse do first for a client who reports pain? Administers pain medication Assesses the level of pain Believes the client's report of pain Calls the provider for a medication order

Believes the client's report of pain

The nurse is teaching a client who is receiving an antiestrogen drug about the side effects she may encounter. Which side effects does the nurse include in the discussion?

Breast tenderness Deep vein thrombosis Breast tenderness and shrinking breast tissue may occur with antiestrogen therapy. Venous thromboembolism may also occur. Irregular menses or no menstrual period is the typical side effect of antiestrogen therapy. Acne may also develop. Hypercalcemia, not hyperkalemia, is typical. Fluid retention with weight gain may also occur.

The nurse is teaching a client with a newly created colostomy about foods to limit or avoid because of flatulence or odors. Which foods are included? (Select all that apply.) Broccoli Buttermilk Mushrooms Onions Peas Yogurt

Broccoli Mushrooms Onions Peas Buttermilk will help prevent odors. Yogurt can help prevent flatus.

When caring for the client receiving cancer chemotherapy, which signs or symptoms related to thrombocytopenia should the nurse report to the health care provider? (Select all that apply.) Bruises Fever Petechiae Epistaxis Pallor

Bruises Petechiae Epistaxis Bruising, petechiae, and epistaxis (nosebleeds) are symptoms of a low platelet count. Fever is a sign of infection secondary to neutropenia. Pallor is a sign of anemia.

A client is diagnosed with irritable bowel syndrome (IBS). What factors does the nurse suspect as possible causes of the client's problem? (Select all that apply.) Antihistamines Caffeinated drinks Stress Sleeping pills Anxiety

Caffeinated drinks Stress Anxiety

A health care provider writes the following order for an opioid-naive patient who returned from the operating room following a total hip replacement. "Fentanyl patch 100 mcg, change every 3 days." Based on this order, the nurse takes the following action: Calls the health care provider, and questions the order Applies the patch the third postoperative day Applies the patch as soon as the patient reports pain Places the patch as close to the hip dressing as possible

Calls the health care provider, and questions the order

The nurse demonstrates understanding of the potential effects of pancreatic disorders when performing which assessment? Blood pressure measurement Capillary blood glucose level Equilibrium, balance, and gait Bilateral muscle strength

Capillary blood glucose level

The nurse case manager is discussing community resources with a client who has colorectal cancer and is scheduled for a colostomy. Which referral is of greatest value to this client initially? Certified Wound, Ostomy, and Continence Nurse (CWOCN Home health nursing agency Hospice Hospital chaplain

Certified Wound, Ostomy, and Continence Nurse (CWOCN

Which finding alarms the nurse when caring for a client receiving chemotherapy who has a platelet count of 17,000/mm3? Increasing shortness of breath Diminished bilateral breath sounds Change in mental status Weight gain of 4 pounds in 1 day

Change in mental status A change in mental status could result from spontaneous bleeding; in this case, a cerebral hemorrhage may have developed. Increasing shortness of breath is typically related to anemia, not to thrombocytopenia. Diminished breath sounds may be related to many factors, including poor respiratory excursion, infection, and atelectasis, which is not related to thrombocytopenia. A large weight gain in a short period may be related to kidney or heart failure; bleeding is the major complication of thrombocytopenia.

Since removal of the patient's Foley catheter, the patient has voided 50 to 100 mL every 2 to 3 hours. Which action should the nurse take first? Check for bladder distention Encourage fluid intake Obtain an order to recatheterize the patient Document the amount of each voiding for 24 hours

Check for bladder distention

The nurse notes that the patient's Foley catheter bag has been empty for 4 hours. The priority action would be to: Irrigate the Foley. Check for kinks in the tubing. Notify the health care provider. Assess the patient's intake.

Check for kinks in the tubing.

A home health client has had severe diarrhea for the past 24 hours. Which nursing action does the RN delegate to the home health aide (unlicensed assistive personnel [UAP]) who assists the client with self-care? Instructing the client about the use of electrolyte-containing oral rehydration products Administering loperamide (Imodium) 4 mg from the client's medicine cabinet Checking and reporting the client's heart rate and blood pressure in lying, sitting, and standing positions Teaching the client how to clean the perineal area after each loose stool

Checking and reporting the client's heart rate and blood pressure in lying, sitting, and standing positions

A client has vague symptoms that indicate an acute inflammatory bowel disorder. Which symptom is most indicative of Crohn's disease (CD)? Abdominal pain relieved by bending the knees Chronic diarrhea, abdominal pain, and fever Epigastric cramping Hypotension with vomiting

Chronic diarrhea, abdominal pain, and fever

The RN working on an oncology unit has just received report on these clients. Which client should be assessed first? Client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature Client with lymphoma who will need administration of an antiemetic before receiving chemotherapy Client with metastatic breast cancer who is scheduled for external beam radiation in 1 hour Client with xerostomia associated with laryngeal cancer who needs oral care before breakfast

Client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature

Which is a correct statement differentiating Crohn's disease (CD) from ulcerative colitis (UC)? Clients with CD experience about 20 loose, bloody stools daily. Clients with UC may experience hemorrhage. The peak incidence of UC is between 15 and 40 years of age Very few complications are associated with CD.

Clients with UC may experience hemorrhage.

Which activity does the RN team leader on a large medical-surgical unit assign to the LPN/LVN? Assessment of a client scheduled for surgery who is crying and expressing fear that the pain will be intolerable Assessment of a client using a transcutaneous electrical nerve stimulation unit to relieve chronic pain Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care Instructions to a postoperative hip replacement client who has just been placed on patient-controlled analgesia for pain relief

Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care

A client with a bowel obstruction is ordered a nasogastric (NG) tube. After the nurse inserts the tube, which nursing intervention is the highest priority for this client? Attaching the tube to high continuous suction Auscultating for bowel sounds and peristalsis while the suction runs Connecting the tube to low intermittent suction Flushing the tube with 30 mL of normal saline every 24 hours

Connecting the tube to low intermittent suction

Which instruction is most appropriate for the nurse to convey to the client with chemotherapy-induced neuropathy? Bathe in cold water. Wear cotton gloves when cooking. Consume a diet high in fiber. Make sure shoes are snug.

Consume a diet high in fiber. The client should bathe in warm water, not hotter than 96° F. Cotton gloves may prevent harm from scratching; protective gloves should be worn for washing dishes and gardening. Wearing cotton gloves while cooking can increase the risk for burns. Shoes should allow sufficient length and width to prevent blisters. Shoes that are snug can increase the risk for blisters in a client with peripheral neuropathy.

A patient with hypothermia is brought to the emergency department. The nurse should explain which most likely treatment to the family members? Core rewarming with warm fluids Ambulation to increase metabolism Frequent oral temperature assessment Gastric tube feedings to increase fluids

Core rewarming with warm fluids

A client with ulcerative colitis is prescribed sulfasalazine (Azulfidine) and corticosteroid therapy. As the disease improves, what change does the nurse expect in the client's medication regimen? Corticosteroid therapy will be stopped. Sulfasalazine (Azulfidine) will be stopped. Corticosteroid therapy will be tapered. Sulfasalazine (Azulfidine) will be tapered.

Corticosteroid therapy will be tapered.

A female patient reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. The probable cause of these symptoms and findings is: Cystitis. Hematuria. Pyelonephritis. Dysuria.

Cystitis.

The nurse is caring for a 78-year-old man with diarrhea. Of the following problems, which is the most important to consider? Malnutrition Dehydration Skin breakdown Incontinence

Dehydration

Which of the following signs or symptoms in an opioid-naive patient is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? Oxygen saturation of 95% Difficulty arousing the patient Respiratory rate of 10 breaths/min Pain intensity rating of 5 on a scale of 0 to 10

Difficulty arousing the patient

The nurse presents a cancer prevention program to teens. Which instruction will have the greatest impact in cancer prevention? Avoid asbestos. Wear sunscreen. Get the human papilloma virus (HPV) vaccine. Do not smoke cigarettes.

Do not smoke cigarettes.

The nurse is assessing a client with lung cancer. Which symptom does the nurse anticipate finding? Easy bruising Dyspnea Night sweats Chest wound

Dyspnea is a sign of lung cancer, as are cough, hoarseness, shortness of breath, bloody sputum, arm or chest pain, and dysphagia Night sweats is a symptom of the lymphomas.

Fill in the Blank. The period during which a cancer patient goes into remission following the basic, rigorous course of chemotherapy and enters a phase of watchful waiting, is called _______________.

EXTENDED SURVIVAL

Which manifestation of an oncologic emergency requires the nurse to contact the health care provider immediately? New onset of fatigue Edema of arms and hands Dry cough Weight gain

Edema of arms and hands -indicates worsening compression of the superior vena cava consistent with superior vena cava syndrome. The compression must be relieved immediately, often with radiation therapy, because death can result without timely intervention. - New onset of fatigue may likely be an early manifestation of hypercalcemia, which usually develops slowly, but because it is an early manifestation, this is not the priority. -Dry cough is not a manifestation that is specific to an oncologic emergency; however, it may be a side effect of chemotherapy. -Weight gain could be an early sign of syndrome of inappropriate antidiuretic hormone; although this should be addressed, it is an early sign so it is not the priority.

A client with a family history of colorectal cancer (CRC) regularly sees a health care provider for early detection of any signs of cancer. Which laboratory result may be an indication of CRC in this client? Decrease in liver function test results Elevated carcinoembryonic antigen Elevated hemoglobin levels Negative test for occult blood

Elevated carcinoembryonic antigen

A client with colorectal cancer had colostomy surgery performed yesterday. The client is very anxious about caring for the colostomy and states that the health care provider's instructions "seem overwhelming." What does the nurse do first for this client? Encourages the client to look at and touch the colostomy stoma Instructs the client about complete care of the colostomy Schedules a visit from a client who has a colostomy and is successfully caring for it Suggests that the client involve family members in the care of the colostomy

Encourages the client to look at and touch the colostomy stoma

The nurse is establishing a plan of care for a hospitalized client with chronic pain caused by fibromyalgia. Which nursing action does the nurse delegate to a nursing assistant? Application of a transcutaneous electrical nerve stimulation (TENS) device Education about nonpharmacologic interventions for pain control Referral to available community resources for pain management Engagement in conversation about the client's family to distract the client

Engagement in conversation about the client's family to distract the client

The nurse assesses that a patient has not been taking antihypertension medication as prescribed. How should the nurse proceed? (Select all that apply.) - Evaluate the teaching plan to determine if there is a need to reeducate the patient - Assess the patient's perception and attitude towards the risks associated with missing doses of medication. - Review and reinforce the need to take the medication as prescribed. - Ask the provider to prescribe a different medication because the patient does not want to take this medication. - Emphasize the risk of stroke or heart attack if the patient does not adhere to the treatment plan.

Evaluate the teaching plan to determine if there is a need to reeducate the patient Assess the patient's perception and attitude towards the risks associated with missing doses of medication. - Review and reinforce the need to take the medication as prescribed.

A support group of cancer survivors is discussing cancer-related fatigue (CRF). The survivor most likely to gain relief from CRF is the survivor who does which of the following? (Select all that apply.) 1Takes naps during the day and evening 2Drinks energy drinks daily 3Exercises every other day 4Eats a balanced diet

Exercises every other day Eats a balanced diet

Which potential side effects does the nurse include in the teaching plan for a client undergoing radiation therapy for laryngeal cancer? (Select all that apply.) Fatigue Changes in color of hair Change in taste Changes in skin of the neck Difficulty swallowing

Fatigue Change in taste Changes in skin of the neck Difficulty swallowing Chemotherapy, which causes alopecia, may cause changes in the color or texture of hair; this does not normally occur with radiation therapy.

A nurse observes a patient walking in the hall. Which assessment is the nurse able to complete? Gait and balance Speech and hearing Mental alertness Ability to follow directions

Gait and balance

The nurse is caring for a client who had a fractured ankle repaired. Twenty minutes after receiving 1.5 mg of hydromorphone (Dilaudid) IV push, the client is slow to respond and has constricted pupils and a respiratory rate of 6 breaths/min. What action does the nurse take initially? Calls the care provider for a change in the medication order Changes the order to every 6 hours rather than every 4 hours Gives the client a dose of naloxone (Narcan) 0.4 mg IV Performs a cognitive assessment on the client

Gives the client a dose of naloxone (Narcan) 0.4 mg IV

A client with cancer who is taking pain medication states, "I am still having pain." During the assessment, the client does not exhibit any physical manifestations of pain. What does the nurse do next? Decreases the client's standard pain medication dose Gives the client a placebo and monitors the outcome Gives the pain medication as requested Withholds the pain medication

Gives the pain medication as requested

A client with a recent surgically created ileostomy refuses to look at the stoma and asks the nurse to perform all required stoma care. What does the nurse do next? Asks the client whether family members could be trained in stoma care Has another client with a stoma who performs self-care talk with the client Requests that the health care provider request antidepressants and a psychiatric consult Suggests that the health care provider request a home health consultation so stoma care can be performed by a home health nurse

Has another client with a stoma who performs self-care talk with the client

A 62-year-old patient is being admitted to a surgical unit for a total hip replacement. The nurse reviews his medical record and learns that the patient has a history of impaired liver function and paresthesias in his feet. After assessing the patient's medical history further, the nurse is not sure what caused the liver impairment or paresthesia. To clarify, an appropriate question to ask the patient is which of the following? 1"Have you been treated for cancer in the past?" 2"What is the nature of your liver problem?" 3"Has the doctor discussed with you whether your liver problems will affect your recovery from surgery?" 4"How long have you had the numbness and tingling in your feet?"

Have you been treated for cancer in the past?

A client with a history of osteoarthritis has a 10-inch incision following a colon resection. The incision has become infected, and the wound requires extensive irrigation and packing. What aspect of the client's care does the nurse make certain to discuss with the health care provider before the client's discharge? Having a home health consultation for wound care Requesting an antianxiety medication Requesting pain medication for the client's osteoarthritis Placing the client in a skilled nursing facility for rehabilitation

Having a home health consultation for wound care

The oncology nurse is caring for a group of clients receiving chemotherapy. The client with which sign/symptom is displaying bone marrow suppression? Hemoglobin of 7.4 and hematocrit of 21.8 Correct Potassium level of 2.9 mEq/L and diarrhea Incorrect 250,000 platelets/mm3 5000 white blood cells/mm3

Hemoglobin of 7.4 and hematocrit of 21.8 Correct Bone marrow suppression causes anemia, leukopenia, and thrombocytopenia; the client with a hemoglobin of 7.4 and hematocrit of 21.8 has anemia demonstrated by low hemoglobin and hematocrit. The client with diarrhea and a potassium level of 2.9 mEq/L has hypokalemia and electrolyte imbalance. The client with 250,000 platelets/mm3 and the client with 5000 white blood cells/mm3 demonstrate normal values.

Nurses discourage patients from straining on defecation primarily because it causes: (Select all that apply.) Pain. Impaction. Hemorrhoids. Dysrhythmias.

Hemorrhoids. Dysrhythmias.

The nurse is teaching a client who has undergone a hemorrhoidectomy about a follow-up plan of care. Which client statement demonstrates a correct understanding of the nurse's instructions? "I should take Ex-Lax after the surgery to 'keep things moving'." "I will need to eat a diet high in fiber." "Limiting my fluids will help me with constipation." Incorrect "To help with the pain, I'll apply ice to the surgical area."

I will need to eat a diet high in fiber."

A hospitalized client anticipates a daily painful dressing change. Which complementary and alternative medicine therapy might the nurse offer before the procedure? Animal-assisted therapy Hydrotherapy Imagery Acupuncture

Imagery

A hospitalized client expresses satisfaction after using a recommended complementary and alternative medicine (CAM) therapy, saying that pain was diminished and anxiety reduced. Which CAM did the client most likely use? Herbs Incorrect Homeopathy Imagery Tai chi

Imagery

What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia? Dyspnea Precordial pain Increased pulse rate Elevated blood pressure

Increased pulse rate

When caring for a client receiving chemotherapy, the nurse plans care during the nadir of bone marrow activity to prevent which complication? Drug toxicity Polycythemia Infection Dose-limiting side effects

Infection The lowest point of bone marrow function is referred to as the nadir; risk for infection is highest during this phase. Drug toxicity can develop when drug levels exceed peak concentrations. Polycythemia refers to an increase in the number of red blood cells; typically chemotherapy causes reduction of red blood cells or anemia. Dose limiting side effects occur when the dose or frequency of chemotherapy need to be altered or held, such as in the case of severe neutropenia or neurologic dysfunction

The nurse explains to a client that which risk factor of those listed most likely contributed to the client's primary liver carcinoma? Infection with hepatitis B virus Consuming a diet high in animal fat Exposure to radon Familial polyposis

Infection with hepatitis B virus Hepatitis B and C are risk factors for primary liver cancer. Alcohol abuse is also a risk factor for the development of liver cancer. Consuming a diet high in animal fat may predispose a person to colon or breast cancer. Exposure to radon is a risk factor for lung cancer. Familial polyposis is a risk factor for colorectal cancer.

A patient with a Foley catheter carries the collection bag at waist level when ambulating. The nurse tells the patient that he or she is at risk for: (Select all that apply.) Infection. Retention. Stagnant urine. Reflux of urine.

Infection. Reflux of urine.

A client has developed gastroenteritis while traveling outside the country. What is the likely cause of the client's symptoms? Bacteria on the client's hands Ingestion of parasites in the water Insufficient vaccinations Overcooked food

Ingestion of parasites in the water

An older male patient states that he is having problems starting and stopping his stream of urine and he feels the urgency to void. The best way to assist this patient is to: Help him stand to void. Place a condom catheter. Have him practice Credé's method. Initiate Kegel exercises.

Initiate Kegel exercises.

A child must experience mobility so he or she can explore and learn about the world. Lack of mobility in a child may interfere with which developmental milestone? Physiological bonding and growth Speech and hearing development Intellectual and psychomotor function Childhood play interaction

Intellectual and psychomotor function

A postoperative client is vomiting and states, "I am having a lot of pain—about a 7 on a scale of 0 to 10." Which route of administration does the nurse choose to administer an analgesic to the client? Intravenous Oral Rectal Transdermal

Intravenous

What is the mechanism of action for the chemotherapeutic drug cetuximab (Erbitux)? It destroys the cancer's cell wall, which will kill the cell. It decreases blood flow to rapidly dividing cancer cells. It stimulates the body's immune system and stunts cancer growth. It blocks factors that promote cancer cell growth.

It blocks factors that promote cancer cell growth.

During the nursing assessment a patient reveals that he has diarrhea and cramping every time he has ice cream. He attributes this to the cold nature of the food. However, the nurse begins to suspect that these symptoms are associated with: Food allergy. Irritable bowel. Lactose intolerance. Increased peristalsis.

Lactose intolerance.

Which type of cancer has been associated with Down syndrome? Breast cancer Colorectal cancer Malignant melanoma Leukemia

Leukemia Leukemia is associated with Down syndrome and Turner syndrome. Breast cancer is often found clustered in families, not in association with Down syndrome. Colorectal cancer is associated with familial polyposis. Malignant melanoma is associated with familial clustering and sun exposure.

To minimize the patient experiencing nocturia, the nurse would teach him or her to: Perform perineal hygiene after urinating. Set up a toileting schedule. Double void. Limit fluids before bedtime.

Limit fluids before bedtime.

A client admitted with severe gastroenteritis has been started on an IV, but the client continues having excessive diarrhea. Which medication does the nurse ask the health care provider about prescribing? Balsalazide (Colazal) Loperamide (Imodium) Mesalamine (Asacol) Milk of Magnesia (MOM

Loperamide (Imodium)

What are the common cancers related to tobacco use? (Select all that apply.) Cardiac cancer Lung cancer Cancer of the tongue Skin cancer Cancer of the larynx

Lung cancer Cancer of the tongue Cancer of the larynx

The nurse correctly identifies an example of exocrine glands when stating the name of which glands? (Select all that apply.) Mammary Salivary Sweat Thyroid Bartholin Pancreas

Mammary Salivary Sweat Bartholin

A client diagnosed with irritable bowel syndrome (IBS) is discharged home with a variety of medications for IBS symptoms. Upon returning to the clinic, the client states, "Most of my symptoms have improved, except for the diarrhea." What does the nurse anticipate will be prescribed for this client? Antidiarrheal agent Muscarinic receptor antagonist Serotonin antagonist Tricyclic antidepressant

Muscarinic receptor antagonist

A client reports increasing pain during dressing changes. Which interventions are recommended for the client? (Select all that apply.) Assistance by the client with the dressing change Distraction Epidural analgesic Music therapy Premedication Transcutaneous electrical nerve stimulation (TENS)

Music therapy Premedication Distraction

Mr. Wallace is a 34-year-old who is a 5-year survivor of Hodgkin's disease. He continues to have symptoms related to his chemotherapy treatment. Mr. Wallace is a computer expert and enjoys Internet discussion groups. What is the best resource a nurse can recommend to help him access a survivorship care plan? 1. Association of Cancer Online Resources 2. National Coalition for Cancer Survivorship 3. American Cancer Society 4. National Cancer Institute

National Coalition for Cancer Survivorship

The patient is to have an intravenous pyelogram (IVP). Which of the following apply to this procedure? (Select all that apply.) Note any allergies. Monitor intake and output. Provide for perineal hygiene. Assess vital signs. Encourage fluids after the procedure.

Note any allergies. Encourage fluids after the procedure

A client with malabsorption syndrome asks the nurse, "What did I do to cause this disorder to develop?" How does the nurse respond? "An excessive intake of alcohol is associated with it, so your substance abuse could have contributed to its development." "It is inherited, so it could run in your family." "It might be caused by a virus, so you could have gotten it almost anywhere." "Nothing you did could have caused it; it is the result of flattening of the mucosa of your large intestine.

Nothing you did could have caused it; it is the result of flattening of the mucosa of your large intestine.

Which statement about the process of malignant transformation is correct? - Mutation of genes is an irreversible event that always leads to cancer development in the initiation phase. - Insulin and estrogen enhance the division of an initiated cell during the promotion phase. - Tumors form when carcinogens invade the gene structure of the cell in the latency phase. - Nutrition of cancer cells is provided by tumor angiogenesis factor (TAF) in the promotion stage.

Nutrition of cancer cells is provided by tumor angiogenesis factor (TAF) in the promotion stage.

The nurse is preparing a client for home care pain management following discharge. Which intervention does the nurse implement? Discuss pain-relieving strategies on the day of discharge. Incorrect Discuss home care with only the client's family, not with the client. Offer flexibility in home management of the client's current regimen. Offer information about end-of-life pain control management.

Offer flexibility in home management of the client's current regimen.

When caring for a client who has had a colostomy created during treatment for colon cancer, which nursing actions help support the client in accepting changes in appearance or function? (Select all that apply.) Explain to the client that the colostomy is only temporary. Encourage the client to participate in changing the ostomy. Obtain a psychiatric consultation. Offer to have a person who is coping with a colostomy visit. Encourage the client and family members to express their feelings and concerns.

Offer to have a person who is coping with a colostomy visit. Encourage the client and family members to express their feelings and concerns Encourage the client to participate in changing the ostomy.

Which statement is true about assessing pain in an older adult client? The nurse should assess for present and past pain. Older adults typically believe that expressing pain is acceptable. Older adults are at great risk for undertreated pain. Older adults usually believe that pain signifies a minor illness.

Older adults are at great risk for undertreated pain.

Which medication does the nurse plan to administer to a client before chemotherapy to decrease the incidence of nausea and vomiting? Morphine Ondansetron (Zofran) Naloxone (Narcan) Diazepam (Valium

Ondansetron (Zofran)

Which one of the following instructions is crucial for the nurse to give to both family members and the patient who is about to be started on a patient-controlled analgesia (PCA) of morphine? Only the patient should push the button. Do not use the PCA until the pain is severe. The PCA prevents overdoses from occurring. Notify the nurse when the button is pushed.

Only the patient should push the button.

The home health nurse is caring for a client who has a history of a kidney transplant and takes cyclosporine (Sandimmune) and prednisone (Deltasone) to prevent rejection. Which assessment finding is most important to communicate to the transplant team? Temperature of 96.6° F Reports of joint pain Pink and dry oral mucosa Palpable lump in the client's axilla

Palpable lump in the client's axilla

Number the steps to irrigating a nasogastric tube (NG) in correct order: Slowly aspirate the syringe. Reconnect the NG tube to suction. Clamp and disconnect the NG tube. Perform hand hygiene and apply clean gloves. Insert tip of syringe into NG tube and slowly inject 30 mL saline.

Perform hand hygiene and apply clean gloves. Clamp and disconnect the NG tube. Insert tip of syringe into NG tube and slowly inject 30 mL saline. Slowly aspirate the syringe. Reconnect the NG tube to suction.

The nurse includes which factors in teaching regarding the typical warning signs of cancer? (Select all that apply.) Persistent constipation Scab present for 6 months Curdlike vaginal discharge Axillary swelling Headache Incorrect

Persistent constipation Scab present for 6 months Axillary swelling

A client with extensive burn injuries is to be weaned from long-term opioid use. What type of opioid dependence does the nurse expect this client to have? Addiction Equianalgesia Physical dependence Pseudoaddiction

Physical dependence

Which client problem does the nurse set as the priority for the client experiencing chemotherapy-induced peripheral neuropathy? Potential for lack of understanding related to side effects of chemotherapy Potential for injury related to sensory and motor deficits Potential for ineffective coping strategies related to loss of motor control Altered sexual function related to erectile dysfunction

Potential for injury related to sensory and motor deficits

A client with an intestinal obstruction has pain that changes from a "colicky" intermittent type to constant discomfort. What does the nurse do first? Administers medication for pain Changes the nasogastric suction level from "intermittent" to "constant" Positions the client in high-Fowler's position Prepares the client for emergency surgery

Prepares the client for emergency surgery

A client demonstrates the manifestations of diverticulitis with a suspected complication of peritonitis. What is the priority nursing intervention? Assessing the client for changes in vital signs Medicating the client for pain Monitoring for changes in the client's mentation Preparing the client for emergency surgery

Preparing the client for emergency surgery

The nurse manager for an oncology unit is evaluating a newly hired staff nurse. Which action by the nurse is of greatest concern to the nurse manager? Asking a client with chest pain if the pain is sharp and stabbing Instructing a confused postoperative client about how to use patient-controlled analgesia Preparing to administer a placebo to a client with chronic back pain Requesting that a client with chronic pain describe the specific location of the pain

Preparing to administer a placebo to a client with chronic back pain

The nurse understands that, when comparing nasogastric tubes used for gastric decompression, a Salem sump is specifically designed to: Minimize the risk of a bowel obstruction. Ensure drainage of the intestines. Prevent gastric mucosal damage. Promote resting the gut.

Prevent gastric mucosal damage.

During infancy, childhood, and adolescence, which nutrients are critical for the musculoskeletal development? Vitamins and minerals Protein and calcium Fats and carbohydrates Zinc and potassium

Protein and calcium

When caring for the client with chemotherapy-induced mucositis, which intervention will be most helpful? Administering a biological response modifier Encouraging oral care with commercial mouthwash Providing oral care with a disposable mouth swab Maintaining NPO until the lesions have resolved

Providing oral care with a disposable mouth swab (sores in the mouth)

A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of: Addiction. Tolerance. Pseudoaddiction. Physical dependence.

Pseudoaddiction.

During change-of-shift report, the day shift staff learns that a client who had back surgery has been reporting increasing lower back pain during the night. It is most appropriate for which day staff member to assess the client's pain? LPN/LVN who is responsible for administering medications to the client RN nurse manager who is in charge of coordinating care for several units RN team leader who is responsible for updating the care plan for the client RN who has floated to the unit from the emergency department

RN team leader who is responsible for updating the care plan for the client

After an abdominoperineal resection, a 75-year-old client is referred to a home health agency. Which staff member does the nurse manager assign to perform the initial assessment on this client? LPN/LVN who has worked with many home health clients after colostomy surgeries LPN/LVN with 20 years of experience in the home health agency RN who is new to the agency with 5 years experience in the emergency department Social worker who is experienced with case management of older clients

RN who is new to the agency with 5 years experience in the emergency department

A postoperative client is receiving epidural analgesia and reports itching. What does the nurse do next?

Reduces the analgesic dose

.ID: 4615448082 A 67-year-old male client reports pain in the inguinal area that occurs when he coughs. A bulge that can be pushed back into the abdomen is found in his inguinal area. What type of hernia does he have? Femoral Reducible Strangulated Ventral

Reducible

An outpatient client is receiving photodynamic therapy. Which environmental factor is a priority for the client to adjust for protection? Storing drugs in dark locations at room temperature Wearing soft clothing Wearing a hat and sunglasses when going outside Reducing all direct and indirect sources of light

Reducing all direct and indirect sources of light

The nurse is caring for a client with end-stage ovarian cancer who needs clarification on the purpose of palliative surgery. Which outcome should the nurse teach the client is the goal of palliative surgery? Cure of the cancer Relief of symptoms or improved quality of life Allowing other therapies to be more effective Prolonging the client's survival time

Relief of symptoms or improved quality of life

The nurse identifies which priority nursing invention for a patient with hyperthermia? Initiating seizure precautions Limiting oral intake Providing a blanket Removing excess clothing

Removing excess clothing

A patient with a history of a stroke that left her confused and unable to communicate returns from interventional radiology following placement of a gastrostomy tube. The health care provider's order reads as follows: "Vicodin 1 tab, per tube, q4 hours, prn." Which action by the nurse is most appropriate? -No action is required by the nurse because the order is appropriate. Request to have the ordered changed to ATC for the first 48 hours. Ask for a change of medication to meperidine (Demerol) 50 mg IVP, q3 hours, prn. Begin the Vicodin when the patient shows nonverbal symptoms of pain.

Request to have the ordered changed to ATC for the first 48 hours.

The nurse is caring for a patient with a colostomy. Which intervention is most important? Cleansing the stoma with hot water Inserting a deodorant tablet in the stoma bag Selecting a bag with an appropriate-size stoma opening Wearing sterile gloves while caring for the stoma

Selecting a bag with an appropriate-size stoma opening

A client returns to the unit after having an exploratory abdominal laparotomy. How does the nurse position this client after the client is situated in bed? High Fowler's Lateral Sims' (side-lying) Semi-Fowler's Supine

Semi-Fowler's

After an automobile crash, a client is admitted to the emergency department with possible abdominal trauma. Which health care provider request does the nurse implement first? Insert a nasogastric tube and connect it to intermittent suction. Obtain a complete blood count and coagulation panel. Start an IV line and infuse normal saline at 200 mL/hr. Arrange for a computed tomography (CT) scan of the abdomen.

Start an IV line and infuse normal saline at 200 mL/hr. After the initial airway, breathing, and circulation assessment is completed, the most immediate concerns are the high risks for hemorrhage and shock. To rapidly treat for these possible complications, IV access and infusion of fluids are necessary as the priority intervention. Inserting a nasogastric tube, laboratory studies, and arranging a CT scan are secondary to establishing IV access and instilling fluids.

An 80-year-old client with a 2-day history of myalgia, nausea, vomiting, and diarrhea is admitted to the medical-surgical unit with a diagnosis of gastroenteritis. Which health care provider request does the nurse implement first? Administer acetaminophen (Tylenol) 650 mg rectally. Draw blood for a complete blood count and serum electrolytes. Obtain a stool specimen for culture and sensitivity. Start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr.

Start an IV solution of 5% dextrose in 0.45 normal saline at 125 mL/hr.

An obese client is discharged 10 days after being hospitalized for peritonitis, which resulted in an exploratory laparotomy. Which assessment finding by the client's home health nurse requires immediate action? Pain when coughing States, "I am too tired to walk very much" States, "I feel like the incision is splitting open" Temperature of 100.8° F (38.2° C)

States, "I feel like the incision is splitting open"

A client asks the nurse, "Can you tell me some foods to include in my diet so that I can reduce my chances of getting colorectal cancer?" Which dietary selection does the nurse suggest? Steak with pasta Spaghetti with tomato sauce Steamed broccoli with turkey Tuna salad with wheat crackers

Steamed broccoli with turkey

A patient is being discharged home on an around-the-clock (ATC) opioid for chronic back pain. Because of this order, the nurse anticipates an order for which class of medication? Stool softener Stimulant laxative H2 receptor blocker Proton pump inhibitor

Stimulant laxative

A patient starts to experience pain while receiving an enema. The nurse notes blood in the return fluid and rectal bleeding. What action does the nurse take first? Administers pain medication Slows down the rate of instillation Tells the patient to breathe slowly and relax Stops the instillation and obtains vital signs

Stops the instillation and obtains vital signs

A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would assess the patient for what manifestations of hypothermia? Stupor Erythema Increased anxiety Rapid respirations

Stupor

A male patient returned from the operating room 6 hours ago with a cast on his right arm. He has not yet voided. Which action would be the most beneficial in assisting the patient to void? Suggest he stand at the bedside Stay with the patient Give him the urinal to use in bed Tell him that, if he doesn't urinate, he will be catheterized

Suggest he stand at the bedside

When teaching a patient about transcutaneous electrical nerve stimulation (TENS), which information do you include? TENS works by causing distraction. TENS therapy does not require a health care provider's order. TENS requires an electrical source for use. TENS electrodes are applied near or directly on the site of pain.

TENS electrodes are applied near or directly on the site of pain.

A 21-year-old with a stab wound to the abdomen has come to the emergency department. Once stabilized, the client is admitted to the medical-surgical unit. What does the admitting nurse do first for this client? Administer pain medication. Assess skin temperature and color. Check on the amount of urine output. Take vital signs.

Take vital signs.

Which activity performed by the community health nurse best reflects primary prevention of cancer? Assisting women to obtain free mammograms Teaching a class on cancer prevention Encouraging long-term smokers to get a chest x-ray Encouraging sexually active women to get annual Papanicolaou (Pap) smears

Teaching a class on cancer prevention

To successfully assess if a patient is experiencing cognitive changes as a result of cancer treatment or complications of treatment, which of the following questions by a nurse is likely most relevant? 1. Describe for me your medication schedule. 2. How distressed are you feeling right now on a scale of 0 to 10? 3. Tell me about when you first noticed symptoms from your chemotherapy. ' 4. Tell me what you notice differently in your ability to get work done at your office.

Tell me what you notice differently in your ability to get work done at your office.

The nurse manager in a long-term care facility is developing a plan for primary and secondary prevention of colorectal cancer. Which tasks associated with the screening plan will be delegated to nursing assistants within the facility? Testing of stool specimens for occult blood Teaching about the importance of dietary fiber Referring clients for colonoscopy procedures Giving vitamin and mineral supplements

Testing of stool specimens for occult blood

The nurse notices that a patient has received oxycodone/acetaminophen (Percocet) (5/325), two tablets PO every 3 hours for the past 3 days. What concerns the nurse the most? The patient's level of pain The potential for addiction The amount of daily acetaminophen The risk for gastrointestinal bleeding

The amount of daily acetaminophen

Mr. Timmons has been receiving treatment for colon cancer on and off for a year. He received multiple chemotherapy regimens and a course of radiation. The 58-year-old patient is able to perform his own hygiene but needs assistance from his wife to move about safely in the home because of ongoing fatigue and weakness. His wife assists him with dressing when he becomes excessively tired. This caregiving skill pattern is best described as which of the following? 1)The self-caregiving pattern 2)The collaborative care pattern 3)The family caregiving pattern 4)The team caregiving pattern

The collaborative care pattern

A newly admitted client who was in an automobile accident has a concussion and is reporting pain from a fractured femur and broken fingers. Which staff member does the charge nurse on the orthopedic unit assign to care for this client? An experienced RN travel nurse who arrived on the unit this morning An LPN/LVN who has worked on the orthopedic unit for 6 years The neurology unit RN who has floated to the orthopedic unit The RN orthopedic case manager who is responsible for discharge planning

The neurology unit RN who has floated to the orthopedic unit

The patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain? -The patient's wife is the best resource for determining the level of pain since she has been with him continually for the entire day. -The patient's report of pain is the best method for assessing the pain. -The patient's health care provider has the best knowledge of the level of pain that the patient that should be experiencing. -The nurse is the most experienced at assessing pain.

The patient's report of pain is the best method for assessing the pain.

A postoperative patient is currently asleep. Therefore the nurse knows that: The sedative administered may have helped him sleep, but assessment of pain is still needed. The intravenous (IV) pain medication is effectively relieving his pain. Pain assessment is not necessary. The patient can be switched to the same amount of medication by the oral route.

The sedative administered may have helped him sleep, but assessment of pain is still needed.

The nurse corrects the nursing student when caring for a client with neutropenia secondary to chemotherapy in which circumstance? The student scrubs the hub of IV tubing before administering an antibiotic. The nurse overhears the student explaining to the client the importance of handwashing. The student teaches the client that symptoms of neutropenia include fatigue and weakness. The nurse observes the student providing oral hygiene and perineal care.

The student teaches the client that symptoms of neutropenia include fatigue and weakness. Symptoms of neutropenia include low neutrophil count, fever, and signs and symptoms of infection

A new medical resident writes an order for OxyContin SR 10 mg PO q12 hours prn. Which part of the order does the nurse question? The drug The time interval The dose The route

The time interval

The nurse is completing an admission assessment and identifies which findings that are most likely related to hormonal imbalances? (Select all that apply.) Thinning hair Dry skin Changes in pigmentation Malformation of fingernails Female facial hair Unsteady gait

Thinning hair Dry skin Changes in pigmentation Malformation of fingernails Female facial hair

While caring for a patient with cancer pain, the nurse knows that the World Health Organization (WHO) analgesic ladder recommends: Transitioning use of adjuvants with nonsteroidal antiinflammatory drugs (NSAIDs) to opioids. Using acetaminophen for refractory pain. Limiting the use of opioids because of the likelihood of side effects. Avoiding total sedation, regardless of how severe the pain is.

Transitioning use of adjuvants with nonsteroidal antiinflammatory drugs (NSAIDs) to opioids.

The postoperative patient has difficulty voiding after surgery and is feeling "uncomfortable" in the lower abdomen. Which action should the nurse implement first? Encourage fluid intake Administer pain medication Catheterize the patient Turn on the bathroom faucet as he tries to void

Turn on the bathroom faucet as he tries to void

The nurse manager on the surgical unit is making assignments for the day. Who is assigned to check and program the patient-controlled analgesia (PCA) pumps on the unit? A pharmacy technician One registered nurse (RN) One registered nurse (RN) and a certified nursing assistant (CNA) Two registered nurses (RNs)

Two registered nurses (RNs)

A client is being evaluated in the emergency department for a possible small bowel obstruction. Which signs and/or symptoms does the nurse expect to assess? Cramping intermittently, metabolic acidosis, and minimal vomiting Intermittent lower abdominal cramping, obstipation, and metabolic alkalosis Metabolic acidosis, upper abdominal distention, and intermittent cramping Upper abdominal distention, metabolic alkalosis, and great amount of vomiting

Upper abdominal distention, metabolic alkalosis, and great amount of vomiting

The nurse assesses that the patient has a full bladder, and the patient states that he or she is having difficulty voiding. The nurse would teach the patient to: Use the double-voiding technique. Perform Kegel exercises. Use Credé's method. Keep a voiding diary.

Use Credé's method.

A client has an anal fissure. Which intervention most effectively promotes perineal comfort for the client? Administering a Fleet's enema when needed Applying heat to acute inflammation for pain relief Avoiding the use of bulk-forming agents Using hydrocortisone cream to relieve pain

Using hydrocortisone cream to relieve pain

A client had a hip replacement 2 days ago and reports having a moderate amount of pain, stating that it is "a 7 on a 0-to-10 scale" of intensity. What intervention has the highest priority in the client's nursing care plan? Encouraging diversional activities Incorporating activities of daily living as soon as possible Teaching key points of the relaxation response Using pre-emptive analgesia

Using pre-emptive analgesia

A client admitted with severe diarrhea is experiencing skin breakdown from frequent stools. What is an important comfort measure for this client? Applying hydrocortisone cream Cleaning the area with soap and hot water Using sitz baths three times daily Wearing absorbent cotton underwear

Using sitz baths three times daily

The oncology nurse should use which intervention to prevent disseminated intravascular coagulation (DIC)? Monitoring platelets Administering packed red blood cells Using strict aseptic technique to prevent infection Administering low-dose heparin therapy for clients on bedrest

Using strict aseptic technique to prevent infection

The nurse is taking a health history of a newly admitted patient with a diagnosis Rule/out bowel obstruction. Which of the following is the priority question to ask the patient? Describe your bowel movements. How often do you have a bowel movement? When was the last time you moved your bowels? Do you routinely use stool softeners, laxatives, or enemas?

When was the last time you moved your bowels?

A client who had surgery for inflammatory bowel disease is being discharged. The case manager will arrange for home health care follow-up. The client tells the nurse that family members will also be helping with care. What information is critically important for the nurse to provide to these collaborating members? A list of medical supply facilities where wound care supplies may be purchased Proper handwashing techniques to avoid cross-contamination of the client's wound The amount of pain medication that the client is allowed to take in each dose Written and oral instructions regarding symptoms to report to the health care provider

Written and oral instructions regarding symptoms to report to the health care provider

Patients who are experiencing immobility often have which of the following emotions? (Select all that apply.) Helplessness Hunger Anger Anxiety Increased communication Improved self-worth

helplessness, anger, anxiety

A client has a diagnosis of lung cancer. To which areas does the nurse anticipate that this client's tumor may metastasize? (Select all that apply.) Brain Bone Lymph nodes Kidneys Liver

liver brain bone lymph nodes

The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient demonstrates: increased respirations. rapid pulse rate. red, sweaty skin. slow capillary refill.

slow capillary refill.