AMS Facts

A nurse is collecting data from a client who is receiving continuous ambulatory peritoneal dialysis. Which of the following findings should the nurse report to the provider?

A cloudy yellow drainage

Lung cancer indications

A productive cough

Reinforcing Preoperative teaching with client who has COLORECTAL CANCER and is scheduled to undergo placement of a colostomy with a perineal wound. Which of the following statements by the client indicates an understanding of the teaching?

"I can have only liquids for 3 day" -Full or clear liquids for 24-48 hours before surgery to decrease bulk. -DIET: low-residue diet for several prior to surgery to decrease PERISTALSIS -Client should sit on foam pads or soft pillows and avoid the use of rubber donut devices -Colostomy should begin to function 2-4 days after surgery

A hospice nurse is reinforcing teaching about palliative care to the partner of a client who has end-stage liver cancer (ESLC). Which of the following statements by the partner indicates an understanding of teaching?

"I will continue to talk to him, even when he's sleeping" -Clients approaching death often refuse nourishment and should Not be forced to eat/drink -Pts approaching death should be positioned with the head elevated or on a side -Clients should be covered with a non-electric blanket to keep the extremities warm

A nurse is reinforcing teaching with a client who has leukemia and has developed thrombocytopenia. Which of the following instructions should the nurse include in the teaching?

-Use an electric shaver when shaving -instruct the client NOT to floss -advise client NOT to blow nose of put anything up the nose -advise the client to wear shoes that have a firm sole to avoid accidental puncture of the sole

A nurse is caring for a group a medical-surgical unit. Which of the following disorders should the nurse identify as increasing the metabolic needs of the client?

1. COPD 2. Cancer 3. Parkinson's disease 4. Major burns

A nurse is caring for a client who had a thyroidectomy to treat hyperthyroidism cause by an adenoma. Which of the following findings should the nurse report to the provider?

1. Positive Trousseau's sign 2. Laryngeal stridor and hoarseness 3. Tachycardia and Hypertension

Peritonitis manifestations

cloudy drainage, fever, and abdominal tenderness

A nurse is collecting data from a client who has colorectal cancer. Which of the following manifestations should the nurse expect to find?

Abdominal cramps, changes in bowel habits, occult blood in the stool in the stool, weight LOSS, fatigue, and "gas pains". -blood in their stool Not in their urine -weight loss than weight gain -ANEMIA not polycythemia

A nurse is contributing to the plan of care for the client who has thrombocytopenia due to chemotherapy. Which of the following interventions should the nurse include?

Avoid IM injections, avoid invasive procedures -Promote safe oral hygiene and should be instructed to AVOID flossing due to risk of bleeding

A nurse is reinforcing teaching about urinary tract infection (UTIs) with a client. Which of the following manifestations should the nurse include?

Back pain, flank pain, frequency, urgency, and cloudy, foul-smelling urine

Current recommendations for early detection of breast cancer. The nurse should recommend which of the following strategies?

Begin annual mammograms at age 40 -Women should begin performing monthly breast examinations at age 20 years old. -(20 to 39 years of age) women should have a breast examination every 3 years -Women with high-risk factors for breast cancer might benefit from having "breast magnetic resonance imaging screening" but NOT recommended for all women

A nurse is assisting with planning care for a client who is postoperative following a radical mastectomy. Which of the following interventions should the nurse include in the plan?

Begin exercises with the client 1 day after the procedure to promote lymphatic and mobility -Nurse should elevate the arm on the affected side when client is in bed to promote return of lymphatic fluid -The nurse should plan to instruct the client to AVOID flexing her arm while ambulating to reduce the risk of contractures -The nurse should plan to ambulate the client on the 1st postoperative day to increase circulation

A nurse collecting data on a client who is 4 hours postoperative following trans-urethral resection of the prostate and has an indwelling urinary catheter in place. Which of the following findings should the nurse expect?

Blood-tinge urine in the drainage bag -The catheter should be free of kinks and coiling -Severe bladder spasms might be an indication of an obstruction; Report to Provider -Urinary output of less than 30 mL/hr can indication HYPOVOLEMIA (decrease in volume of blood in your body) or renal complications

A client who has stage II breast cancer asks the nurse about sites of metastasis for this cancer. Which of the following responses should the nurse make?

Breast cancer tends to metastasize to the (bones, lung, brain, and liver)

A nurse is caring for a client who has a fractured right hip. Which of the following types of traction should the nurse expect the client to have prior to hip arthroplasty surgery?

Buck traction (is used prior to a hip arthroplasty to maintain alignment and prevent muscle spasm before surgery)

A nurse is reinforcing dietary teaching with a client who has late-stage chronic kidney disease (CKD). Which of the following nutrients should the nurse instruct the client to increase in her diet?

Calcium -client with CKD can develop hypocalcemia DUE to production of active vitamin D, which is needed for calcium absorption -Client with CKD, can develop HYPERphosphatemia because of excretion of phosphorous by the kidneys -A client who has CKD can develop HYPERkalemia because of excretion of potassium by the kidneys - A client with CKD can develop HYPERatremia because of excretion of sodium by the kidneys

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse notes that the dialysate output is less than the input and that the client's abdomen is distended. Which of the following actions should the nurse take?

Change clients position - Peritoneal dialysis us used for clients who has acute or chronic kidney disease - If client is retaining the dialysate solution after the dwell time. Pain meds will NOT correct the cause.

A nurse is planning care for a client who is postoperative following a urinary diversion to treat bladder cancer. Which of the following interventions should the nurse include in the plan of care?

Change the collection pouch in the early morning -empty the collect pouch when it is 1/3 full to keep the excess of the urine from causing the pouch to separate from the skin -Nurse should expect NO DELAY in urinary output following surgery. -Monitor clients urine output hourly postoperative, then monitor every 4-8 hours after -Do not use hydrogen peroxide to cleanse skin. -Use water and soap for cleansing to decrease the risk for irritating the area around the stoma

A nurse is assisting with the plan of care for a client who has chronic obstructive pulmonary disease (COPD) and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan?

Eat high-calorie diet -client should rest before meals to decrease dyspnea (labored/difficulty breathing)

A nurse in an oncology clinic is collecting data from a client who has early stage Hodgkin's lymphoma. Which of the following findings should the nurse expect?

Enlarged lymph nodes -large lymph nodes, spleen, liver, and bone marrow - 1st manifestations of this cancer are enlarged painless lymph nodes, or nodes, which appear without a known cause -Other manifestations (night sweats, unexplained weight loss, a fever, and pruritus (itching)

A nurse is reviewing the laboratory data of a client who reports manifestations that suggest systemic lupus erythematosus (SLE). The nurse should expect an increase in which of the following parameters for a client who has SLE?

Erythrocyte sedimentation rate (ESR)

A nurse is caring for a client who has lung cancer that has metastasized. Which of the following findings indicates the client is developing superior vena cava syndrome?

Facial edema, upper extremity edema

A nurse is caring for a client who was in a motor-vehicle crash 2 days ago and sustained fractures to his tibia, ulna, and several ribs. The client is disorientated to tie and place and has an SaO2 at 87%. The nurse notes generalized petechiae (bleeding) on the clients skin. Which of the following complications should the nurse suspect?

Fat embolism syndrome

A nurse is reinforcing dietary teaching with a client who has chronic renal failure. Which of the following food choices by the client indicates the teaching has been understood?

Grilled fish our poultry (chicken) - AVOID foods high in sodium

A nurse is caring for a client who recently had chemotherapy and now has myelosuppression (bone-marrow depression). Which of the following interventions should the nurse initiate? (Select all that apply)

HIGH-RISK for infection after chemotherapy Prohibit bringing fresh flowers and plants into the clients room, -Ensure thorough cleaning of the clients room & bathroom daily, -Use delicate equipment items such as stethoscope

A nurse is caring for a client who has chronic glomerulonephritis with oliguria (small amounts of urine). For which of the following electrolyte imbalances should the nurse monitor?

Hyperkalemia; potassium retention Potassium Range: 3.5-5.0 mEq/L -Calcium levels usually below expected range of 9-10.5 mg/dL -Magnesium levels usually withing expected range of 1.3-2.1 mEq/L -Phosphorous level above the expected reference range of 3-4.5 mg/dL

A nurse is caring for a postoperative client whose surgeon informed him of a metastasizing malignant neoplasm in the colon. Which of the following statements indicates that the client understands this information?

I have cancer of the colon that has begun to spread. Neoplasm- is a continued growth of nonessential cells, and the term "malignant" means that these cells are cancerous. Mestasizing (spreading) to adjacent tissue -client does have growths in his bowel -client is still at high-risk for morbidity & mortality

A nurse is reinforcing discharge teaching with a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching?

I should take ibuprofen for my joint pain -SLE affects the skin, joints, organs, and any structure in the body that contains connective tissue

A nurse is reinforcing teaching with a client who is being treated for genital warts. Which of the following statements indicates that the client understands how to prevent transmission of his sexually transmitted infection (STI)?

I will bring in my sexual partner for treatment

A nurse is reinforcing teaching with a client who has Stomatitis due to chemotherapy. Which of the following statements by the client indicate a need for further instructions?

I will cleanse my mouth after meals with an alcohol-based mouthwash

A nurse is reinforcing discharge with a client following open radical prostatectomy. The client is going home with an indwelling urinary catheter. Which of the following statements by the client indicates an understand of the teaching?

I will take acetaminophen if i have any pain -AVIOD Aspirin & acetaminophen for at least 2 weeks followin surgery to PREVENT the risk of bleeding -Shower vs taking a bath for 2-3 weeks following an open radical proctectomy -Nurse should instruct client to use stool softeners rather than suppositories to control constipation -clients bladder control might not return immediately; but practicing Kegel exercises can help with incontinence. -Urinary incontinence can last 1-2 years following surgery

A nurse is collecting data from a client who had radioallergosorbent (RAST) testing completed due to seasonal allergies. The nurse should anticipate an elevation in which of the following laboratory values?

IgE (immunoglobulin E)

A nurse is assisting with the admission of a client who has manifestations of tuberculosis. Which of the following actions is the nurses priority?

Initiate airborne precautions

A nurse is assisting with planning of an in-service training session regarding nutrition. Which of the following minerals should the nurse include as a factor in oxygen transportation?

Iron (transports oxygen via hemoglobin and myoglobin)

A nurse is caring for a client who is receiving "brachytherapy" (radiation therapy: in which radiation source in direct contact with Tumor). Which of the following measures should the nurse contributes to the clients plan of care?

Keep the door to the client's room closed -Nurse should organize tasks to limit the time spent with the pt -Brachytherapy so not involve chemo meds -Limit visitors to 30 min a day and caution visitors to stay at least 1.8M (6 FEET) away from client

Neutropenia Interventions

Limit visitors for the client

Stones in the bladder

Manifestations: irritation PAIN in: vulva & scrotal areas

A nurse is collecting data from a client who has cancer of the cervix. Which of the following manifestations should the nurse expect?

Most common manifestation is PAINLES VAGINAL BLEEDING

Fat embolism syndrome

Neurological changes, petechial rash, and hypoxemia

A nurse is collecting data from a cleint who has acute kidney injury (AKI). According to the RIFLE classification system, which of the following findings should the nurse identify as an indication that the client has end-stage kidney disease?

No urine output without renal replacement therapy for more than 3 months RIFLE R: risk I: Injury F: failure L: Loss E: End-stage kidney disease

A nurse is collecting a health history from a client who has skin cancer. Which of the following findings in the client's history is the highest risk factor for developing skin cancer?

OVERexposure to sunlight -Being over the age of 6 is a risk for skin cancer; but the greater risk is Overexposure to sunlight -A genetic predisposition is a risk factor -Being of a light-skinned race is a risk factor

A nurse is caring for a client who is receiving radiation therapy for breast cancer and reports a metallic taste in the mouth. Which of the following dietary recommendations should the nurse relay?

Offer mints -Encourage to pt to eat with plastic utensils -Encourage coffee to sweet beverages or milk to cut the sweet taste for a client who reports "metallic taste" in mouth -Encourage pt to consume foods that contain citrus or have tart flavor.

Stones in the KIDNEYS (renal tubules & renal pelvis)

PAIN in: cost-vertebral region & flank pain

A nurse is contribution to the plan of care for a client who has cancer and is scheduled to receive internal radiation therapy. Which of the following actions should the nurse recommend?

Place client in private room; to prevent exposing other clients/visitors to radiation -All staff should wear dosimeter badges to monitor radiation exposure -Staff should don a lead apron before entering the clients room to decrease radiation exposure. -pick up dislodged implants with forceps and place them in LEAD container to prevent radiation exposure.

A nurse is assisting with the care of a client who has a chest tube in place following a thoracotomy. Which of the following actions should the nurse take?

Place the drainage unit below the client's chest level

Elevated IgA

associated with autoimmune disease and chronic infection

A nurse is planning a presentation in a community center about risk factors for cancer. Which of the following types of cancer should the nurse include when discussing familiar clustering of specific types if cancer?

Prostate -cancers familiar tendencies (breast, colorectal, ovarian, and prostate)

Thrombophlebitis/DVT

Reports: tenderness and warmth over the involved vein

Elevated igM level

associated with bacterial or viral infection (produces antibodies to protect against infections)

Decline in muscle mass is common with aging

Risk factor for mobility problems NOT cancer

Mucositis (Adverse effect of chemotherapy)

Sores in the mucous membrane

A nurse is collecting data from a client who has cancer and is receiving chemotherapy by peripheral IV infusion. The client reports pain at the insertion site, and the nurse notes fluid leaking around the catheter. Which of the following actions should the nurse take first?

Stop the infusion -nurse should take a photograph of the IV site to document potential harm from extravasation, however their is something else that is priority -nurse should take/record clients vital signs, however something else is more important -nurse should identify all medications administer through IV site for the past 24 hours; but something else is priority

A nurse is caring for a client who has breast cancer and is receiving a combination of chemotherapy medications. The client expresses confusion about the therapy. Which of the following explanations should the nurse provide?

The chemotherapy medications acts at different stages of cell division so more tumor cells are destroyed

Alopecia (Adverse Effect of chemotherapy)

Thinning of the scalp

A nurse is caring for a client who has testicular cancer and is experiencing peripheral neuropathy as an adverse effect of chemotherapy. Which of the following client manifestations is an expected finding of peripheral neuropathy?

Tingling of the hands & feet; numbness tinging of extremity

Elevated IgG

associated with infection especially blood borne and tissue infections

Cervical cancer manifestations

Unexplained weight loss, dysuria (painful urination), & pelvic pain)

A nurse is assisting with the admission of a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications?

Vasopressin

A nurse is preparing a client who is scheduled for an intravenous pyelogram (IVP). Which of the following findings should the nurse REPORT to the provider?

Vomiting & diarrhea for the last 6 hours -allergic reaction to IVP; client who is allergic to... 1. shellfish 2. iodine 3.contrast

A nurse is reinforcing teach about foot care with a client who diabetes mellitus. Which of the following pieces of information should the nurse include in the teaching?

Wash your feet daily with lukewarm water and soap

A nurse is planning a presentation for a group of older adults at a senior community center about risk factors for cancer. Which of the following factors increases the risk of developing cancer after age 60?

Weakened immune responses, hormonal changes, altered immune responses, and accumulation of free radicals carcinogenic factors (tobacco & alcohol use, environmental pollutants, & radiation) -High-fat, low-fiber diet is at risk for colon cancer

A nurse is collecting data from a client who has urolithiasis and report pain in his thigh. A nurse should identify that this finding indicates the stone is in which of the following structures?

When stones are in ureters, pain radiates to the genitalia and to the thighs

A nurse is reinforcing with a client who is HIV positive about the early manifestations of acquired immune deficiency syndrome e(AIDS). Which of the following statements should the nurse include in the teaching?

You can expect a persistent fever and swollen glands AIDS manifestations -fever -swollen glands -diarrhea -weight loss -fatigue

A nurse is reinforcing teaching about a prostate-specific antigen (PSA) test with a client. Which of the following statements should the nurse make?

You don't need to fast prior to the PSA test -Fasting is not required for the PSA test; client may eat and drink -American Cancer Society recommends that all men begin annual PSA tesing at age 50 -If family hx of of prostate cancer, discuss with provider; possible benefits of initiating testing at age 45 -Ejaculation within 24 hours prior to the test can cause falsely elevated levels of PSA

A nurse is reinforcing postoperative discharge teaching with a client following a panhysterectomy (removal of uterus/ovaries) for uterine cancer. Which of the following pieces of information should the nurse provide?

You might have manifestations of menopause (hot flashes, sweats, and vaginal dryness) -Pregnancy is not possible, and birth control is no longer -Do not lift anything heavier than 5-10 lbs -Report: pain or burning on urination

A nurse is reinforcing teaching with a client who has acute pyelonephritis. Which of the following instructions should the nurse include in the teaching?

You should complete the entire cycle of antibiotic therapy -Pt with acute pyelonephritis can take NSAIDs as needed for pain -A pt should balance rest and activity and does NOT require complete bed rest -Pt should drnk at least 2,000 mL per day

A nurse on an oncology unit is reinforcing discharge teaching with an adolescent client who received a bone marrow transplant for leukemia. Which of the following pieces of information should the nurse include? (select all that apply)

You should take your temperature at least once a day; examine your feet every day -Raw foods can carry bacteria that may lead to an increased risk of infection -Alcohol can cause trauma and irritation to the gum and tissue. Rinse the toothbrush in a weak bleach solution or pacing it in the dishwasher weekly are safer alternatives -Avoid crowds such as those encountered at school, a mall, or a movie theater

Hypovolemic Shock

hypotension following extreme fluid loss, as with uncontrolled bleeding, dehydration, or severe edema

Bladder cancer indications

intermittent blood in the urine

UTI manifestations

muscle cramps

Osteomyelitis

open wound fracture and report hyperthermia

Vaginal infection manifestation

vaginal discharge

Acute kidney injury manifestations

weight gain

Fluid retention manifestation

weight gain