exam 2 modules 4-7

The nurse is caring for four clients. Which does the nurse identify that is at the greatest risk for developing vision disturbances? A. 29 year old who plays sports B. 39-year old who uses a computer for work C. 50 year old with rheumatoid arthritis D. 62-year old with hypertension

D. 62-year old with hypertension

Which patient does the nurse identify at highest risk for development of dry age-related macular degeneration (AMD)? A. 55-year old client who recently began wearing glasses B. 59-year old client who has controlled hypertension C. 62-year old client with hypothyroidism D. 65-year old client with diabetes

D. 65-year old client with diabetes

What teaching will the nurse provide to a client who has just been fitted for new hearing aids? A. Leave the hearing aid on, even if not wearing it B. Immerse the ear mold in alcohol to fully clean it C. Store the hearing aid in a warm, humid bathroom when not in use D. Avoid using hair spray, makeup, and personal care products around the device

D. Avoid using hair spray, makeup, and personal care products around the device

the nurse understands that normal cells and benign cells share which characteristics? SATA 1. no migration 2. orderly growth 3. tight adherence 4. specific morphology 5. large nuclear-to-cytoplasmic ratio

1. no migration 2. orderly growth 3. tight adherence 4. specific morphology

which primary prevention strategy does the nurse recommend to a client concerned about development of cancer? 1. removal of a mole on the abdomen 2. have a fecal occult blood test annually 3. obtain a baseline colonoscopy at 50 years old 4. women should speak to their provider about a mammogram

1. removal of a mole on the abdomen

The nurse performs an initial health assessment of an older adult. Which assessment findings indicate that the client may be at risk for falls? Select all that apply. A. Has presbyopia B. Has peripheral neuropathy C. Uses a cane D. Takes multiple medications E. Has bilateral cataracts F. Has thin papery skin

A. Has presbyopia B. Has peripheral neuropathy C. Uses a cane D. Takes multiple medications E. Has bilateral cataracts

which provider order will the nurse implement first when caring for this client? 1. feed clear liquid diet 2. apply support stockings 3. obtain lab samples 4. administer D5 1/2 NS @125 mL/hr

4. administer D5 1/2 NS @125 mL/hr

A 74-year-old client has been diagnosed with a cataract in the left eye. He reports a decrease in visual acuity and cloudiness in the vision of the left eye. What is the nurse's appropriate response when the client questions why this only affected on eye?

A cataract is an opacity of the lens that distorts the image projected onto the retina. As a person ages, the lens gradually loses water and increases in density. As the density of the lens increases, it becomes opaque. Both eyes may have cataracts; however, the rate of progression in each eye is usually different. Surgery is the only cure for cataracts, but people can live with reduced vision for years before it is necessary to remove a cataract.

The client is discharged, and home health services are arranged. What is the home health nurse's assessment priority? (Select all that apply.) A. GI status B. Condition of the stoma C. Peristomal skin condition D. Patient and family's coping skills E. Results of daily laxative prescription

A. GI status B. Condition of the stoma C. Peristomal skin condition D. Patient and family's coping skills

The nurse is caring for four female clients. Which client does the nurse identify at the risk for breast cancer? A. 28-year-old African-American with early menarche B. 36-year old Asian-American with 3 children C. 45-year-old Native American with family history of lung cancer D. 50-year-old Caucasian American withongoing menarche

A. 28-year-old African-American with early menarche

The nurse is caring for an older client who is experiencing acute confusion and agitation following a fractured hip repair this morning. Which risk factors may be contributing to the client's delirium? Select all that apply. A. Anesthesia used during surgery B. Surgical pain C. Unfamiliar environment D. Noisy hospital unit E. Medications used to manage pain

A. Anesthesia used during surgery B. Surgical pain C. Unfamiliar environment D. Noisy hospital unit E. Medications used to manage pain

The nurse is assessing a client with a chest tube following a pneumonectomy. Which assessment finding requires nursing intervention? A. Bandage around the posterior tube is loose. B. 2 cm of water is in the second chest tube chamber. C. The water in the water seal chamber rises and falls with inhalation/exhalation. D. Bubbling present in the water seal chamber when the client coughs

A. Bandage around the posterior tube is loose.

An older client reports all of the following changes since his last checkup. Which changes alert the nurse to the possibility of prostate cancer? Select all that apply. A. Bloody urine B. Constipation intermittent with diarrhea C. Erectile dysfunction D. Night sweats and fever E. Persistent pain in the lower back and legs F. Reduced urine stream

A. Bloody urine D. Night sweats and fever E. Persistent pain in the lower back and legs F. Reduced urine stream

Which new symptoms in a client who is being managed for sickle cell crisis does the nurse report immediately to prevent harm? Select all that apply. A. Decreased handgrip strength on one side B. Diffuse abdominal pain C. Fever of 102.2 F (39 C) D. Increased urine output E. Shortness of breath F. Sore throat

A. Decreased handgrip strength on one side C. Fever of 102.2 F (39 C) E. Shortness of breath

When caring for a 28-year old healthy client, how frequently does the nurse recommend a clinical breast examination (CBE)? A. Every 3 years B. At each annual physical C. Not until age 30 as the risks are low D. To begin at age 40 when risks increase

A. Every 3 years

Which statement about the genetics of cystic fibrosis is true? A. Recessive disorder affecting chloride transport B. Recessive disorder affecting alpha1-antitrypsin levels C. Dominant disorder inhibiting alveoli formation D. Dominant disorder increasing production of interleukin-5

A. Recessive disorder affecting chloride transport

With which types of anemia does the nurse ask the client about the presence of the disorder in other family members? Select all that apply. A. Sickle cell anemia B. Folic acid deficiency anemia C. Glucose-6-phosphate dehydrogenase deficiency anemia D. Iron deficiency anemia E. Pernicous anemia F. Vitamin B12 deficiency anemia

A. Sickle cell anemia C. Glucose-6-phosphate dehydrogenase deficiency anemia E. Pernicious anemia

Which communication method is appropriate when the nurse is interacting with a client who is deaf? A. Use pictures and writing B. Speak with enunciated words C. Ask client to read the nurse's lips D. Dialogue specifically with the client's caregivers

A. Use pictures and writing

Six months later, the client returns because she has noticed a lump in her left breast. Upon examination, a small mass is palpated. A diagnostic mammogram is ordered and confirms the presence of a 2 × 3 cm mass. The client is scheduled for a surgical excisional biopsy. What should the client be taught about this procedure?

An excisional biopsy removes the mass itself for histologic (cellular) evaluation for cancer.

The nurse is teaching about infection prevention to a client with cancer who is neutropenic. Which client statement requires additional teaching? A. "I will call the healthcare provider if I get a temperature of 100.4 or greater. B. "I will wash my hands after attending church." C. "I will wear a condom when having intercourse." D. "I will not drink anything that has been at room temperature for more than an hour."

B. "I will wash my hands after attending church."

A client with COPD has just been reclassified for disease severity from a GOLD 2 to a GOLD 3. Which client statement about changes in management or lifestyle indicate to the nurse that more teaching is needed to prevent harm? A. "This year I will get the pneumonia vaccination in addition to a flu shot." B. "Now I will try to rest as much as possible and avoid any unnecessary exercise." C. "Maybe drinking a supplement will help me retain weight and have more energy." D. "Perhaps using a spacer with my metered dose inhaler will make the drug work better."

B. "Now I will try to rest as much as possible and avoid any unnecessary exercise."

A client with a history of BPH calls the telehealth nurse reporting the sudden onset of testicular pain after moving heavy furniture. What is the appropriate nursing response? A. "Taking ibuprofen may help alleviate the pain." B. "Please go to your closest emergency department right away." C. "This is a common reaction when performing labor; the pain will go away." D. "Your BPH is probably giving you difficulty because you were moving furniture."

B. "Please go to your closest emergency department right away."

When caring for four clients, which individual does the nurse identify at the highest risk for development of breast cancer? A. 33-year-old male with gynecomastia and obesity B. 45-year-old female whose mother has breast cancer C. 60-year-old male whose father died from colon cancer D. 72-year-old female who was treated for breast cancer 3 years ago

B. 45-year-old female whose mother has breast cancer

A client with a history of asthma reports shortness of breath. The nurse observes that the peak flow meter indicates a peak expiratory flow (PEF) reading that is in the red zone. What is the priority nursing action? A. Obtain vital signs. B. Administer rescue drugs. C. Notify the health care provider. D. Repeat the PEF reading to verify results

B. Administer rescue drugs.

The client, who is 24 hours postoperative after a right lower lobectomy for stage II lung cancer and has two chest tubes in place, reports intense burning pain in his lower chest. On assessment, the nurse notes there is no bubbling on exhalation in the water seal chamber. What action will the nurse perform first? A. Immediately notify either the Rapid Response Team or the thoracic surgical resident. B. Assist the client to a side-lying position and re-assess the water seal chamber for bubbling. C. Administer the prescribed opioid analgesic immediately, and then assess the chest tube system. D. No action is needed because these responses are normal for the first post-op day after lobectomy.

B. Assist the client to a side-lying position and re-assess the water seal chamber for bubbling.

A client has a new diagnosis of irritable bowel syndrome (IBS) with diarrhea. What health teaching by the nurse is appropriate for this client? A. "Take a stool softener every day to ease defecation." B. "Avoid high-fiber foods in your diet." C. "Avoid dairy products and caffeinated beverages." D. "Ask your primary health care provider for an antidepressant."

C. "Avoid dairy products and caffeinated beverages."

When performing a medication reconcilliation for a newly admitted client before planned abdominal surgery, the nurse notes that the client is prescribed salmeterol and fluticasone daily for asthma control. What is the priority action for the nurse to take regarding this information to prevent harm? A. Record and display the information in a prominent place within the client's medical record. B. Ask the client how long the drugs have been prescribed and how well the asthma is controlled. C. Collaborate with the surgeon to arrange for continuation of this therapy in the postoperative period. D. Ensure that parenteral forms of these drugs are prescribed for use while the client remains NPO after surgery.

C. Collaborate with the surgeon to arrange for continuation of this therapy in the postoperative period.

The family of a client receiving a blood transfusion excitedly report to the nurse that although the the blood bag hanging has the client's name on it, the bag label says B negative and the client's blood type is B positive. What is the nurse's priority action? A. Alert the blood bank and Rapid Response team to a potential error. B. Thank the family for being alert and preventing a serious complication. C. Explain that a person who is Rh positive can receive Rh negative blood. D. Immediately go and stop the infusion but keep the IV line open with normal saline.

C. Explain that a person who is Rh positive can receive Rh negative blood.

Which specific cancer types have a higher rate of occurrence among the Hispanic/Latino population of the United States compared with the non-Hispanic white population? Select all that apply. A. Breast B. Colorectal C. Gall bladder D. Liver E. Lung F. Prostate G. Stomach

C. Gall bladder D. Liver G. Stomach

Which statements made by a 62-year-old client alert the nurse to the possibility that he may be at increased genetic risk for cancer development? Select all that apply. A. An older aunt died from a brain tumor while she had breast cancer. B. He had two benign colon polyps removed during his most recent routine colonoscopy. C. His sister died from cancer of the appendix. D. His brother is being treated for breast cancer. E. His 32-year-old daughter has been recently diagnosed with cervical cancer. F. One person in each of the previous three generations of his family died from lung cancer.

C. His sister died from cancer of the appendix. D. His brother is being treated for breast cancer.

The nurse is assessing a client that has advanced bone cancer. Which client assessment data causes the nurse to suspect spinal cord compression? Select all that apply. A. Reports of a headache for the past 7 hours. B. Decreased breath sounds in the left lung. C. Worsening mid-thoracic back pain. D. Tingling in the right lower extremity. E. Unsteady gait when ambulating to the bathroom. F. Reports of difficulty sleeping.

C. Worsening mid-thoracic back pain. D. Tingling in the right lower extremity. E. Unsteady gait when ambulating to the bathroom.

What priority question will the nurse ask when taking a history of a client with BPH? A. "Do you have high blood pressure?" B. "Have you had a recent urinary tract infection?" C. "Do you have a family history of kidney disease?" D. "Do you have difficulty starting and continuing urination?"

D. "Do you have difficulty starting and continuing urination?"

What is the appropriate nursing response when a 66-year-old healthy client asks how often a visit to the eye care provider is recommended? A. "Annually." B. "Every 6 months." C. "Only if you have vision problems." D. "Every 1 to 2 years if you have no eye problems."

D. "Every 1 to 2 years if you have no eye problems."

A client with primary pulmonary arterial hypertension (PAH) receiving treprosinil by continuous IV infusion now has a fever of 101.6 degrees F (38.7 degrees C). Which actions will the nurse perform to prevent harm? Select all that apply. A. Administer the prescribed antipyretic B. Ask the client whether a productive cough is present C. Apply oxygen by nasal cannula D. Culture the IV site E. Determine whether a durable power of attorney has been signed F. Increase the treprostinil flow rate G. Initiate a second IV access and administer prescribed antibiotic H. Place the client in protective isolation

D. Culture the IV site F. Increase the treprostinil flow rate G. Initiate a second IV access and administer prescribed antibiotic

Pathologic examination of the removed breast lump tissue reveals malignancy. The client undergoes a modified radical mastectomy with lymph node dissection, which will be followed by radiation and chemotherapy.4. What immediate postoperative intervention will the nurse implement? A. Check vital signs every four hours. B. Position the client supine to facilitate drainage. C. Instruct assistive personnel (AP) to avoid taking blood pressure (BP) in the client's right arm. D. Measure the Jackson-Pratt tube drainage and assess color and odor

D. Measure the Jackson-Pratt tube drainage and assess color and odor

Three days later the stoma is functioning. Whatstool assessment finding does the nurse anticipate? A. Very little stool and mostly gas B. Diarrhea liquid stool C. Pasty stool D. More solid stool

D. More solid stool

The nurse is conducting an assessment of an older adult living in the community. Which assessment findings are considered usual physiologic changes of aging? Select all that apply. A. Dementia B. Relocation stress C. Urinary incontinence D. Presbyopia E. Obesity

D. Presbyopia

The client's stool is positive for occult blood. He is admitted to the inpatient oncology unit, and soon passes bright red blood from the rectum. Where does the nurse anticipate that the client's tumor is located? A. Ascending colon B. Transverse colon C. Descending colon D. Rectosigmoid colon

D. Rectosigmoid colon

The health care provider orders a prostate ultrasound; the client is soon diagnosed with BPH, and prescribed finasteride. What teaching will the nurse provide?

Finasteride is a 5-alpha reductase inhibitor (5-ARI) that lowers DHT and shrinks the prostate as well as prevents further growth. It is important to remind clients taking a 5-ARI drug that it may take up to 6 months before improvement occurs.Side effects include erectile dysfunction and decreased libido

Six months later, the client's symptoms have not significantly improved. After consulting with a surgeon, heis scheduled for a transurethral resection of the prostate(TURP). Which postoperative interventions will the nurse provide?

The client should be helped out of bed to the chair as soon as permitted to prevent complication of immobility. The nurse will assess for signs of infection, check urinary output every 2 hours, remind the client that urine may beblood-tinged, and administer pain and antispasmodic medications as needed

When assessing the patient with benign prostatic hyperplasia (BPH). Which assessment finding does the nurse anticipate?

In a patient with BPH, a distended bladder is anticipated.

The nurse is caring for a 56-year old client with a family history (sister, father) of colorectal cancer(CRC). He reports that steak and fried foods are his diet of choice. He was diagnosed with ulcerative colitis 3 years ago and treated for prostate cancer 2 years ago. What risk factors does the nurse identify that place the client at risk for CRC?

Positive family history with first-degreerelatives; dietary habits (red meat and friedfoods); history of ulcerative colitis and prostatecancer.

A 60-year-old woman with COPD who smoked cigarettes for 40 years is admitted to the hospital. When the client arrives to the unit, she is assessed and is in acute respiratory distress.Her respirations are labored with a respiratory rate of 32. Oxygen saturation is 82% on O2 at2 L/min via nasal cannula. What will the nurse do next?

The Rapid Response Team should be notified immediately. All of these assessment findings indicate acute respiratory difficulty. The oxygen saturation should be at least 90% on 2 L per NC

what does the nurse teach a client undergoing chemotherapy about the expected outcome related to hair loss? 1. hair loss maybe permanent. 2. viable treatments exist for the prevention of alopecia 3. hair regrowth usually begins about 1 month after completion of chemotherapy 4. new hair growth is usually identical to previous hair growth in color and texture

3. hair regrowth usually begins about 1 month after completion of chemotherapy

The nurse is caring for a client who has a transurethral resection of the prostate (TURP). which assessment finding requires immediate nursing intervention? 1. Temperature 99.9 F 2. Pain of 6/10 3. Report of bladder spasms 4. Bleeding from the surgical site

4. Bleeding from the surgical site

After recovery, the nurse provides postoperative teaching for the patient. Which client statement indicates a need for further teaching by the nurse? A. "Aspirin will help decrease discomfort." B. "I will wear dark sunglasses to protect my eyes." C. "My daughter will help me if I need to lift something." D. "The surgeon needs to know if I experience reduced vision."

A. "Aspirin will help decrease discomfort."

A client with prostate cancer is receiving external beam radiation for treatment. What teaching will the nurse provide following the radiation treatment? A. "After the treatment, there is no radiation hazard to others." B. "Do not share a bathroom with your spouse for 2 days." C. "Visitors should be limited to 30 minutes to avoid prolonged radiation exposure." D. "Report a temperature of 99.1F to the healthcare provider."

A. "After the treatment, there is no radiation hazard to others."

Which client statement regarding a new diagnosis of tinnitus requires nursing teaching? Select all that apply. A. "I am so glad this condition will go away permanently." B. "It is important that I do not drive when I have tinnitus." C. "Watching my diet will make a difference in my condition." D. "Surgery is the only treatment that is available for tinnitus." E. "I have found a couple of support groups that I like to attend."

A. "I am so glad this condition will go away permanently." C. "Watching my diet will make a difference in my condition." D. "Surgery is the only treatment that is available for tinnitus."

A week later, the client's hearing is tested by audiometry and it is recommended that she would benefit from a hearing aid. Which client statement indicates the need for additional nursing teaching about hearing aid care? A. "I can wear my hearing aid at all times, even when bathing." B. "I should check and replace the battery whenever needed." C. "I can clean the hole in the hearing aid of debris with a toothpick." D. "I should adjust the hearing aid's volume to the lowest setting that lets me hear without hearing feedback."

A. "I can wear my hearing aid at all times, even when bathing."

What is the priority nursing intervention when providing care to a client with hearing loss? A. Creating a safe environment B. Providing written information regarding medications that are prescribed C. Having the client repeat instructions to evaluate additional teaching needs D. Ensuring that the client can directly visualize the nurse who is providing teaching

A. Creating a safe environment

The client is diagnosed with suspected hearing loss. What teaching will the nurse provide? (Select all that apply.) A. Have hearing assessments annually. B. Avoid exposure to loud music or other noises. C. Ear plugs should be used if you are swimming. D. Use cotton swabs to clean your ear canal showering. E. Nothing smaller than a fingertip should be inserted into the ear canal.

A. Have hearing assessments annually. B. Avoid exposure to loud music or other noises. C. Ear plugs should be used if you are swimming. E. Nothing smaller than a fingertip should be inserted into the ear canal.

1. A nurse is reviewing the lab values of a cancer patient. The client has thrombocytopenia with a platelet count of 2500 mm3. Which of these actions should the nurse take? SATA A. Pad sharp surfaces to protect injury B. Educate client to avoid fresh fruits and vegetables (avoid warfarin) C. Use large bore needle for venipuncture (limit invasive procedures) (use small bore needle) D. Lift patient up when transferring and repositioning E. Provide client with soft diet (pureed etc.)

A. Pad sharp surfaces to protect injury D. Lift patient up when transferring and repositioning E. Provide client with soft diet (pureed etc.)

1. A client receiving chemo develops erythema and ulcers in mouth. Which of these actions is (are) appropriate for the nurse to take? SATA A. Provides client with soft bristled toothbrush B. Encourages client to eat spicy food C. Gives client cold foods D. Apply topical anesthetics before and after meals E. Provide small frequent meals F. Moisturize the client's mouth with nonalcoholic swabs

A. Provides client with soft bristled toothbrush D. Apply topical anesthetics before and after meals E. Provide small frequent meals F. Moisturize the client's mouth with nonalcoholic swabs

1. The nurse delegates care of a client with thrombocytopenia from prostate cancer to UAP. Which action by the UAP should cause the nurse to intervene? The UAP A. Slides patient on bed when repositioning patient in bed B. Uses an electric shaver rather than a razor to shave client's beard C. Asks the client to wear shoes with firm soles whenever ambulating D. Notifies the nurse about a clients fall in the bathroom

A. Slides patient on bed when repositioning patient in bed

1. A nurse is performing cancer screening in a community. Which of the following clients requires an immediate referral for screening and evaluation after the nurse's assessment? SATA A. The client reporting unintended weight loss of 30 pounds over past month B. Client who has developed small flat macules of brown melanin on her back C. The client who has thickening or lump in breast D. The client who reports nagging cough and hoarse voice in last 2-3 months E. The client who reports periodic hematuria with urinary frequency F. The client who reports ribbon like stool with periodic diarrhea

A. The client reporting unintended weight loss of 30 pounds over past month C. The client who has thickening or lump in breast D. The client who reports nagging cough and hoarse voice in last 2-3 months E. The client who reports periodic hematuria with urinary frequency F. The client who reports ribbon like stool with periodic diarrhea

The nurse is taking a history for a 66-year-old female client whose sister has breast cancer. She is married and has never been pregnant. She smokes, but states she has "cut down a lot lately" and reports consuming"a couple" of glasses of wine daily. What factors place this client at risk for breast cancer? (List all that apply.)

Age is the primary risk factor for breast cancer. Additional risk factors include family history with first-degree relatives, nulliparity,smoking, and alcoholic consumption of two or more drinks per day

A 70-year-old man reports difficulty with starting a urine stream and dribbling after urination. What questions will the nurse ask when taking the client's history?

Ask the patient about urinary pattern, frequency,nocturia, and changes in the force and size of the urinary stream. Ask about blood in the urine—BPH is a common cause of hematuria in older men.

Which client statement affirms that nurse teaching about instillation of multiple different eye drops has been effective? Select all that apply. A. "It will be very easy for me to instill all of the drops at one time." B. "A schedule will help me remember when to instill the eyedrops." C. "If I have trouble instilling the drops, there are devices that can be helpful." D. "I can label the eye drops by color to help me easily distinguish which one is which." E. "I will not touch the droppers to my eyes as this can cause contamination and infection."

B. "A schedule will help me remember when to instill the eyedrops." C. "If I have trouble instilling the drops, there are devices that can be helpful." D. "I can label the eye drops by color to help me easily distinguish which one is which." E. "I will not touch the droppers to my eyes as this can cause contamination and infection."

1. The nurse is teaching a client who has been prescribed an oral chemotherapy agent. What teaching will the nurse include? A. "Oral chemotherapy drugs are not as toxic as IV chemotherapy." B. "Do not crush, split, break, or chew the oral chemotherapy drug." C. "You may dispose of unused oral chemotherapy drugs in the trash." D. "Oral chemotherapy drugs are not absorbed through the skin."

B. "Do not crush, split, break, or chew the oral chemotherapy drug."

The nurse is teaching a client with erectile dysfunction about taking sildenafil to achieve an erection. Which client statement demonstrates an understanding of this drug? A. "I can have sex up to 8 hours after taking the drug." B. "I might get a headache or stuffy nose when this drug is used." C. "Taking this with a drink or two of alcohol will enhance my performance." D. "If one pill doesn't work, it is acceptable for me to quickly take another pill."

B. "I might get a headache or stuffy nose when this drug is used."

Which assessment finding alerts the nurse that a client is at risk for hearing loss? Select all that apply. A. Is male B. Advanced age C. Takes furosemide regularly D. Has a history of heart failure E. Worked as a sound manager for a band

B. Advanced age C. Takes furosemide regularly E. Worked as a sound manager for a band

1. A nurse is caring for a client who has a NG tube placed after colon resection. The surgery was completed 2 hours ago. The nurse notes 400 mL of bright red blood in the collection canister. Select all the appropriate actions should nurse take? A. Clamp the NG tube at this time B. Obtain clients VS C. Assess surgical incision for bleeding D. Assess the client's abdomen for distention E. Notify HCP

B. Obtain clients VS C. Assess surgical incision for bleeding D. Assess the client's abdomen for distention E. Notify HCP

When teaching a community group of older adults, what information will the nurse include regarding normal hearing changes associated with aging? Select all that apply. A. Hair in the ear thins and fall outs B. Hearing acuity changes in all older adults C. Cerumen dries and becomes impacted more easily D. The ability to hear low-frequency pitches diminishes first E. Sounds such as f, s, sh, and pa may be more difficult to discern

C. Cerumen dries and becomes impacted more easily E. Sounds such as f, s, sh, and pa may be more difficult to discern

The nurse reaches the patient that an important measure to prevent perineal skin damage from external radiation beam treatment is to: A. Test all stools for the presence of blood B. Inspect the mouth and throat daily for thrush appearance C. Perform perineal care with cool sitz baths using plain water only, no soap D. Maintain a high residue (this is recommended), high fat diet (not recommended)

C. Perform perineal care with cool sitz baths using plain water only, no soap

The nurse is caring for a client who just had a bilateral mastectomy. When the client states, "my partner is going to hate how I look", what is the appropriate nursing response? A. "I'm sure your partner will be accepting." B. "Have you asked your partner about their feelings?" C. "We can work on that after you are feeling stronger." D. "It sounds like you are concerned about how your body looks after surgery."

D. "It sounds like you are concerned about how your body looks after surgery."

When caring for four clients, which individual does the nurse identify that should not receive an otoscopic examination? A. 25-year-old with throat and ear pain B. 39-year-old experiencing dizziness C. 46-year-old who has type II diabetes D. 60-year-old experiencing delirium

D. 60-year-old experiencing delirium

While taking a history, the nurse notices a deformity of a client's right external ear. What is the priority nursing assessment? A. Visual accuracy B. Hearing deficits C. Cardiopulmonary history D. Kidney or urinary tract problems

D. Kidney or urinary tract problems

Which intervention is a priority for the nurse to teach the client with polycythemia vera to prevent harm related to injury as a result of impaired platelet function? A. Wear gloves and socks outdoors in cool weather. B. Elevate your feet whenever you are seated. C. Drink at least 3 liters of liquids per day. D. Use a soft-bristled toothbrush.

D. Use a soft-bristled toothbrush.

The client is in the ICU for 3 days and then transferred back to a pulmonary stepdown unit.She is still slightly short of breath with exertion. Her O2 saturation is 99% on oxygen at 2L/min via nasal cannula. She denies any shortness of breath when resting during the assessment.The health care provider plans to discharge the client on home oxygen in the morning. What will the nurse include in this client's discharge teaching?

Make sure that the client understands any new medication regimen. She should be instructed to call 911 for any severe respiratory distress. Because she is being discharged with home oxygen, home health services should be arranged

The client's daughter asks what she can do to better communicate with her mother. What suggestions will the nurse make?

Promoting family dialogue about hearing aids opens the door for more understanding about a reasonable approach to better communication.

when does the nurse determine that a client with non-hodgkins lymphoma is at greatest risk for developing lysis syndrome? 1. after the first cycle of chemotherapy 2. during the second cycle of chemotherapy 3. anytime during the clients treatment course 4. while undergoing radiation and therapy

4. while undergoing radiation and therapy

for which side effect does the nurse assess in a client undergoing radiation for breast cancer? 1. fatigue 2. hair loss 3. mucositis 4. n/v

1. fatigue

a nurse is assessing a client with a genetic history of cancer. which assessment finding requires immediate nursing intervention? 1. blood pressure 140/90 2. nagging cough with hoarseness 3. nasal congestion for several days 4. muscle tension in cervical spine

2. nagging cough with hoarseness

The next morning the client is scheduled for surgery to remove the tumor and placement of a sigmoid colostomy. He returns to the unit with aclear ostomy pouch system in place. The stoma appears healthy. 4. How will the nurse document this finding? 5. How soon postoperatively will the nurse expect the colostomy to begin functioning?

4. "Reddish pink, moist, and protrudes about 2 cm from the abdominal wall." Initially the stoma maybe slightly edematous and there may a small amount of bleeding. 5. About 2 to 4 days postoperatively.

A client with COPD who smokes 1 PPD presents for a routine appointment. Which client statement causes the nurse to suspect an increase in dyspnea? A. "I prop myself up at night to sleep." B. "I decided to put on some makeup today." C. "I have a productive cough in the morning." D. "I have gained weight since I was here last."

A. "I prop myself up at night to sleep."

The community nurse is talking with a group of older clients about colorectal cancer (CRC) risk factors. Which of the following factors are considered to be CRC risk factors? Select all that apply. A. High-fat diet B. Crohn's disease C. Smoking D. Alcoholism E. Family history of cancer F. Obesity

A. High-fat diet B. Crohn's disease C. Smoking D. Alcoholism E. Family history of cancer F. Obesity

Which supplement will the nurse recommend to a client who wishes to enhance eye health? A. Lutein B. Vitamin D C. Magnesium D. Saw palmetto

A. Lutein

Which assessment finding in a client who recently had a right mastectomy 2 days ago will the home health nurse report to the healthcare provider? A. Temperature of 99°F B. Tingling sensation in the right arm C. Impaired range of motion in the right arm D. Drainage of 20 mL collected over 24 hours

B. Tingling sensation in the right arm

The nurse is observing the unlicensed assistive personnel (UAP) provide care to a client who is neutropenic. Which action by the UAP requires the nurse to intervene? A. Performing a bed bath because the client is too tired to get in the shower. B. Using the unit mobile blood pressure machine to assess the client's vitals. C. Using alcohol-based hand foam before touching the client. D. Cleaning the client's bathroom with disinfectant.

B. Using the unit mobile blood pressure machine to assess the client's vitals.

A client receiving radiation for head and neck cancer reports that the skin in the radiation field is itching and painful. Which nursing education will the nurse provide? A. "This is likely from medication, not the radiation treatment." B. "Cover the area with soft clothing." C. "Be sure to wash your hands well before touching the area." D. "Sunlight to the radiated area can help the skin heal." E. "Use a washcloth to thoroughly clean the area with soap and water." F. "Do not remove the ink markings on the skin."

B. "Cover the area with soft clothing." C. "Be sure to wash your hands well before touching the area." F. "Do not remove the ink markings on the skin."

An older adult's furosemide dosage was increased two days ago to 40 mg daily. This morning the nurse observes that the client has become confused and very weak. What is the nurse's best action? A. Encourage fluid intake. B. Withhold this morning's dose of furosemide. C. Review the most recent serum electrolyte levels. D. Place the patient on strict intake and output.

B. Withhold this morning's dose of furosemide.

Which change in laboratory test results of a client with sickle cell disease who was started on therapy with Endari 2 months ago indicates to the nurse that the therapy is effective? A. Increased HbF from 2% to 10% B. Increased HbA from 3% to 5% C. Decreased reticulocyte count from 12% to 4% D. Decreased white blood cells from 8,200/mm3 to 7,000/mm3 (8.2 x 109/L to 7.0 x 109/L)

C. Decreased reticulocyte count from 12% to 4%

A client returning to clinic 7 weeks after hematopoietic stem cell transplantation for leukemia has a total White blood cell (WBC) count of 5,200/mm3 (5.2 x 109/L) and a neutrophil count of 3000/mm3 (3 x 109/L). What is the nurse's priority action in view of these values? A. Notify the health care provider immediately. B. Assess the client for other symptoms of infection. C. Document the laboratory report as the only action. D. Obtain a urine specimen, sputum specimen, and chest X-ray.

C. Document the laboratory report as the only action.

A nurse conducts an assessment of an older adult's medications, including both prescription and over-the-counter drugs. Which drug would the nurse identify as being potentially inappropriate for older adults? A. Vitamin D B. Losartan C. Nortriptyline D. Hydrochlorothiazide (HCTZ)

C. Nortriptyline

The nurse is caring for a client with a complete large bowel obstruction. What assessment findings will the nurse expect? Select all that apply. A. Obstipation B. Dehydration C. Metabolic alkalosis D. Abdominal distention E. Abdominal pain F. Profuse vomiting

A. Obstipation D. Abdominal distention E. Abdominal pain

After seeing the ophthalmologist, the patient is scheduled for cataract surgery. What preoperative teaching will the nurse provide? A. Expect vision to be improved immediately following surgery. B. Inform that reading glasses will not be necessary after cataract removal. C. Plan for administration of different types of eye drops prior to having surgery. D. Avoid wearing dark glasses because the retina needs a direct source of light for best vision.

C. Plan for administration of different types of eye drops prior to having surgery.

What teaching will the nurse provide to a client who continues to experience more frequent episodes associated with Ménière disease? Select all that apply. A. Reducing activity can reduce frequency of episodes. B. Episodes will eventually decrease in severity and number. C. Reducing sodium, caffeine, and alcohol intake can be beneficial. D. The only treatment that is effective is to undergo labyrinthectomy. E. When moving from sitting to standing, be cautious and take your time.

C. Reducing sodium, caffeine, and alcohol intake can be beneficial. E. When moving from sitting to standing, be cautious and take your time.

The daughter of an 80-year-old client reports that her father's hearing has significantly diminished over the past few years. The client tells the nurse, "that's not true; my hearing is just fine." What is the appropriate nursing response? A. "I'm sure you are just fine, too." B. "Why don't you believe your daughter?" C. "Everyone worries about losing their hearing." D. "It must feel frightening to think about losing your hearing."

D. "It must feel frightening to think about losing your hearing."

Which assessment finding will the nurse report to the healthcare provider for a client who had an orchiectomy and laparoscopic radical retroperitoneal lymph node dissection this morning? A. BP 130/80, T 98.9°F, R 16, P 70 B. Urinary catheter draining clear yellow urine C. Expresses fearfulness of inability to perform sexually D. Reports pain of 9 on a 1-10 scale after receiving pain medication

D. Reports pain of 9 on a 1-10 scale after receiving pain medication

The client reports vomiting, fatigue, and weightloss of about 15 pounds over the past month. What is the priority diagnostic test that the nurse anticipates the health care provider will order? A. Esophagogastroduodenoscopy (EGD) B. Colonoscopy C. Serum electrolytes D. Stool for fecal occult blood

D. Stool for fecal occult blood

The nurse notes bright red urinary drainage from a client who had a transurethral resection of the prostate (TURP) with continuous bladder irrigation yesterday. What is the appropriate initial nursing action? A. Calculate intake and output. B. Monitor hemoglobin and hematocrit. C. Increase the rate of the bladder irrigation. D. Document findings in the electronic health record.

C. Increase the rate of the bladder irrigation.

What assessment finding does the nurse anticipate in a client who has just undergone surgery for cataract removal? A. Yellowish drainage and photophobia B. Mild itching and bloodshot appearance C. Pain accompanied by nausea and vomiting D. Change in visual acuity with tearing and redness

B. Mild itching and bloodshot appearance

A client's cancer is staged as T1, N2, M1 according to the TNM classification system. How does the nurse interpret this report? A. The client has two tumors that are nonresponsive to treatment. B. The client has leukemia confined to the bone marrow. C. The client has a 2-cm tumor with one regional lymph node involved and no distant metastasis. D. The client has a small primary tumor extension into three lymph nodes and one site of distant metastasis.

D. The client has a small primary tumor extension into three lymph nodes and one site of distant metastasis.

a 44 year old women with breast cancer is admitted for severe dehydration from n/v associated with chemotherapy 10 days ago. she has had two adjuvant treatments for with doxorubicin and cyclophosphamide. she has a groshong port than was inserted 2 months ago for chemotherapy administration. the HCP orders include: -Strict I&Os q12 hours -May use port for blood draws and IV fluids -Call for vomiting or temp of 100 or more -D5 1/2 NS at 125mL/hr -Ondansetron 8mg IV q8 hours -Clear liquid diet and progress as tolerated -CBC, Ca level, and BMP in AM -Bed rest with bathroom privileges -Knee-high support stockings What does the nurse identify as the rationale for each of these providers orders?

-Strict I&Os q12 hours because client was admitted with dehydration, it is very important to monitor I&O. -May use port for blood draws and IV fluids: when the client has n/v, you often see a decrease in electrolytes from the excessive fluid volume loss. -Call for vomiting or temp of 100 or more: any temperature elevation maybe a sign of infection and should be reported ASAP. -D5 1/2 NS at 125mL/hr: to replace the fluids. -Ondansetron 8mg IV q8 hours: prevent n/v caused by cancer chemotherapy. -Clear liquid diet and progress as tolerated: this is to replace fluids and to provide some nutrition with decreased risk of n/v. -CBC, Ca level, and BMP in AM: when the client has n/v you see a decrease in electrolytes from excessive fluid loss. -Bed rest with bathroom privileges: because the client is weak and dehydrated, these restrictions are for safety. having bathroom privileges is often less stressful than using a bedpan. -Knee-high support stockings: there is a concern for DVT with prolonged bedrest, so support hose is ordered for the client to increase venous return and prevent pooling of the blood.

While the Rapid Response Team is at the bedside, the client's health care provider arrives. The provider writes several orders.3. Which order will the nurse implement immediately? A. Transfer to ICU B. Increase O2 to 3 L per nasal cannula C. ABGs 30 minutes after oxygen is increased D. Methylprednisolone sodium succinate (Solu-Medrol) 40 mg IVP

B. Increase O2 to 3 L per nasal cannula

Which nursing intervention is appropriate when caring for a female client who has undergone a mastectomy and will receive chemotherapy? Select all that apply. A. Encourage client to accept her new body image B. Provide self-care resources to the primary caretaker C. Teach client about birth control options that are available D. Refer to support groups for people who have had mastectomy E. Involve partner in discussions about sexuality if client desires

B. Provide self-care resources to the primary caretaker C. Teach client about birth control options that are available D. Refer to support groups for people who have had mastectomy E. Involve partner in discussions about sexuality if client desires

How does a mutation in a suppressor gene, such as BRCA1, increase the risk for cancer development? A. Converting a proto-oncogene into an oncogene B. Removing the control over proto-oncogene expression C. Reducing the amount of cyclins produced by the oncogenes D. Inhibiting the recognition of abnormal cells through immunosurveillance

B. Removing the control over proto-oncogene expression

a 44 year old women with breast cancer is admitted for severe dehydration from n/v associated with chemotherapy 10 days ago. she has had two adjuvant treatments for with doxorubicin and cyclophosphamide. she has a groshong port than was inserted 2 months ago for chemotherapy administration. Two hours later, the client reports difficulty swallowing because of sores in her mouth. 3a. What does the nurse anticipate is the problem with the client's mouth? 3b. What nursing interventions will be implemented?

3a. The client is most likely experiencing mucositis (sores in mucous membranes). With chemotherapy, mucous membrane cells are killed more rapidly than they are replaced, resulting in the formation of mouth sores. Mouth sores are painful and interfere with eating. 3b. Examine the mouth and between the teeth every 4 hour for fissures, blisters, lesions, or drainage. Document the findings.Provide frequent good mouth care. Encourage the client to avoid mouthwashes that contain alcohol. For mouth care, use a soft-bristled toothbrush or disposable mouth sponges. Do not use dental floss or pressure gum cleaners. Rinse the mouth with ½peroxide and ½ normal saline every 8 hour. Normally the clients should drink at least 2 L of fluids, but due to the client's nausea and vomiting, this is not possible. Continue to monitor IV fluid replacement.

A 60-year-old woman with COPD who smokedcigarettes for 40 years is admitted to the hospital.The ED nurse reports the following to the medical-surgical nurse: -Has a saline lock in the R forearm and is on oxygen at 2L per nasal cannula -Had a bronchodilator respiratory treatment in the ED. -Has bilateral expiratory wheezes and crackles, anterior lyand posteriorly. Which assessment finding does the nurse expect to see when the client arrives? (Select all that apply.) A. Bradycardia B. Shortness of breath C. Use of accessory muscles D. Sitting in a forward posture E. Barrel chest appearance

B. Shortness of breath C. Use of accessory muscles D. Sitting in a forward posture E. Barrel chest appearance

A nurse working provides discharge teaching for a male client who had a minimally invasive hernia repair this morning. Which statement by the client indicates a need for further teaching? A. "I should avoid coughing if at all possible." B. "I can shower in day or two after I remove my surgical bandage." C. "I can't go back to work for at least 6 weeks." D. "I should use an ice pack to help relieve my pain."

C. "I can't go back to work for at least 6 weeks."

A client who is 5 weeks post-transplant from an allogeneic stem cell transplantation for acute lymphocytic leukemia comes to the clinic with a swollen belly and weight gain. Which additional assessment data supports the nurse's suspicion of possible sinusoidal obstructive syndrome (SOS)? Select all that apply. A. Jaundiced skin and sclera B. Platelet count is 28,000/mm3 C. Skin peeling on the hands and feet D. Mixed chimerism by laboratory finding E. Slightly below normal body temperature F. Pain in the upper right abdominal quadrant

A. Jaundiced skin and sclera F. Pain in the upper right abdominal quadrant

The nurse has delegated care for a client with a radical left mastectomy for breast cancer to assistive personnel (AP). Which AP action requires nursing intervention? Select all that apply. A. Obtains blood pressure via left arm B. Reports client's pain level to the nurse C. Applies gait belt prior to walking with the client D. Records vital signs in the electronic health record E. Assists client to administer patient-controlled analgesia (PCA)

A. Obtains blood pressure via left arm E. Assists client to administer patient-controlled analgesia (PCA)

Which assessment data does the nurse anticipate when a client presents to the emergency department reporting the sensation of a foreign body in the eye that started 30 minutes prior? Select all that apply. A. Pain B. Fever C. Tearing D. Photophobia E. Blurred vision

A. Pain C. Tearing D. Photophobia E. Blurred vision

Which symptoms will the nurse teach the client who just had surgery to correct a retinal detachment to immediately report to the eye care provider? Select all that apply. A. Pain in the affected eye B. Pus in the affected eye C. Decreased visual acuity D. Temperature of 99.0 degrees F E. Pupil that constricts in response to light

A. Pain in the affected eye B. Pus in the affected eye C. Decreased visual acuity

1. The nurse is caring for a client with a sealed radiation implant for the treatment of cancer. Which nursing intervention is appropriate? Select all that apply. A. Place a caution sign on the door of the client's room. B. Wear a dosimeter badge for protection when providing care. C. Allow the client's spouse to stay with the client at least 6 feet away for 4 hours. D. Do not allow children to visit the client for any length of time. E. Keep the door to the client's room closed.

A. Place a caution sign on the door of the client's room. D. Do not allow children to visit the client for any length of time. E. Keep the door to the client's room closed.

A client had an open partial colectomy and colostomy placement 6 hours ago. Which assessment would concern the nurse? A. Purple, moist stoma B. Stoma edema C. Liquid stool collecting in the drainage bag D. Serosanguineous fluid draining from the drain(s)

A. Purple, moist stoma

What information will the nurse include when teaching this client about health promotion? (Select all that apply.) A. Mammograms are not effective in diagnosing breast cancer. B. An MRI of the breasts should be completed every year. C. Ask your provider to perform a clinical breast examination (CBE). D. Notify your provider if you notice changes in your breasts. E. Breast self-examination (BSE) is the best way to detect breast cancer early

C. Ask your provider to perform a clinical breast examination (CBE). D. Notify your provider if you notice changes in your breasts.

After cataract surgery, the client is brought to the recovery area. The nurse is preparing to administer eye drops and other medications. Which order should the nurse question? A. Warfarin B. Steroid ophthalmic ointment C. Antibiotic ophthalmic ointment D. Acetaminophen with oxycodone

A. Warfarin

1. A client with chemotherapy induced neutropenia is prescribed filgrastim. The client states, "The bones in my legs are aching so bad." What nursing response is appropriate? A. "The pain in your legs is likely from the cancer." B. "Bone pain is a side effect of filgrastim that improves with time." C. "Increasing activity will help with the bone pain." D. "Have you had any fever or nausea?"

B. "Bone pain is a side effect of filgrastim that improves with time."

Which priority intervention will the nurse provide when caring for an older adult client with vision problems? A. Write names and indications of medication on prescription bottles. B. Ensure adequate, non glare lighting in the room. C. Review the medication administration record for artificial tears. D. Provide written and verbal instruction when giving discharge teaching.

B. Ensure adequate, non glare lighting in the room.

A client asks the nurse why his colorectal cancer is being tested for genetic mutations even though no one else in the family has ever had cancer. What is the nurse's best response? A. "Colorectal cancer is rare and most cases are caused by a genetic mutation." B. "The results of this testing will indicate what caused your cancer so you can avoid further exposure." C. "Many tumors have one or more genetic differences that can help determine the most effective treatment options." D. "Genetic testing of tumor cells can help determine the stage of your cancer and whether it has spread to other organs."

C. "Many tumors have one or more genetic differences that can help determine the most effective treatment options."

What finding does the nurse anticipate when assessing a client with a new diagnosis of glaucoma? A. Seeing "shooting stars" B. Decrease in central vision C. Gradual loss of visual fields D. Abrupt onset of excruciating pain

C. Gradual loss of visual fields