Med Surg - Chapter 15 & 16
Stop the infusion if swelling is observed at the site.
The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take?
Daily weight
A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?
Serum calcium is 18 mg/dL.
A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?
There are crackles audible throughout both lung fields.
A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?
Lung sounds
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion?
Rinse the mouth before and after each meal and at bedtime with a saline solution.
A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient?
I can buy some aloe vera gel to use on the area.
A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective?
Encourage the patient to purchase a wig or hat and wear it once hair loss begins.
A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to maintain the patients self-esteem?
The patients visitors bring in some fresh peaches from home.
A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching?
Assign the patient to a room near the nurses station.
A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action?
Daily alcohol intake
A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make?
Mental status
A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of just blowing up and has peripheral edema and shortness of breath. Which assessment should the nurse complete first?
Check the patients blood pressure.
A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first?
A, C, E
A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan (select all that apply)? a. Cook food thoroughly before eating. b. Choose low fiber, low residue foods. c. Avoid public transportation such as buses. d. Use rectal suppositories if needed for constipation. e. Talk to the oncologist before having any dental work done.
The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line.
A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate?
The patient is experiencing laryngeal stridor.
A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?
Apply the ordered anesthetic gel to oral lesions before meals
A patient has been assigned the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers. Which nursing action will be most effective in improving oral intake?
Give the patient the PRN IV morphine sulfate 4 mg.
A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patients respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?
Serum sodium level of 120 mg/dL
A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding?
Oral digoxin (Lanoxin) 0.25 mg daily
A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication?
Dysfunctional family processes related to effect of illness on family members
A patient who has ovarian cancer is crying and tells the nurse, My husband rarely visits. He just doesn't care. The husband indicates to the nurse that he never knows what to say to help his wife. Which nursing diagnosis is most appropriate for the nurse to add to the plan of care?
The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs.
A patient who has severe pain associated with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective?
Assess for sensation and strength in the legs.
A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first?
The cancer involves only the cervix.
A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is most appropriate?
Metabolic acidosis
A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?
Malignant tumors may spread to other tissues or organs.
A patient who is scheduled for a right breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct?
Ask the health care provider to order a basic metabolic panel.
A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action?
Respiratory alkalosis
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
Establish time to take a short walk almost every day.
A patient with Hodgkins lymphoma who is undergoing external radiation therapy tells the nurse, I am so tired I can hardly get out of bed in the morning. Which intervention should the nurse add to the plan of care?
Tumor size will decrease and this will improve the effects of other therapy.
A patient with a large stomach tumor that is attached to the liver is scheduled to have a debulking procedure. Which information should the nurse teach the patient about the outcome of this procedure?
Avoid giving the patient foods that are strongly disliked.
A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action is most appropriate?
Hospitalization will be required for several weeks after the stem cell transplant procedure is performed.
A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). The nurse will include which information in the patients teaching plan?
Administer prescribed antiemetics 1 hour before the treatments.
A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. Which action, if taken by the nurse, is most appropriate?
Notify the patients health care provider
A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first?
Infuse 5% dextrose in water at 125 mL/hr.
A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?
Why don't we talk about the options you have for the care of your children?
A widowed mother of four school-age children is hospitalized with metastatic ovarian cancer. The patient is crying and tells the nurse that she does not know what will happen to her children when she dies. Which response by the nurse is most appropriate?
Patient who is neutropenic and has a temperature of 100.5 F (38.1 C)
After change-of-shift report on the oncology unit, which patient should the nurse assess first?
Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes
After receiving change-of-shift report, which patient should the nurse assess first?
Patient has audible crackles to the midline posterior chest.
An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hour in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider?
Edema
An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?
Na+ 154 mEq/L (154 mmol/L)
An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?
Obtain more information from the patient about the family history.
During a routine health examination, a 40-year-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next?
Risk for ineffective health maintenance related to anxiety about new leukemia diagnosis
During the teaching session for a patient who has a new diagnosis of acute leukemia the patient is restless and is looking away, never making eye contact. After teaching about the complications associated with chemotherapy, the patient asks the nurse to repeat all of the information. Based on this assessment, which nursing diagnosis is most appropriate for the patient?
Clean the perianal area carefully after every bowel movement.
External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation?
Presence of the Chvosteks sign
Following a thyroidectomy, a patient complains of a tingling feeling around my mouth. Which assessment should the nurse complete immediately?
Infuse the KCl at a rate of 10 mEq/hour.
IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?
IL-2 enhances the immunologic response to tumor cells
Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient?
Decreased peripheral edema
The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patients condition has improved?
I will drink apple juice instead of orange juice for breakfast.
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?
I rarely have the energy to get out of bed
The home health nurse cares for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment?
Increase fluids if your mouth feels dry.
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?
Gradually decreasing level of consciousness (LOC)
The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be apriority for the nurse to report to the health care provider?
Crackles heard at the lower scapular border
The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider?
Shortness of breath
The nurse assesses a patient with non-Hodgkins lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse?
A, C, D, E
The nurse at the clinic is interviewing a 64-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk (select all that apply)? a. Pap testing b. Tobacco use c. Sunscreen use d. Mammography e. Colorectal screening
Hematuria
The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect?
Encourage fluid intake up to 4000 mL every day.
The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?
Use the push-pause method to flush the CVAD after giving medications.
The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?
Can you tell me what has been helpful to you in the past when coping with stressful events?
The nurse is caring for a patient who has been diagnosed with stage I cancer of the colon. When assessing the need for psychologic support, which question by the nurse will provide the most information?
Discuss the risks associated with cigarettes during every patient encounter
The nurse is caring for a patient who smokes 2 packs/day. To reduce the patients risk of lung cancer, which action by the nurse is best?
Blood pressure is 90/40 mm
The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?
The patient swims a mile 3 days a week.
The nurse is caring for a patient with colon cancer who is scheduled for external radiation therapy to the abdomen. Which information obtained by the nurse would indicate a need for patient teaching?
Serum sodium 126 mEq/L
The nurse is caring for a patient with left-sided lung cancer. Which finding would be most important for the nurse to report to the health care provider?
Monitor ionized calcium level
The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next?
Administer the prescribed normal saline bolus and insulin.
The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take?
Increase in carcinoembryonic antigen (CEA)
The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in therapy with the health care provider?
24-year-old patient who received neck radiation and has blood oozing from the neck
The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first?
White blood cell (WBC) count of 2700/L
The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider?
Roasted chicken
The nurse should include which food choice when providing dietary teaching for a patient scheduled to receive external beam radiation for abdominal cancer?
The UAP stands by the patients bed for 30 minutes talking with the patient.
The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention?
The biopsy will help decide the treatment for my enlarged prostate
The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement, if made by the patient, indicates that teaching was effective?
Blueberry yogurt
The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective?
I will need to have follow-up examinations for many years after I have treatment before I can be considered cured.
The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective?
The patellar and triceps reflexes are absent.
When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?
The UAP assists the patient to use dental floss after eating.
When caring for a patient who is pancytopenic, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene?
Milk carton
When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patients food tray?
Monitor the IV sites for redness, swelling, or tenderness.
Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?
Auscultate the patients breath sounds
Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter?
Suggest use of a daily planner and encourage adequate rest and sleep
Which action should the nurse take when caring for a patient who is receiving chemotherapy and complains of problems with concentration?