Medical Surgical 1- Unit 5

A nurse is caring for a client who's doctor informed him preoperatively that he has a metastasizing malignant neoplasm in the colon. Which statement by the client shows a understanding of the teaching? a. "I have colon cancer that is beginning to spread." b. "I have a growth in the bowel that the doctor can easily treat." c. "As long as my tumor doesn't get any bigger, I'll be okay." d. "There is no point in having treatment."

a. "I have colon cancer that is beginning to spread."

A nurse is providing teaching to a client who has cervical cancer and is scheduled to receive brachytherapy in an ambulatory care clinic. Which of the following statements by the client indicates an understanding of the teaching? a. "I need to lie still in bed during my brachytherapy" b. "I will have an implant implanted once a month during my brachytherapy." c. " I must stay at least three feet away from others during my brachytherapy." d. "I should expect some blood in my urine after brachytherapy."

a. "I need to lie still in bed during my brachytherapy"

A nurse is providing teaching to a client with cancer who is receiving external radiation therapy. Which of the following statements shows an understanding of the teaching? a. "I need to protect the area from sunlight" b. "I will apply a heating pad to the area after treatment." c. "I'll massage the area once a day." d. "I will wash off the markings i receive during the treatment."

a. "I need to protect the area from sunlight"

A nurse on an oncology unit is providing teaching to an adolescent female who just received bone marrow transplant for leukemia. Which of the following should the nurse include in the teaching? Select all that apply. a. "Take your temperature twice daily" b. "You may return to school if you feel strong enough" c. "It is important to wear shoes, always." d. "Clean your tooth brush weekly with isopropyl alcohol." e. "Avoid using tampons"

a. "Take your temperature twice daily" c. "It is important to wear shoes, always." e. "Avoid using tampons"

A nurse is planning care for a client who has myelogenous leukemia and a platelet count of 48,000/mm3. Which of the following interventions should the nurse include? a. Avoid IM injections b. Assess the client for ecchymosis once per shift c. Do not allow the client to have visitors d. Encourage daily flossing between teeth

a. Avoid IM injections

A nurse is teaching a client who has iron-deficiency anemia. The nurse should encourage the client to increase which of the following foods in their diet? a. Beef Liver b. Oranges c. Turnips d. Whole Milk

a. Beef Liver

A nurse is teaching degenerative complications to a partner of a client who has a new diagnosis of Parkinson's disease. Which of the following manifestations is priority? a. Dysphagia b. Emotional libaility c. impaired speech d. self-care dependency

a. Dysphagia

A nurse is caring for a client who is concerned that she might have an increased risk of breast cancer. After obtaining an assessment, which of the following assessment findings are an increased risk of breast cancer? (Select all that apply) a. Increased breast density b. BMI of 32 c. Having given birth to 5 children d. Undergoing hormonal replacement for 10 years e. having 1-2 alcoholic drinks per week

a. Increased breast density b. BMI of 32 d. Undergoing hormonal replacement for 10 years

A nurse is teaching a client who has iron-deficiency anemia. The nurse should teach the client to increase her intake of which of the following foods? a. Lentils b. Avocados c. Cabbage d. Broccoli

a. Lentils

A nurse is caring for a client who recently had chemotherapy and now has myelosuppression. Which of the following interventions should the nurse initiate. (Select all the apply) a. Prohibits visitors from bringing fresh flowers and plants into the clients room b. Encourage frequent visitation from family members c. Ensure the thorough cleaning of the clients room and bathroom daily d. Replace wound dressings every other day e. Use dedicated equipment such as stethoscopes

a. Prohibits visitors from bringing fresh flowers and plants into the clients room c. Ensure the thorough cleaning of the clients room and bathroom daily e. Use dedicated equipment such as stethoscopes

A nurse is caring for a patient who has Alzheimer's Disease. Which action should the nurse take? a. Add gestures when speaking to the client b. ask open-ended questions c. Limit to 3 visitors at a time d. Use different words if a client does not understand a topic

a. add gestures when speaking to a client

During a neurological assessment, a nurse asks a client to name all of his children, their ages, and their birth dates. Which type of memory is the nurse testing? a. Remote b. Sensory c. Recall d. Immediate

a. remote

A client who has stage 2 breast cancer asks the nurse about metastasizing sites for this type of cancer. Which of the following should the nurse respond with? a. "It's too soon to worry about something like that happening" b. "Breast cancer tends to metastasize to the stomach" c. "Metastasis is unlikely since we found your cancer early" d. "Breast cancer tends to metastasize to the bones."

d. "Breast cancer tends to metastasize to the bones."

A hospice nurse is providing education about palliative care to the partner of a client who has end stage liver cancer. Which of the following statements by the family member indicates an understanding of the teaching? a. "I will do my best to get him to eat something." b. "I will lay him flat if his breathing becomes shallow" c. "I will use an electric blanket to keep him warm" d. "I will continue to talk to him even when he is sleeping"

d. "I will continue to talk to him even when he is sleeping"

A nurse is caring for a client who is in hypovolemic shock. While waiting on a unit of blood, the nurse should administer which of the following IV solutions? a. 0.45% sodium chloride b. Dextrose 5% in 0.9% sodium chloride c. Dextrose 10% in water d. 0.9% sodium chloride

d. 0.9% sodium chloride

A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take? a. Have the client gently blow the clots out softly every 5 minutes b. Instruct the client to sit with their head hyperextended c. Apply ice compress to the back of the clients neck d. Apply lateral pressure to the clients nose for 10 minutes

d. Apply lateral pressure to the clients nose for 10 minutes

A nurse is assessing a client for manifestations of aplastic anemia. Which of the following findings should the nurse expect? a. Plethoric appearance of the facial skin b. Glossitis and weight loss c. Jaundice with enlarged liver d. Ecchymosis and petechiae

d. Ecchymosis and petechiae

A nurse is caring for a client who has lung cancer that has metastasized. Which of the following indicated that the client is developing superior vena cava syndrome. a. Irregular cardiac rhythm b. Numbness in the hands c. Muscle cramps d. Facial edema

d. Facial Edema

A nurse is assessing a client who is receiving a unit of whole blood. Which of the following findings should the nurse identify as a manifestation of an acute hemolytic reaction? a. Bradycardia b. Paresthesia c. Hypertension d. Low back pain

d. Low back pain

A nurse is collecting a patients health history. Which of the following findings is a risk factor for developing skin cancer? a. Age over 60 b. Genetic Disposition c. Light-skinned race d. Overexposure to sunlight

d. Overexposure to sunlight

A nurse is caring for a client who is receiving brachytherapy to treat uterine cancer. The nurse should ensure that the client understands that she will receive which of the following interventions? a. Chemotherapy via a central venous access device b. Radiation to the tumor from an outside source c. Precise delivery of high-dose radiation after tumor imaging d. Radioactive infusions or insertions onto or near the tumor

d. Radioactive infusions or insertions onto or near the tumor

A nurse is caring for a client who has dementia and is experiencing anxiety. Which of the following actions should the nurse take? a. Place a restraint vest on the client to protect others in the area b. Provide a variety of routines to keep the client from getting bored c. Explain to the client that episodes of anxiety will decrease overtime d. Redirect the client to a different activity with a small group of people

d. Redirect the client to a different activity with a small group of people

A nurse is teaching a client with a new diagnosis for myasthenia gravis, which should the nurse include? a. Use enemas to treat constipation caused by medications b. Take a hot bath when muscles ache c. Eat a low calorie diet d. Set an alarm to take medications at the same time daily

d. Set an alarm to take medications at the same time daily

A nurse is teaching a client with a seizure disorder about Aura's. Which of the following statements indicated proper teaching? a. An aura is a sensory warning that a seizure is eminent b. An aura is a continuous seizure c. An aura is a period of sleepiness following a seizure d. An aura is a brief loss of consciousness following a seizure

A. an aura is a sensory warning that a seizure is eminent

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? a. "The risk of renal failure is lessened with combination therapy." b. "The chemotherapy medications work on different stages of cell division so more cells will be killed this way." c. "The use of more chemotherapy treatment, the less time you will be in treatment." d. The combination of chemotherapy will lessen the risk of bone marrow suppression."

b. "The chemotherapy medications work on different stages of cell division so more cells will be killed this way."

A nurse is planning care for a client who has developed thrombocytopenia after chemotherapy. Which of the following instructions should the nurse give to decrease the adverse reactions to thrombocytopenia? a. "Monitor visitors for manifestations of infection." b. "Use an electric razor when shaving." c. "Encourage frequent rest periods." d. "Rinse mouth daily with normal saline."

b. "Use an electric razor when shaving."

A nurse is providing postoperative discharge teaching to a client who had a panhysterectomy for uterine cancer. Which of the following pieces of information should the nurse include in the teaching? a. "You will need to use some form of birth control for 6 months" b. "You may experience signs of menopause." c. "Do not lift anything heavier than 15lbs." d. "Pain or urination is expected after this surgery."

b. "You may experience signs of menopause."

A nurse is preforming an admission assessment on a client who has colorectal cancer. Which of the following manifestations should the nurse expect to see? a. Hematuria b. Abdominal Cramps c. Weight gain d. Polycythemia

b. Abdominal Cramps

A nurse is assessing a client for disseminated intravascular coagulation (DIC) in a client who has septic shock secondary to an untreated foot wound. Which of the following findings should the nurse expect? (Select all that Apply) a. Bradycardia b. Bleeding at the venipuncture site c. Petechiae on the chest and arms d. Flushed, dry skin e. Abdominal distention

b. Bleeding at the venipuncture site c. Petechiae on the chest and arms e. Abdominal distention

A nurse in an oncology clinic is assessing a client with early stage Hodgkin's Lymphoma. Which of the following findings should the nurse expect? a. Bone and joint pain b. Enlarged lymph nodes c. Intermittent hematuria d. Productive cough

b. Enlarged lymph nodes

A nurse is caring for a client who has acute lymphocytic leukemia and reports, fever, chills, and pallor over the last week. When checking the client's laboratory results, which of the following values should the nurse identify as contributing to the fatigue and pallor? a. Magnesium 2.0mEq/L b. Hgb 6.5 g/dL c. WBC Count of 9.6/mm3 d. Creatinine 0.8mg/dL

b. Hbg 6.5 g/dL

A nurse is caring for a client who has thrombocytopenia. Which of the following interventions should the nurse add into the patients plan of care? a. Restrict fluid intake to 1,000mL/day b. Measure the patients abdominal girth daily c. Check IV site every 4 hours for bleeding d. Administer an enema as needed for constipation

b. Measure the patients abdominal girth daily

A nurse is planning a presentation at a community center about risk factors for cancer. Which of the following cancers should the nurse include when discussing familial clustering of specific types of cancer? a. Skin b. Prostate c. Bone d. Bladder

b. Prostate

A nurse is collecting a health history from a client. Which of the following is the highest risk factor for developing bladder cancer? a. The client is a hair dresser b. The client uses tobacco c. The client is over 60 years of age d. The client has frequent UTI

b. The client uses tobacco

A nurse is preparing a client for an EEG. Which of the following information should the nurse give to the client? a. This test will take 3 hours b. You will begin side laying with your eyes closed c. You'll be asleep for this test d. Expect some electrical shocks throughout the procedure

b. You will begin side laying with your eyes closed

A nurse is providing teaching to the family of a client who was diagnosed with a seizure disorder. Which action should the nurse consider priority to the family? a. reorient the client b. protect the clients head c. loosen constrictive clothing d. turn the client on their side

b. protect the client's head

A nurse is caring for a client who begins having a seizure, which of the following actions should the nurse take? a. insert an oral airway b. turn the client on their side c. place a pillow under their head d. restrict the clients arms

b. turn the client on their side

A nurse is teaching a client with a seizure disorder about what to do before their scheduled EEG. Which should the nurse include? a. Remain NPO 6-8 hours before the EEG b. Wash your hair thoroughly c. sleep for at least 8 hours before the EEG d. Take a sedative the night before the test

b. wash your hair thoroughly

A nurse is providing discharge instructions to a client who has aplastic anemia. Which of the following statements indicates the clients understanding of the teaching? a. "I need to stay active to prevent blood clots in my legs." b. "If I have a bad headache, I can take aspirin to get rid of it." c. "I should eliminate all uncooked foods from my diet now." d. "I should eat more iron-fortified cereal to strengthen my blood."

c. "I should eliminate all uncooked foods from my diet now."

A nurse is providing teaching to a client who is receiving chemotherapy and has developed neutropenia. Which of the following statements indicates further teaching? a. "I'll keep an antimicrobial hand gel in my purse." b. "My partner will have to take care of my cats litter boxes for a while." c. "I'm planning a large family gathering for the holiday's." d. "I will eat canned fruits and vegetables."

c. "I'm planning a large family gathering for the holiday's."

A nurse is providing discharge teaching to a client who has had a sickle cell crisis. Which of the following statements shows an understanding of the teaching? a. "I should try to drink at least 2L of water a day." b. "I can still fly out to visit my sister in Colorado for a while." c. "Physical activity is good for me but I need to avoid overexertion." d. "I can still go skiing over the cold winter months."

c. "Physical activity is good for me but I need to avoid overexertion."

A nurse is preparing a client for a bone-marrow biopsy. Which of the following information should the nurse include in the teaching? a. "You'll receive heavy sedation, and might even sleep through the entire process." b. "You'll have to lie on your back for the entirety of the test." c. "You'll feel a painful, pulling sensation when the doctor pulls out the bone marrow." d. "Expect the procedure to take about an hour."

c. "You'll feel a painful, pulling sensation when the doctor pulls out the bone marrow."

A nurse is providing teaching to a client with a new diagnosis for multiple sclerosis. The client asks about the usual cause of MS. What should the nurse reply with? a. Each client is different, we cannot predict what will happen b. I can see you are worried, but it is too soon to see what will happen c. Acute episodes usually are usually followed by remissions, which can vary in duration d. It is too early to focus on the future, let's focus on the present and take it day by day

c. Acute episodes usually are usually followed by remissions, which can vary in duration

A nurse is talking to a group of women at a community center about current recommendations for early breast cancer detection of breast cancer. The nurse should explain which of the following actions? a. Begin self exams at 40 b. Have a clinical breast exam every year after 30 c. Begin annual mammograms after 40 d. Have a breast MRI every year after 50

c. Begin annual mammograms after 40

A charge nurse is observing a newly licensed nurse provide care to a client who is receiving internal radiation therapy for cervical cancer. Which of the following actions needs intervention by the charge nurse? a. Leaving soiled linens in the clients room b. Instructing visitors to stay 2 m (6ft) away from the client c. Borrowing a dosimeter badge from another nurse before entering the clients room d. Removing the extra IV pole to use for another client

c. Borrowing a dosimeter badge from another nurse before entering the clients room

A nurse is preparing a client for a CT scan. Which of the following will affect how the nurse prepares the client for the scan? a. NPO for 6 hours b. Difficulty recalling events c. Development of Hives when eating shrimp d. Paresthesia in both hands

c. Development of Hives when eating shrimp

A nurse is caring for a patient who has pernicious anemia. Which of the following interventions should the nurse include in the plan of care? a. Administer ferrous sulfate supplementation b. Increase dietary intake of folic acid c. Initiate weekly injections of vitamin B12 d. Initiate a blood transfusion

c. Initiate weekly injections of vitamin B12

A nurse in an acute care facility is caring for a client with myasthenia gravis. Which of the following supplies should be at the client's bedside? a. Metered-dose inhaler b. Continuous passive motion machine c. Oral-nasal suction equipment d. external defibrillator pads

c. Oral-nasal suction equipment

A nurse is caring for a client who is receiving chemotherapy to treat cancer. Which of the following effects should the nurse anticipate from the chemotherapy? a. Gingival Hyperplasia b. Hirsutism c. Pancytopenia d. Weight gain

c. Pancytopenia

A nurse is assessing a client who has pernicious anemia. Which of the following findings should the nurse expect? a. Thick, white coating on the clients tongue b. Decreased pulse rate c. Paresthesia's in the client's hands and feet d. Joint pain at the extremities

c. Paresthesia's in the client's hands and feet

A nurse is providing teaching to a client who is going to receive an electroencephalogram. Which of the following piece's should the nurse share? a. You'll feel some mild electrical shocks b. Do not eat or drink after midnight c. Shampoo your hair and do not use product in it d. It is common to have short term memory loss after this procedure

c. Shampoo your hair and do not use product in it

A nurse is monitoring a client who is receiving chemotherapy by peripheral IV infusion. The client reports pain at the injection site and the nurse notes leaking around the injection site. Which is the first action the nurse should take? a. Take a photograph of the patients peripheral IV site b. Obtain and record the clients vital signs c. Stop the infusion d. Identify all medications given through the IV site within the last 24 hours

c. Stop the infusion

A nurse is reviewing the medical history of a man scheduled for an MRI. Which is a contraindication to getting this procedure done? a. A new tattoo b. The client is experiencing paralysis c. The client has a pacemaker d. The client has a history of PVD

c. The client has a pacemaker

A nurse is obtaining a history on a patient who has caner of the cervix. Which of the following manifestations should the nurse expect? a. Weight gain b. Oliguria c. Vaginal Bleeding d. Back Pain

c. Vaginal Bleeding

A nurse is caring for a client who has a new diagnosis or pernicious anemia. The nurse should expect the client's provider to prescribe which of the following medications for this client? a. Ferrous Sulfate b. Epoetin Alfa c. Vitamin B12 d. Folic Acid

c. Vitamin B12

A nurse is preparing to transfuse a unit of packed red blood cells for a client who has anemia. Which of the following actions should the nurse take first? a. Hang an IV solution of 0.9% sodium chloride with the blood b. Compare the client ID band to the number on the blood c. Witness the informed consent document d. Obtain pretransfusion vital signs

c. Witness the informed consent document

Your client just had a seizure, what is the priority action by the nurse? a. measure vitals b. perform a neurological exam c. check for a patent airway d. assess for injury

c. check for a patent airway

A nurse is assessing a client who has Guillian-Barre syndrome. Which of the following should the nurse expect? a. Tonic-clonic seizures b. Reports of a severe headache c. weakness of the lower extremities d. Decreased LOC

c. weakness of the lower extremities