NURS202 Exam #2

The client with brown hair is concerned about losing hair as a result of chemotherapy. What should the nurse tell the client?

"The hair loss is temporary. "

The nurse is administering intravenous magnesium sulfate as prescribed for a client at 34 weeks gestation with severe preeclampsia. What are desired outcomes for us therapy? Select all that apply.

-Temperature 98°F, pulse 72, respiratory rate 14 -Deep tendon reflexes 2+ -Magnesium level 5.6

Which outcome with the nurse identify as a priority to achieve when developing a plan of care for a primigravid client at 38 weeks gestation was hospitalized with severe preeclampsia and receiving intravenous magnesium sulfate?

Absence of any seizure activity during the first 48 hours

When caring for a client with nonresectable colon cancer, which nursing diagnosis requires the nurse to function collaboratively to wish you the best outcome related to client comfort?

Acute pain

The third stage of labor ends

After the birth of the placenta

The nurse is speaking to a group of women about early detection of breast cancer. Which screening does the nurse recommends to women age 50 and older?

Annual mammogram

A client with diabetes Molite us gives birth to a 9 pound 10 ounce neonate at 38 weeks. What is the nurses priority action after the stabilization of the neonate?

Assess the neonate's blood glucose level

After a mastectomy for breast cancer, the nurse teaches the client how to avoid the development of lymphedema. The nurse should teach the client to:

Elevate the affected arm on a pillow

Which nurse should be assigned to a client receiving brachytherapy for the treatment of cervical cancer?

Female nurse with three years experience working in oncology

A client with colon cancer is having a barium enema. The nurse should instruct the client to take which type of medication after the procedure is completed?

Laxative

While performing a circle examination on a client in labor, a nurse his fingertips for your pulsating tissue. What is the most appropriate nursing intervention?

Leave the fingers in place and press the nurse call light

The nurse caring for the labor and client performed a sterile vaginal exam. Exam results are dilated 10 cm, I faced 100%, and +2 station. What is the priority nursing intervention?

Prepare for birth of the neonate

A client is admitted to the hospital for diagnostic testing to rule out colon rectal cancer. Which intervention should the nurse include in the plan of care?

Test all stools for a cold blood

A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which assessment made after the procedure would indicate the development of a potential complication?

The client experiences a sudden increase in temperature

Which client is at highest risk for colon rectal cancer?

The client who has been treated for Crohn's disease for 20 years

A client with chronic cancer pain has been receiving opiates for four months. She rated the pain as an eight on a 10 point scale before starting the opioid medication. Following a thorough examination, there is no new evidence of increased disease, yet the pain is close to eight again. What is the most likely explanation for the increasing pain?

Tolerance to the opioid

The client gives birth to a neonate who is giving a score of nine at five minutes on the Apgar rating system. How does the nurse interpret the new needs physical condition?

Good

A client, who is one week postpartum, is concerned about the possibility of postpartum depression because she has a history of depression. Which, by the client would indicate that she understood the nurse is teaching about the postpartum. And her risk for postpartum depression?

"If I'm feeling guilty or not capable of caring for the baby and I'm not sleeping or eating well, I need to contact the office."

A client who is receiving chemotherapy express his concern at the thought of losing hair on their head. The nurses best response is:

"Your hair loss will be temporary. Would you like to tell me about your concerns?"

A nurse is caring for a newborn with transient tachypnea of the newborn. Which responses made by the newborns mother demonstrates that she understands the newborns condition? Select all that apply

-"Having a cesarean section increase the risk of transient tachypnea of my newborn." -" The healthcare provider will need chest x-rays to monitor my babies respiratory distress."

A client who is 15 weeks pregnant comes to the clinic for amniocentesis. The nurse knows that this test can be used to identify which characteristics or problems? Select all that apply.

-Chromosomal defects -Neural tube defects -Sex of the fetus

The nurse is assessing in our old newborn. Which observations with the nurse know as being abnormal? Select all that apply.

-Expiratory grunting -Temperature of 97.4°F -nasal flaring

A client is receiving monthly doses of chemo therapy for treatment of stage III Colon cancer. Which laboratory results to the nurse reports be oncologist before the next dose of chemotherapy is administered. Select all that apply.

-Platelet count of 40,000/mm3 -White blood cell count of 2300/mm3 -temperature of 101.2°F

A nurse is completing a physical assessment of a neonate following birth. When completing the musculoskeletal assessment, which findings would indicate developmental dysplasia of the hip? Select all that apply.

-positive Barlow test -asymmetrical leg skin folds

Which client has the highest risk of ovarian cancer?

45-year-old woman who has never been pregnant

A nurse is conducting a cancer risk screening program. Which client is at greatest risk for skin cancer?

60 year old mountain biker

The care of which client can be assigned to an unlicensed assistant personal (UAP)?

A client who is having radiation for cancer of the stomach is to have the radiation site beers with warm water, followed by an application of a moisturizer

A client with human papilloma virus infection is being treated by a colposcopy. The client asked the nurse if this procedure is really necessary. The nurse can tell the client that if the HPV infection is not treated which health problem is likely to occur?

Cervical cancer

The nurse provides care to a client with anogenital warts. The nurse teachers that anogenital increase in adolescent females risk of which condition?

Cervical cancer

What is a risk factor for women who have had human papillomavirus?

Cervical cancer

When caring for the neonate weighing 4564g (10.lb) born vaginally to a woman with diabetes, the nurse should assess the neonate for fracture of which area?

Clavicle

At 6 cm dilation, a client in labor receives a lumbar epidural for pain control. Which nursing diagnosis is most appropriate?

Altered tissue perfusion related to effects of anesthesia

A client with an uncomplicated term pregnancy arrives at the labor and delivery unit in early labor saying that she thinks her water has broken. What is the nurse is best action?

Ask what time this happened and note the color, amount, and odor of the fluid

A client is being discharged after abdominal surgery and colostomy formation to treat: cancer. Which nursing action is most likely to promote continuity of care?

Asking the physician to write an order for home skilled nursing assessments and interventions

The nurse is assessing a to our old newborn. The nurse notes nasal flaring and acrocyanosis. Which of the following is the nurse is priority intervention?

Assess the newborns oxygen saturation

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of risk for impaired skin integrity. Which intervention should be part of this clients care plan?

Avoiding using deodorant soap on the irradiated areas

Which intervention should the nurse anticipate using when caring for attorney and he diagnosed with transient tachypnea at two hours after birth?

Provide warm, humidified oxygen in a warm environment

Which action is most important when the nurses planning pain management for a client after a lobectomy for lung cancer?

Reassessing the client after administering pain medication

A client is receiving chemo therapy to treat breast cancer. Which assessment findings indicate a chemo therapy-induced complication?

Serum potassium level of 2.6

The client with stage to ovarian cancer undergoes a total abdominal hysterectomy and bilateral salpingo-oophorectomy with tumor resection, omentectomt, appendectomy, and Lymphadenectomy. During the second postoperative day, which assessment finding requires immediate intervention?

Shallow breathing and increasing lethargy

On a visit to the gynecologist, a client complains of urinary frequency, pelvic discomfort, and weight loss. After a complete physical examination, blood studies, and a pelvic examination with a Papanicolaou Test, the Physician diagnosis stage for ovarian cancer. The nurse expect to prepare the client for which initial treatment?

Surgical procedure

The nurse teaches the client with chronic cancer pain about optimal pain control. Which recommendation is most effective for pain control?

Take prescribed analgesics on an around-the-clock schedule to prevent recurrent pain.

A client with ovarian cancer ask the nurse, "what is the cause of this cancer?" Which is the most accurate response by the nurse?

The risk of developing ovarian cancer is related to environmental, endocrine, and genetic factors

The primary healthcare provider prescribes betamethasone 43-year-old multigravid client at 32 weeks gestation who is experiencing preterm labor. Previously, the client has experienced one infant death due to preterm birth at 28 weeks gestation. The nurse explains that this drug is given for which reason?

To enhance the feet along maturity

A primivada client is admitted to labor and delivery area, where the nurse evaluates her. Which assessment findings may indicate the need for a cesarean birth?

Umbilical cord prolapse

The client underboss and amniotomy. Afterword, the nurse to text large variable decelerations in the fetal heart rate on the external electronica fetal monitor. These findings signify:

Umbilical cord prolapse

The nurse is assigned a client with end-stage ovarian cancer with recurrent ascites, and the client is to undergo paracentesis. Which activity is best to delegate to an experienced licensed professional nurse (LPN)?

Vital signs every 15 minutes after the paracentesis

For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which assessment finding would alert the nurse to suspect hypermagnesemia?

Decreased deep tendon reflexes

I'm at Sexting is recommended for a 68-year-old client diagnosed with breast cancer week ago. When approached about giving consent for the mastectomy, the client says, "what's the use in trying to get rid of the cancer? It will just come back! I can't handle another thing - having diabetes is enough. Besides, I'm getting old. It would be different if I were younger and had more energy." What should the nurse to?

Explore with client her feelings about her health problems and proposed surgery

A 30-year-old client whose mother died of breast cancer at age 44 and his sister has ovarian cancer, is concerned about developing cancer. As a member of the oncology multidisciplinary team, The nurse should suggest that the client ask the physician about which topic?

Genetic counseling

A client had a right pneumonectomy Four lung cancer yesterday and now has dyspnea. What position in bed will be best for this client?

Head of bed elevated

Journey initial assessment of labor and client, the nurse notes the following: blood pressure 160/110, pulse 88, Respiratory rate 22, reflexes +3 Dash +4 with to be clonus. Urine specimen reveals +3 protein, negative sugar in key tones. Based on these findings, a nurse should expect the client to have which complaints?

Headache, blurred vision, and facial and extremity swelling

A client with suspected cervical cancer has a colposcopy with conversation. What information should the nurse give the client about her menstrual period after the surgery?

Her next two or three periods may be heavier and more prolonged than usual

A client, age 42, visits the gynecologist. After examining the client, the healthcare provider suspects cervical cancer. What will be most important for the nurse to include in assessing the clients health history?

History of human papilloma virus infection.

The nurse should teach clients about which potential risk factor for the development of colon cancer?

History of inflammatory bowel disease

A pregnant client arrives in the emergency department in states, "my baby is coming." The nurse is a portion of the umbilical cord protruding from the vagina. What should the nurse do first?

Hold pressure on the fetal head

What conditions with the nurse expect to find in a preterm neonate suffering from cold stress?

Hyperactivity and twitching

A client in her first trimester of pregnancy comes to the prenatal clinic and states, "I feel nauseous and vomiting all the time. I can't even keep down water." This client should be evaluated for what condition?

Hyperemesis gravidarum

The nurse should be especially alert for what problem and caring for terminate, who weighed 10 pounds at birth, one hour after a vaginal birth?

Hypoglycemia

When evaluating a pregnant clients knowledge of symptoms to report immediately, which statement indicates to the nurse at the client understands the information given to her?

If I have blurred or double vision, I should call the clinic immediately

When unit is admitted to the neonatal intensive care unit for observation with a diagnosis of probable meconium aspiration syndrome. The neonate weighs 10 lbs. 4 oz. and is at 41 weeks gestation. What would be the priority problem for this neonate?

Impaired gas exchange

The nurse is witnessing the client signature on the inform the surgical consent for an abdominal hysterectomy. The nurse should be certain the client understands that what will be the outcome of the surgery?

Infertility

Well if you see a position with an NST pieces on a blank client at 38 weeks gestation, the nurse observes the fluid is very cloudy and thick. The nurse interpret this finding is indicating which of the following?

Intrauterine infection

A client tells the nurse that her bra fits more snuggly at certain times of the month and she is concerned that she may have a side of breast cancer. The nurse should give the client which information about the situation?

It is normal for the breast to increase in size before menstruation begins

The healthcare provider orders in amniocentesis for a primigravid client at 37 weeks gestation to determine feet along maturity. Which is an indicator of feet along with charity?

Lecithin-sphingomyelin (L/S ratio)

A woman tells the nurse, "T has been a lot of cancer in my family." The nurse should instruct the client to report which possible sign of cervical cancer?

Light bleeding or watery vaginal discharge

What should the nurse include in the plan of care for a client with diabetes he was in labor?

Monitor blood glucose levels every hour

A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention?

Monitor fetal heart tones

The membranes of a blank client in active labor back for spontaneously, revealing greenish any colored amniotic fluid. How does the nurse interpret this finding?

Passage of meconium by the fetus

I'm Delachal cord prolapse occurs after spontaneous rupture of membranes. What should the nurse do immediately?

Placethe client in a Trendelenburg position

The nurses in being a client about the past medical history. Which pre-existing condition may need the nurse to suspect that the client has colorectal cancer?

Polyps

The nurse is caring for a woman who gave birth vaginally to a healthy 6 pound newborn after two hour labor at 37 weeks gestation period for which complication with a nurse assessed as a priority due to the increased risk in this client?

Postpartum hemorrhage

Several pregnant clients are waiting to be seen in the triage area of the OB unit. Which client should the nurse see first?

A client at 32 weeks gestation who has preeclampsia and +3 proteinuria and who is returning for evaluation of epigastric pain

A nurse is caring for a client receiving IV magnesium sulfate. Which drug is the antidote for magnesium toxicity?

Calcium gluconate

After instructing a 20-year-old nulligravid About adverse effects of oral contraceptives, the nurse determines that further instructions needed when the client states which has an adverse effect?

Ovarian cancer

A 52-year-old client is scheduled for total abdominal hysterectomy Pacifico cancer. When discussing the potential impact of this procedure on a client sexuality, how should the nurse respond to the client?

"Most women have concerns about their sexuality after this type of surgery. Do you have any concerns or questions?"

Which statement indicates that the client understands the need for routine screening to detect colorectal cancer?

"I need to have a colonoscopy at age45 then every 10 years until age 75."

The nurse is admitting a primigravid client at 37 weeks gestation who has been diagnosed with preeclampsia to the labor and birth area. Which client care rooms is most important first client?

A darkened private room as close to the nurses station as possible

The nurse is conducting a health history for a client at risk for cancer. Which lifestyle factors considered at risk for colorectal cancer?

A high-fat, low-fiber diet

A nurse is caring for a client who is receiving chemotherapy for lung cancer. During the hand-off report, the nurse from the previous shift stated the client has been placed on neutropenic precautions. Which laboratory value supports this nursing action?

A white blood cell count of 2200/mm3

The 29-year-old multigravida c at 37 weeks gestation is being treated for severe preeclampsia and has magnesium sulfate in fusing at 3 g/hour. What is the priority intervention to maintain safety for this client?

Assess reflexes, clonus, visual disturbances, and headache

A client with suspected lung cancer is scheduled for thoracentesis as part of the diagnostic work up. The nurse reviewed the clients history for conditions that might contraindicate this procedure. Which condition is a contraindication for thoracentesis?

Bleeding disorder

A nurse is assisting in developing a teaching plan for a client who's about to enter the third trimester of pregnancy. The teaching plan should know that which symptom should be reported immediately?

Blurred vision

The client has given birth to a pre-terminate. The client tells the nurse that she wants to breast-feed her neonate. The nurse should explain to the mother that:

Breast milk contains antibodies that help protect her neonate

A client in active labor asked the nurse why her blood pressure is being monitored so frequently. What is the most appropriate response by the nurse?

Changes in your blood pressure can affect the fetus

An adult with a history of chronic obstructive pulmonary disease (COPD) and metastatic carcinoma of the long has not responded to radiation therapy and is being admitted to the hospice program. The nurse should conduct a focused assessment for which symptom?

Dyspnea

The nurse is teaching a client who is receiving chemotherapy and the family how to manage possible nausea and vomiting at home. What information should the nurse include in the teaching plan?

Eating small frequent meals

A surgeon is discussing surgery with a client diagnosed with colon cancer. The client is visibly shaken over the possibility of a colostomy. Based on the clients response, the surgeon should collaborate with which health team member?

Enterostomal nurse

Which strategy would be most effective in improving trans cultural communications with oncology clients and their families?

Establish a rapport and listen to their concerns.

After a lobectomy for lung cancer, the nurse instructed the client to perform deep breathing exercises. What is the expected outcome of these exercises?

Expand the alveoli and increase long surfaces available for ventilation

A client with cervical cancer and is undergoing internal radium implant therapy. A lead lined container in a pair of long forceps have been placed in the clients hospital room. What should the nurse tell the client about how these will be used? The forceps in the container will be used for:

Handling of the dislodged radiation source

A nurse is the average age of 47 following American Cancer Society Guidelines, the nurse she recommends that the women:

Have a mammogram annually

The nurse is reviewing a clients prenatal history. Which of the following is a significant factor in anticipating complications in labor and birth?

History of postpartum hemorrhage

A multigravid client in active labor at 39 weeks gestation has a history of smoking one or two packs of cigarettes daily. Which problem is the nurse most likely to find during the infants assessment?

Low birth weight

A client is undergoing a left modified radical mastectomy for breast cancer. Postoperatively, blood pressure should be a clean from the right arm, and the clients left arm and hand should be elevated as much as possible to prevent:

Lymphedema

A client with a clamp Sia begins to experience a seizure. Which intervention should the nurse to do immediately?

Maintain a patent airway

The nurse covers the Myelomeningocele of a neonate with the sterile dressing. Which statements direct the nurses action?

Preventing infection

A client ask the nurse with PSA is. The nurse should reply that it stands for:

Prostate-specific antigen, which is used to screen for prostate cancer

16-year-old unmarried client visiting the prenatal clinic at 32 weeks gestation and currently weighing 144 pounds is being closely monitored for early signs of preeclampsia. The client is 5 feet, 2 inches tall and weighed 120 pounds before the pregnancy. Which factor would be most important to assess?

Protein in her urine

An 18-year-old pregnant client tells the nurse that she is concerned that she may not be able to take care of herself during her pregnancy. She states that she is not sure what prenatal care is available, or if she should access it. The nurse should recognize that the client:

Should be referred to community resources available for pregnant women

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes at the drainage system is functioning correctly when the nurse notes title movements or fluctuations in which compartment of the system as the client breathes?

Water-seal chamber

A client is admitted to the labor area for induction with intravenous oxytocin because she is 42 weeks pregnant. What should the nurse include in the induction teaching plan for this client?

Continuous fetal heart rate monitoring will be implemented

Which outcome is expected of a nursing referral to a cancer support group? The client can:

Cope with cancer.

The family of an older adult with terminal cancer asks about having hospice services. What should the nurse tell the family? Hospice care:

Focuses on supportive care for the client and family.

Which expected outcome about nutrition would be appropriate for a client who has had a total gastrectomy for gastric cancer? The client will:

Maintain adequate nutrition through oral or parenteral feedings

A client tell the nurse that she has found a painless lump in her right breast during her monthly self examination. Which assessment finding would strongly suggest that this clients lump is cancerous?

Non-mobile mass with irregular edges

The nurse on the previous night shift documented that the lungs have a client has lung cancer we are clear to auscultation in all fields. While doing the shift assessment, the dayshift nurse noticed decreased breath sounds, especially in the right lower lobe. Which action is the nurses best choice?

Notified the physician of the change in client status

The nurse is planning a presentation about ovarian cancer to a group of women. Which topic should receive priority attention in the lesson plan?

Ovarian cancer signs and symptoms are often vague until late in development

A 32-year-old blank return to the clinic for a routine prenatal visit at 36 weeks gestation. The assessments during this visit include: blood pressure 140/90, pulse 80, respiratory rate 16. What further information should the nurse obtained to determine if this client is becoming preeclamptic?

Protein in her urine

A client with a modified radical mastectomy has been discharged. The client has been very reluctant to discuss the surgery or her situation. The nurse making assignments should delegate the clients care to the:

Same nurse who has cared for her the past three days, for continuity of care.

During the fourth stage of labor, the client should be assessed carefully for:

Uterine atony

A nurse is caring for a newborn exposed to drugs while in utero. Which behaviors will the nurse expects a newborn to exhibit? Select all that apply.

-Tachypnea with excessive secretions -Sensitive gag reflex -hyper activity and increased muscle tone

A nurse is completing a prenatal assessment on a woman who is 28 weeks pregnant with gestational hypertension. Which finding should be reported to the primary care provider?.

-dull headache -Blurred vision -1+ urine protein

A multigravid client is receiving oxytocin augmentation. When the client cervix is dilated to 6 cm, her membranes rupture spontaneously with Laconian-staying amniotic fluid. Which actions should the nurse perform first?

Assess the fetal heart rate

Cowbell to tell the nurse at the clients membrane to rupture" something is hanging out on the bed!" The nurse visualizes an overt prolapsed umbilical cord. What is the priority nursing action?

Place the mother in a knee-to-chest position

A nurse is assessing a client with a family history of cancer. Which finding requires immediate follow up?

The client reports a feeling of a lump in the throat.

After amniotomy, Which client goal should take the highest priority?

The client will maintain adequate fetal tissue perfusion

A nurse obtained the antepartum history of a client who is six weeks pregnant. Which finding is a concern?

The clients consumption of 68 cans of beer on weekends