Symptom Management NCLEX

Changes in the delivery of health care have required nurses to become more skilled in: A. Primary care and prevention care management. B. Resource management. C. Personnel management. D. Financial management."

"Correct Answer: B. Resource management."

"The nurse is caring for a patient suffering from anorexia secondary to chemotherapy. Which of the following strategies would be most appropriate for the nurse to use to increase the patient's nutritional intake? "a. Increase intake of liquids at mealtime to stimulate the appetite. b. Serve three large meals per day plus snacks between each meal. c. Avoid the use of liquid protein supplements to encourage eating at mealtime. d. Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods."

"Correct answer: d The nurse can increase the nutritional density of foods by adding items high in protein and/or calories (such as peanut butter, skim milk powder, cheese, honey, or brown sugar) to foods the patient will eat."

"The client is complaining of left shoulder pain. Which response would be best for the nurse to assess the pain? "1.Request that the client describe the pain. 2.Inquire if the pain is intense, throbbing, or stabbing. 3.Ask if the client wants pain medication. 4.Instruct the client to complete the pain questionnaire."

"Correct: 1. Request that the client describe the pain. Rationale: This request allows the client to use terms and descriptions so that the nurse can eval-uate the pain and the effectiveness of thetreatment"

The nurse is caring for a patient suffering from anorexia secondary to chemotherapy. Which of the following strategies would be most appropriate for the nurse to use to increase the patient's nutritional intake? "A. Increase intake of liquids at mealtime to stimulate the appetite. B. Serve three large meals per day plus snacks between each meal. C. Avoid the use of liquid protein supplements to encourage eating at mealtime. D. Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods."

"Correct: D. The nurse can increase the nutritional density of foods by adding items high in protein and/or calories (such as peanut butter, skim milk powder, cheese, honey, or brown sugar) to foods the patient will eat."

"The client is taking cascara sagrada and develops abdominal cramps. What interpretation by the nurse is most likely correct? "1. The client has peptic ulcer 2. The client has influenza 3. The client may have partial bowel obstruction 4. This is a common side effect of this medication"

#4. Cascara sagrada is a laxative that causes nausea and abd cramps. The other options are not diagnosed on a single symptom

Which nursing intervention is the highest priority when administering pain medication to a client experiencing acute pain? 1. Monitor the client's vitals 2. Verify time of the last dose 3. Check the client's allergies 4. Discuss the pain with the client

Answer: 4. The nurse should question the client to rule out complications and to determine which medication and amount would be most appropriate. This is assessment.

Which of the following factors should be the primary focus of nursing management in a patient with acute pancreatitis? A. Nutrition management. B. Fluid and electrolyte balance. C. Management of hypoglycemia. D. Pain control.

"(Correct Answer: B) Acute pancreatitis is commonly associated with fluid isolation and accumulation in the bowel secondary to ileus or peripancreatic edema. Fluid and electrolyte loss from vomiting is a major concern. Therefore, your priority is to manage hypovolemia and restore electrolyte balance. Pain control and nutrition also are important. Patients are at risk for hyperglycemia, not hypoglycemia."

"A client with a history of alcoholism is brought to the emergency room in an agitated state. He is vomiting and diaphoretic. He says he had his last drink 5 hours ago. The nurse would expect to administer which of the following medications? "1. Chlordiazepoxide hydrochloride (Librium) 2. Disulfiram (Antabuse) 3. Methadone hydrochloride (Dolophine) 4. Naloxone hydrochloride (Narcan)"

"1. (CORRECT) Chlordiazepoxide hydrochloride (Librium) - antianxiety; used to treat symptoms of alcohol withdrawal 2. Disulfiram (Antabuse) - used as a deterrent to compulsive drinking; contraindicated if client drank alcohol in previous 12 hours 3. Methadone hydrochloride (Dolophine) - opioid analgesic, used to treat narcotic withdrawal 4. Naloxone hydrochloride (Narcan) - narcotic antagonist used to reverse narcotic-induced respiratory depression"

The client diagnosed with AIDS is complaining of a sore mouth and tongue. When the nurse assesses the buccal mucosa, the nurse notes white, patchy lesions covering the hard and soft palates and the right inner cheek. Which interventions should the nurse implement? 1.Teach the client to brush the teeth and patchy area with a soft-bristle toothbrush.2.Notify the HCP for an order for an antifungal swish-and-swallow medication.3.Have the client gargle with an antiseptic-based mouthwash several times a day.4.Determine what types of food the client has been eating for the last 24 hours

"1.This client probably has oral candidiasis, afungal infection of the mouth and esophagus. Brushing the teeth and patchy areas will not remove the lesions and will cause considerable pain. 2.(CORRECT) This most likely is a fungal infection known as oral candidiasis, commonly called thrush. An antifungal medication is needed to treat this condition. 3.Antiseptic-based mouthwashes usually contain alcohol, which would be painful for the client.4.The foods the client has eaten did not cause this condition. TEST-TAKING HINT: The client is complaining of a "sore mouth." The test taker must notice all the important information in the stem before attempting to choose an answer. How are brushing the area, an antiseptic mouthwash, or the foods that have been eaten going to alleviate the pain"

"A preschool-age child undergoing chemotherapy experiences nausea and vomiting. Which of the following would be the best intervention to include in the child's plan of care? "A. Offer fluids only between meals B. Offer small frequent meals C. Allow the child to choose what to eat for meals D. Administer tube feedings"

"ANSWER: Allow the child to choose what to eat for meals. While all options can be done to encourage nutrition, allowing the preschooler choices meets two issues: nutrition and developmental tasks."

A client receiving chemotherapy is experiencing mucositis. The nurse advises the client to use which of the following as the best substance to rinse the mouth? "a. Alcohol-based mouthwash b. Hydrogen peroxide mixture c. Lemon-flavored mouthwash d. Weak salt and bicarbonate mouth rinse"

"ANSWER: d Rationale: An acidic environment in the mouth is favorable for bacterial growth, particularly in an area already compromised from chemotherapy. Therefore, the client is advised to rinse the mouth before every meal and at bedtime with a weak salt and sodium bicarbonate mouth rinse. This lessens the growth of bacteria and limits plaque formation. The other substances are irritating to oral tissue. If hydrogen peroxide must be used because of the presence of severe plaque, it should be a weak solution, because hydrogen peroxide dries the mucous membranes."

"The male client diagnosed with chronic pain since a construction accident which broke several vertebrae tells the nurse he has been referred to a pain clinic and asks, ""What good will it do? I will never be free of this pain."" Which statement is the nurse's best response? "1) ""Are you afraid of the pain never going away?"" 2) ""The pain clinic will give you medication to cure the pain."" 3) ""Pain clinics work to help you achieve relief from pain."" 4) ""I'm not sure. You should discuss this with your HCP."""

"Answer 3 is correct: 1) This is a therapeutic response and the client is requesting information. 2) Pain clinics do not cure pain; The do identify measures to help relieve pain. 3) Pain clinics use a variety of methods to help the client to achieve relief from pain. Some measures include guided imagry, transcutaneous electrical nerve stimulation (TENS) units, nerve block surgery or injections, or medications. 4) This is not an appropriate answer, even if the nurse is not sure. The nurse should attempt to discover the information for the client then give factual information."

"The female client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing: "a. Rupture of the bladder b. The development of a vesicovaginal fistula c. Extreme stress caused by the diagnosis of cancer d. Altered perineal sensation as a side effect of radiation therapy"

"Answer B. A vesicovaginal fistula is a genital fistula that occurs between the bladder and vagina. The fistula is an abnormal opening between these two body parts and, if this occurs, the client may experience drainage of urine through the vagina. The client's complaint is not associated with options A, C, and D"

"A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. An important nursing intervention for the patient is to? "a. teach about the importance of nutrition during treatment. b. have the patient eat large meals when nausea is not present. c. administer prescribed antiemetics 1 hour before the treatments. d. offer dry crackers and carbonated fluids during chemotherapy."

"Answer C Rationale: Treatment with antiemetics before chemotherapy may help to prevent anticipatory nausea. Although nausea may lead to poor nutrition, there is no indication that the patient needs instruction about nutrition. The patient should eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea."

"A 35 years old client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis (inflammation of the mouth)? "a. White, cottage cheese-like patches on the tongue b. Yellow tooth discoloration c. Red, open sores on the oral mucosa d. Rust-colored sputum"

"Answer C. The tissue-destructive effects of cancer chemotherapy typically cause stomatitis, resulting in ulcers on the oral mucosa that appear as red, open sores. White, cottage cheese-like patches on the tongue suggest a candidal infection, another common adverse effect of chemotherapy. Yellow tooth discoloration may result from antibiotic therapy, not cancer chemotherapy. Rust-colored sputum suggests a respiratory disorder, such as pneumonia."

A patient received surgery and chemotherapy for colon cancer, completing therapy 3 months previously, and she is now in remission. At a follow-up appointment, she complains of fatigue following activity and difficulty with concentration at her weekly bridge games. Which of the following explanations could account for her symptoms? No options - see answer

"Answer: A Three months after surgery and chemotherapy the patient is likely to be feeling the after-effects, which often includes anemia because of bone-marrow suppression. There is no evidence that the patient is immunosuppressed, and fatigue is not a typical symptom of immunosuppression. The information given does not indicate that depression or dehydration is a cause of her symptoms."

"The laboratory results for a male client diagnosed with leukemia include RBC count 2.1 x 10^6/mm^3, WBC count 150 x 10^3/mm^3, K+ 3.8 mEq/L, and Na+ 139 mEq/L. Based on these results, which intervention should the nurse teach the client? "A. Encourage the client to eat foods high in iron. B. Instruct the client to use an electric razor when shaving. C. Discuss the importance of limiting sodium in the diet. D. Instruct the family to limit visits to once a week."

"Answer: B Rationale: A. The anemia that occurs in leukemia is not related to iron deficiency, and eating foods in iron will not help. B. The platelet count of 22 x 10^3/mm^3 indicates a platelet count of 22,000. The definition of thrombocytopenia is a count of less than 100,000. The client is at high risk for bleeding. Bleeding precautions include decreasing the risk by using soft-bristle toothbrushes and electric razors and holding all venipuncture sites for a minimum of 5 (five) minutes. C. The sodium level is within normal limits. D. Yes the client is at risk for an infection, but unless a family member is ill, they should be encouraged to visit whenever possible."

"During chemotherapy, an oncology client has a nursing diagnosis of impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis? "a. Recommending that the client discontinue chemotherapy b. Providing a solution of hydrogen peroxide and water for use as a mouth rinse c. Monitoring the client's platelet and leukocyte counts d. Checking regularly for signs and symptoms of stomatitis"

"Answer: B To decrease the pain of stomatitis, the nurse should provide a solution of hydrogen peroxide and water for the client to use as a mouth rinse. The nurse also may administer viscous lidocaine or systemic analgesics as prescribed. Stomatitis occurs 7 to 10 days after chemotherapy begins; thus, stopping chemotherapy wouldn't be helpful or practical. Instead, the nurse should stay alert for this potential problem to ensure prompt treatment."

"A nurse is administering IV furosemide to a patient with congestive heart failure. After the infusion, which of the following symptoms is NOT expected? "A. Increased urinary output B. Decreased edema C. Decreased pain D. Decreased blood pressure"

"Answer: C Furosemide, a loop diuretic, does not alter pain. Furosemide acts on the kidneys to increase urinary output. Fluid may move from the peripher, decreasing edema. Fluid load is reduced, lowering blood pressure."

"Patients with Type 1 diabetes mellitus may require which of the following changes to their daily routine during periods of infection? "A. No changes. B. Less insulin. C. More insulin. D. Oral diabetic agents."

"Answer: C During periods of infection or illness, patients with Type 1 diabetes may need even more insulin to compensate for increased blood glucose levels."

"Which of the following signs and symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm?" "A. abdominal pain B. absent pedal pulses C. chest pain D. lower back pain"

"Answer: D lower back pain results from expansion of the aneurysm. the expansion applies pressure and the pain is reffered to the lower back."

"A patient who has been treated for HIV infection for 7 years has developed fat redistribution to the trunk, with wasting of the arms, legs, and face. The nurse will anticipate teaching the patient about "a. treatment with antifungal agents. b. a change in antiretroviral therapy. c. foods that are higher in protein. d. the benefits of daily exercise"

"B Rationale: A frequent first intervention for metabolic disorders is a change in ART. Treatment with antifungal agents would not be appropriate because there is no indication of fungal infection. Changes in diet or exercise have not proven helpful for this problem"

"As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of the greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed when the client states: "a) I should avoid blowing my nose b) I may need a platelet transfusion if my platelet count is too low c) I'm going to take aspirin for my headache as soon as I get home d)I will count the number of pads and tampons I use when menstruating"

"C - During the period of greatest bone marrow suppression (the nadir), the platelet count may be low, less than 20,000 cells/mm3. Option C describes an incorrect statement by the client. Aspirin and nonsteroidal anti-inflammatory drugs and products that contain aspirin should be avoided because of their antiplatelet activity, thus further teaching is needed. Options A, B, and D are correct statements by the client to prevent and monitor bleeding."

"The home health nurse is caring for a client with cancer and the client is complaining of acute pain. The most appropriate nursing assessment of the client's pain would include which of the following? "1. The client's pain rating 2. Nonverbal cues from the client 3. The nurse's impression of the client's pain 4. Pain relief after appropriate nursing intervention"

"Correct Answer: 1 Rationale: The client's self report is a critical component of pain assessment. The nurse should ask the client about the description of pain and listen carefully to the client's words used to describe the pain. The nurse's impression of the client's pain is not appropriate in determining the client's pain level. Nonverbal cues are important, but not the most appropriate assessment. Pain relief is also important but not related to the question being asked."

"The client diagnosed with cancer has been undergoing systemic treatments and has red blood cell deficiency. Which signs and symptoms should the nurse teach the client to manage? "1. Nausea associated with cancer treatment. 2. Shortness of breath and fatigue. 3. Controlling mucositis and diarrhea. 4. The emotional aspects of having cancer."

"Correct Answer: 2 Anemia causes the client to experience dyspnea and fatigue. Teaching the client to pace activities and rest often, to eat a balanced diet, and to cope with changes inlifestyle is needed."

"The client diagnosed with ARF is admitted to the ICU and placed on a therapeutic diet. Which diet is most appropriate for the client? "1. A high potassium and low calcium diet 2. A low-fat and low-cholesterol diet 3. A high cardohydrate and restricted-protein diet 4. A regular diet with 6 small feedings a day"

"Correct Answer: 3 1. The diet is low in K+, and Ca is not restricted in ARF 2. This is a diet recommended for clients with cardiac disease and atherosclerosis 3. Carbohydrates are increased to provide for the client's caloric intake and protein is restricted to minimize protein breakdown and to prevent accumulation of toxic waste products 4. The client must be on a therapeutic diet, and small feedings are not required"

A patient with osteoarthritis has been taking ibuprofen (Motrin) 400 mg every 8 hours. The patient states that the drug does not seem to work as well as it used to in controlling the pain. The most appropriate response to the patient is based on knowledge of which of the following? "A. Another NSAID may be indicated because of individual variations in response to drug therapy. B. The patient is probably not compliant with the drug therapy and therefore the nurse must initially assess the patient's knowledge base and initiate appropriate teaching. C. If NSAIDs are not effective in controlling symptoms, systemic corticosteroids are the next line of therapy. D. It may take several months for NSAIDs to reach therapeutic levels in the blood and thus be effective."

"Correct Answer: A A. Patients vary in their response to medications so when one NSAID does not provide relief, another should be tried. B.There is no evidence in the stem of the question to ascertain any noncompliance to drug therapy. C. oral corticosteroids are not first line therapy for pain management and have restricted uses. D. Therapeutic levels vary depending on the NSAID and are reached within minutes to hours."

The nurse is providing preop teaching about pain management techniques for the client having surgery. The client has a hx of drug abuse. What should the nurse include in this client's plan of care? "A. The nurse should know that these clients always require too much nursing care. B. The client should select 2 alternative therapies to replace medications. C. The client should receive complementary therapies in addition to medications. D> The nurse should plan to administer a double dose of medication to the client."

"Correct Answer: C A. The nurse is responsible for ensuring the client receives quality care regardless of the client's hx or the amount of care required. B. The client should be encourage to use alternative therapies for pain management to supplement medication, not replace medication . C. The nurse should assist the client's pain management by using complementary therapies as well as medications, but never in place of pain medication. D. A double dose of medication requires HCPs order and if administered, careful monitoring is quired."

A patient on chemotherapy for 10 weeks started at a weight of 121 lbs. She now weighs 118 lbs and has no sense of taste. Which nursing interventions would be a priority? "A. Advise the patient to eat foods that are fatty, fried, or high in calories B. Discuss with the physician the need for parenteral or enteral feedings C. Advise the patient to drink a nutritional supplement beverage at least three times a day D. Advise the patient to experiment with spices and seasoning to enhance the flavor of food."

"Correct Answer: D Instruct the patient to experiment with spices and other seasoning agents in an attempt to mask taste alterations. Lemon juice, onion, mint, basil, and fruit juice marinades may improve the taste of certain meats and fish. Bacon bits, onion, and pieces of ham may enhance the taste of vegetables."

"A 20-year-old patient is being treated for pneumonia. He has a persistent cough and complains of severe pain on coughing. What could you tell him to help him r"A. ""Hold your cough as much as possible."" B. ""Place the head of your bed flat to help with coughing."" C. ""Restrict fluids to help decrease the amount of sputum."" D. ""Splint your chest wall with a pillow for comfort.""" educe his discomfort?

"Correct Answer: D Rationale:Showing this patient how to splint his chest wall will help decrease discomfort when coughing. Holding in his coughs will only increase his pain. Placing the head of the bed flat may increase the frequency of his cough and his work of breathing. Increasing fluid intake will help thin his secretions, making it easier for him to clear them."

In assessing the patient with stress incontinence, the nurse should anticipate which of these signs or symptoms? "A. Pain on urination B. A brownish urethral discharge C. Voiding excessive amounts of urine D. Loss of urine when laughing, coughing, or sneezing"

"Correct Answer: D. Loss of urine when laughing, coughing, or sneezing Rationale: Stress incontinence is the involuntary loss of urine when intra-abdominal pressure is increased, such as during coughing or laughing."

"A patient diagnosed with cancer is experiencing severe pain. Which regimen would the nurse teach the client about to control the pain? "a. Nonsteroidal antinflammatory drugs (NSAIDs) around the clock with narcotics used for severe pain. b. Morphine sustained release, a narcotic, routinely with liquid morphine preparation for breakthrough pain. c. Extra-Strength Tylenol, a narcotic analgesic, plus therapy to learn alternative methods of pain control. d. Demerol, an opioid narcotic, every six hours orally with a suppository when the pain is not controlled."

"Correct answer is B. Morphine is the drug of choice for cancer pain. There is o ceiling effect, it metabolizes without harmful byproducts, and it is relatively inexpensive. A sustained-release formulation, such as MS Contin, is administered every 6-8 hours, and a liquid fast-acting form is administered sublingually for any pain which is not controlled."

"Which of the following patients should be seen first by the oncoming nurse? "A. A 60 year old female requesting an antacid and feeling sweaty B. A 59 yo male post cardiac cath by 8 hours C. A 28 yo female diagnosed with asthma, who has just received a treatment by respiratory therapy D. A diabetic whose blood glucose was 120 one hour ago"

"Correct answer: A Feelings of indigestion and sweating can be signs of an impending myocardial infarction. B - This patient has no signs / symptoms that take priority. C - This patient has no signs / symptoms that take priority. D - This patient has no signs / symptoms that take priority."

"18. Serotonin release stimulates vomiting following chemotherapy. Therefore, serotonin antagonists are effective in preventing and treating nausea and vomiting related to chemotherapy. An example of an effective serotonin antagonist antiemetic is: "a. ondansetron (Zofran). b. fluoxetine (Prozac). c. paroxetine (Paxil). d. sertraline (Zoloft)."

"Correct answer: Answer A Chemotherapy often induces vomiting centrally by stimulating the chemoreceptor trigger zone (CTZ) and peripherally by stimulating visceral afferent nerves in the GI tract. Ondansetron (Zofran) is a serotonin antagonist that bocks the effects of serotonin and prevents and treats nausea and vomiting. It is especially useful in single-day highly emetogenic cancer chemotherapy (for example, cisplatin). The agents in options 2-4 are selective serotonin reuptake inhibitors. They increase the available levels of serotonin."

A client with glomerulonephritis is at risk of developing acute renal failure. The nurse monitors the client for which sign of this complication? "a) bradycardia b) hypertension c) decreased cardiac output d) decreased central venous pressure"

"Correct answer: B Acute renal failure caused by glomerulonephritis is classified as intrinsic or intrarenal failure. This form of acute renal failure is commonly manifested by hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. Acute renal failure from prerenal causes is characterized by decreased blood pressure or a recent history of the same, tachycardia, and decreased cardiac output and central venous pressure. Bradycardia is not part of the clinical picture for renal failure."

"The patient has had abdominal surgery. The nurse is teaching her about deep vein thrombosis (DVT). The nurse will include positive conversation and instruction on all of the following factors except: "A. Exercise can decrease the risk for developing DVT B. Briskly massage any red, tender areas in the calf C. Frequent lab work will be necessary D. Report any leg discomfort immediately"

"Correct answer: B Massaging the thrombotic area can dislodge all or part of the clot and cause severe complications and death. A - Exercise before a DVT develops increases circulation and decreases the risk of DVT. C - Frequent labs may be necessary to test clotting time and the potential risk for DVT. D - Leg pain, swelling, redness, or hot spots are signs of DVT."

"5. Which of the following positions would best aid breathing for a patient with acute pulmonary edema? "A. Lying flat in bed. B. Left side-lying position. C. High Fowler's position. D. Semi-Fowler's position."

"Correct answer: C High Fowler's position facilitates breathing by reducing venous return. Lying flat and side-lying positions worsen breathing and increase the heart's workload."

"A female client with cancer is scheduled for radiation therapy. The nurse knows that radiation at any treatment site may cause a certain adverse effect. Therefore, the nurse should prepare the client to expect: "A. Hair loss B. Stomatitis C. Fatigue D. Vomiting"

"Correct answer: C Rationale: Radiation therapy may cause fatigue, skin toxicities, and anorexia regardless of the treatment site. Hair loss, stomatitis, and vomiting are site-specific, not generalized, adverse effects of radiation therapy"

A patient with Hodgkin's lymphoma is undergoing external radiation therapy on an outpatient basis. After 2 weeks of treatment, the patient tells the nurse, "I am so tired I can hardly get out of bed in the morning." An appropriate intervention for the nurse to plan with the patient is to: "a. exercise vigorously when fatigue is not as noticeable. b. consult with a psychiatrist for treatment of depression. c. establish a time to take a short walk every day. d. maintain bed rest until the treatment is completed"

"Correct answer: C Rationale: Walking programs are used to keep the patient active without excessive fatigue. Vigorous exercise when the patient is less tired may lead to increased fatigue. Fatigue is expected during treatment and is not an indication of depression. Bed rest will lead to weakness and other complications of immobility."

"During an admission assessment of a 35 year old client with advanced ovarian cancer, the nurse recognizes which symptom as typical of the disease? "A. Diarrhea B. Hypermenorrhea C. Abdominal bleeding D. Abdominal distention"

"Correct answer: D Clinical manifestations of ovarian cancer include abdominal distention, urinary frequency and urgency, pleural effusion, malnutrition, pain from pressure caused by the growing tumor and the effects of urinary or bowel obstruction, constipation, ascites with dyspnea, and ultimately general severe pain. Abnormal bleeding, often resulting in hypermenorrhea, is associated with uterine cancer."

"During the acute phase of burn treatment, important goals of patient care include which of the following? Select all that apply. "1. providing for patient comfort 2. preventing infection 3. providing adequate nutrition for healing to occur 4. splinting, positioning, and exercising affected joints 5. assessing home maintenance management"

"Correct: 1,2,3,4 Rationale: The goals of treatment for the acute period include wound cleansing and healing; pain relief; preventing infection; promoting nutrition; and splinting, positioning, and exercising affected joints. Assessment of home maintenance management is an important goal in the rehabilitative stage, not the acute stage."

"The client diagnosed with septicemia has the following health-care provider orders. Which order has the highest priority? 1. Provide clear liquid diet. 2. Initiate IV antibiotic therapy. 3. Obtain a STAT chest x-ray. 4. Perform hourly glucometer checks.

"Correct: 2 1.)The client's diet is not priority when transcribing orders. 2.)An IV antibiotic is the priority medication for the client with an infection, which is the definition of sepsis—a systemic bacterial infection of the blood. A new order for an IV antibiotic should be implemented within one (1) hour of receiving the order. 3.)Diagnostic tests are important but not priority over intervening in a potentially life-threatening situation such as septic shock.4.)There is no indication that this client has diabetes in the stem of the question, and glucose levels are not associated with signs/symptoms of septicemia. TEST-TAKING HINT: Remember if the test taker can rule out two answers—"1" and "4"—and cannot determine the right answer between "2" and "3," select the option that directly affects or treats the client, which would be the antibiotics. Diagnostic tests do not treat the client."

"A client with acquired immunodeficiency syndrome (AIDS) has a nursing diagnosis of fatigue. The nurse teaches the client which strategy to conserve energy after discharge from the hospital? "1.) Bathe before eating breakfast 2.) Sit for as many activities as possible 3.) Stand in the shower instead of taking a bath 4.) Group all tasks to be performed early in the morning"

"Correct: 2 The client is taught to conserve energy by sitting for many activities as possible, including dressing, shaving, preparing food, ironing, and so on. The client should also sit in a shower chair instead of standing while bathing. The client needs to prioritize activities such as eating breakfast before bathing, and he or she should intersperse each major activity with a period of rest."

"The nurse is assessing a client diagnosed with chronic pain. Which characteristics would the nurse observe? "1.The client's blood pressure is elevated. 2.The client has rapid shallow respirations. 3.The client has facial grimacing. 4.The client is lying quietly in bed."

"Correct: 4 1.Blood pressure elevates in acute pain. Chronic pain, by definition, lasts more than six (6)months, lasts far beyond the expected time forthe pain to resolve, and may have an unclearonset. Changes in vital signs result from the fight-or-flight response by the body. The body cannot maintain this response and must adjust. 2.Rapid shallow respirations might be attributed to acute pain if it was painful to breathe. The client with a chest injury or pain will splint the area and slow the respirations or attempt tobreathe shallowly and rapidly. 3.Facial grimacing will occur in acute pain and is an objective sign the nurse can identify. Clients with chronic pain may be laughing and still be in pain. Remember that pain is whatever the client says it is and occurs whenever the client says it does. 4.The client in chronic pain will have adapted to living with the pain, and lying quietly may be the best way for the client to limit the feeling of pain."

"A 70-year-old male patient has multiple myeloma. His wife calls to report that he sleeps most of the day, is confused when awake, and complains of nausea and constipation. Which complication of cancer is this most likely caused by? "a. hypercalcemia b. Tumor lysis syndrome c. spinal cord compression d. Superior vena cava syndrome"

"correct answer: a Rationale: Hypercalcemia can occur with multiple myeloma; immobility and dehydration can contribute to or exacerbate hypercalcemia. The primary manifestations of hypercalcemia include apathy, depression, fatigue, muscle weakness, electrocardiographic changes, polyuria and nocturia, anorexia, nausea, and vomiting."

"A 70-year-old male patient has multiple myeloma. His wife calls to report that he sleeps most of the day, is confused when awake, and complains of nausea and constipation. Which complication of cancer is this most likely caused by? "A. hypercalcemia B. Tumor lysis syndrome C. Spinal cord compression D. Superior vena cava syndrome"

"correct answer: a Rationale: Hypercalcemia can occur with multiple myeloma; immobility and dehydration can contribute to or exacerbate hypercalcemia. The primary manifestations of hypercalcemia include apathy, depression, fatigue, muscle weakness, electrocardiographic changes, polyuria and nocturia, anorexia, nausea, and vomiting."

The male client that has made himself a do not resuscitate (DNR) is in pain. The client's vital signs are P 88, R 8, and BP 108/70. Which intervention should be the nurse's priority action? "1.Refuse to give the medication because it could kill the client.2.Administer the medication as ordered and assess for relief from pain.3.Wait until the client' respirations improve and then administer the medication.4.Notify the HCP that the client is unstable and pain medication is being held."

(CORRECT = 2) The client is in pain. The American Nurse's Code of Ethics states that clients have the right to die as comfortably as possible even if the measures used to control the pain indirectly hasten the impending death. The Dying Client's Bill of Rights reiterates this position. The client should be allowed to die with dignity and with as much comfort as the nurse can provide.

A patient with a history of congestive heart failure arrives at the clinic complaining of dyspnea. Which of the following actions is the first the nurse should perform? "A. Ask the patient to lie down on the exam table. B. Draw blood for chemistry panel and arterial blood gas (ABG). C. Send the patient for a chest x-ray. D. Check blood pressure.

(Correct Answer: D)A patient with congestive heart failure and dyspnea may have pulmonary edema, which can cause severe hypertension. Therefore, taking the patient's blood pressure should be the first action. Lying flat on the exam table would likely worsen the dyspnea, and the patient may not tolerate it. Blood draws for chemistry and ABG will be required, but not prior to the blood pressure assessment.

Which problem would be most appropriate for the nurse to identify for the client experiencing acute pain? 1.) Ineffective coping. 2.) Potential for injury. 3.) Alteration in comfort. 4.) Altered sensory input.

*3. Alteration in comfort is addressing the client's acute pain (CORRECT). 1. This is a psychosocial problem, which is not appropriate for an acute physiological problem (omit #1). 2. A potential problem is not priority for a client in acute pain (omit #2). 3. NANDA's list of client problems and nursing diagnoses includes alteration in comfort for pain; Potential problems DO NOT have priority over acutal problems (CORRECT). 4. Altered sensory input does not address the client's acute physical pain (omit #4).

A male client with a nagging cough makes an appointment to see the physician after reading that this symptom is one of the seven warning signs of cancer. What is another warning sign of cancer? "a. Persistent nausea b. Rash c. Indigestion d. Chronic ache or pain"

.Answer C. Indigestion, or difficulty swallowing, is one of the seven warning signs of cancer. The other six are a change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, a thickening or lump in the breast or elsewhere, an obvious change in a wart or mole, and a nagging cough or hoarseness. Persistent nausea may signal stomach cancer but isn't one of the seven major warning signs. Rash and chronic ache or pain seldom indicate cancer.

The client being hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale, and anxious. The nurse suspects air embolism. The priority action of the nurse is to? 1. Discontinue dialysis and notify HCP 2. Monitor VS Q15 min for the next hour. 3. Continue dialysis at a slower rate after checking the lines for air. 4. Bolus the client with 500 ml of NS to break up the embolus.

1. If the client experiences air embolus during hemodialysis, the nurse should terminate dialysis immediately, notify the HCP, and administer O2 as needed.

"A nurse is caring for a client 24 hours after he has undergone an abdominal-perineal resection for a bowel tumor. The client's wife asks if she can bring him some of his favorite home-cooked Italian minestrone soup. What would be an appropriate action by the nurse? 1. Auscultate for bowel sounds. 2. Ask the client if he feels hunger or gas pains. 3. Consult the dietician. 4. Encourage the wife to bring the soup.

1. The nurse should perform a thorough assessment of the abdomen and auscultate for bowel sounds in all four quadrants. Clients who have gastrointestinal surgery may have decreased peristalsis for several days after surgery. The nurse should check the abdomen for distention and check with the client and the medical record regarding the passage of flatus or stool. Consulting a dietician would be inappropriate because the client must be kept on nothing-by-mouth status until bowel sounds are present. The nurse should explain to the wife that it is too soon after surgery for her husband to eat.

The client is hospitalized for insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. The initial action by the nurse is to: 1 Call the physician; 2. reinsert the implant into the vagina immediately; 3. pick up the implant with gloved hands and flush it down the toilet; 4. pick up the implant with long-handled forceps and place in in a lead container.

4. pick up the implant with long-handled forceps and place it in a lead container. Rationalle: a lead container and long-handled forceps should be kept in the client's room at all times during internal radiation therapy. If the ijmplant becomes dislodged, the nurse should pick up the implant with long-handled forceps and place it in the lead container.

"Which of the following medication prescriptions to help relieve discomfort in a child with leukemia should the nurse question? "1. Hydromorphone (Dilaudid) 2. Acetaminophen with codeine (Tylenol with Codeine) 3. Ibuprofen (Motrin) 4. Acetaminophen with Hydrocodone (Lortab)"

Answer 3: Ibuprophen prolongs bleeding timeand is contraindicated in clients with leukemia. Nonnarcotic drugs other than ibuprofen or aspirin, such as acetaminophen (Tylenol), may be prescribed to control pain and may be used in combination with codeine or hydrocodone if pain is more severe. Hydromorphone may also be used for severe pain.

"8. A patient received surgery and chemotherapy for colon cancer, completing therapy 3 months previously, and she is now in remission. At a follow-up appointment, she complains of fatigue following activity and difficulty with concentration at her weekly bridge games. Which of the following explanations could account for her symptoms? "A. The symptoms may be the result of anemia caused by chemotherapy. B. The patient may be immunosuppressed. C. The patient may be depressed. D. The patient may be dehydrated."

Answer A Three months after surgery and chemotherapy the patient is likely to be feeling the after-effects, which often includes anemia because of bone-marrow suppression. There is no evidence that the patient is immunosuppressed, and fatigue is not a typical symptom of immunosuppression. The information given does not indicate that depression or dehydration is a cause of her symptoms."

"For a female client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the plan of care? "a. Administering aspirin if the temperature exceeds 102° F (38.8° C) b. Inspecting the skin for petechiae once every shift c. Providing for frequent rest periods d. Placing the client in strict isolation"

Answer B. Because thrombocytopenia impairs blood clotting, the nurse should inspect the client regularly for signs of bleeding, such as petechiae, purpura, epistaxis, and bleeding gums. The nurse should avoid administering aspirin because it may increase the risk of bleeding. Frequent rest periods are indicated for clients with anemia, not thrombocytopenia. Strict isolation is indicated only for clients who have highly contagious or virulent infections that are spread by air or physical contact.

During chemotherapy, an oncology client has a nursing diagnosis of impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis? "a. Recommending that the client discontinue chemotherapy b. Providing a solution of hydrogen peroxide and water for use as a mouth rinse c. Monitoring the client's platelet and leukocyte counts d. Checking regularly for signs and symptoms of stomatitis"

Answer B. To decrease the pain of stomatitis, the nurse should provide a solution of hydrogen peroxide and water for the client to use as a mouth rinse. (Commercially prepared mouthwashes contain alcohol and may cause dryness and irritation of the oral mucosa.) The nurse also may administer viscous lidocaine or systemic analgesics as prescribed. Stomatitis occurs 7 to 10 days after chemotherapy begins; thus, stopping chemotherapy wouldn't be helpful or practical. Instead, the nurse should stay alert for this potential problem to ensure prompt treatment. Monitoring platelet and leukocyte counts may help prevent bleeding and infection but wouldn't decrease pain in this highly susceptible client. Checking for signs and symptoms of stomatitis also wouldn't decrease the pain.

"A female client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a fluid and electrolyte imbalance induced by chemotherapy? "a. Urine output of 400 ml in 8 hours b. Serum potassium level of 3.6 mEq/L c. Blood pressure of 120/64 to 130/72 mm Hg d. Dry oral mucous membranes and cracked lips"

Answer D. Chemotherapy commonly causes nausea and vomiting, which may lead to fluid and electrolyte imbalances. Signs of fluid loss include dry oral mucous membranes, cracked lips, decreased urine output (less than 40 ml/hour), abnormally low blood pressure, and a serum potassium level below 3.5 mEq/L.

Following surgery, Mario complains of mild incisional pain while performing deep- breathing and coughing exercises. The nurse's best response would be: "A. "Pain will become less each day." B. "This is a normal reaction after surgery." C. "With a pillow, apply pressure against the incision." D. "I will give you the pain medication the physician ordered.""

Answer: (C) "With a pillow, apply pressure against the incision." Applying pressure against the incision with a pillow will help lessen the intra-abdominal pressure created by coughing which causes tension on the incision that leads to pain.

A 45-year-old patient has breast cancer that has spread to the liver and spine. The patient has been taking oxycodone (OxyContin) and amitriptyline (Elavil) for pain control at home but now has constant severe pain and is hospitalized for pain control and development of a pain-management program. When doing the initial assessment, which question will be most appropriate to ask first? A. how would you describe your pain? B. How much medication do you take for the pain C. How long have you had this pain? D. How many times do you medicate for pain?

Answer: A Because pain is a multidimensional experience, asking a question that addresses the patient's experience with the pain is likely to elicit more information than the more specific in formation asked in the rest.

"Which of the following interventions should be your first priority when treating a patient experiencing chest pain while walking? "A. Have the patient sit down. B. Get the patient back to bed. C. Obtain an ECG. D. Administer sublingual nitroglycerin."

Answer: A. The initial priority is to decrease oxygen consumption by sitting the patient down. Administer sublingual nitroglycerin as you simultaneously do the ECG. When the patient's condition is stabilized, he can be returned to bed.

A postoperative patient who has undergone extensive bowel surgery moves as little as possible and does not use the incentive spirometer unless specifically reminded. The patient rates the pain severity as an 8 on a 10-point scale but tells the nurse, "I can tough it out." In encouraging the patient to use pain medication, the best explanation by the nurse is that A .very few patients become addicted to opioids when using them for acute pain control. B.there is little need to worry about side effects because these problems decrease over time. C.there are many pain medications and if one drug is ineffective, other drugs may be tried. D. unrelieved pain can be harmful due to the effect on respiratory function and activity level.

Answer: D The patient's low activity level, lack of spirometer use, and statement to the nurse indicate that there is a lack of understanding about the purpose of postoperative pain management. The patient did not indicate a concern about becoming addicted, a desire for alternate medications, or anxiety about analgesic side effects.

Gastroesophageal reflux disease (GERD) weakens the lower esophageal sphincter, predisposing older persons to risk for impaired swallowing. In managing the symptoms associated with GERD, the nurse should assign the highest priority to which of the following interventions? "A. Decrease daily intake of vegetables and water, and ambulate frequently. B. Drink coffee diluted with milk at each meal, and remain in an upright position for 30 minutes. C. Eat small, frequent meals, and remain in an upright position for at least 30 minutes after eating. D. Avoid over-the-counter drugs that have antacids in them."

C. Rationale: Small, frequent feedings requires less release of hydrochloric acid. Remaining in an upright position for 30 minutes after meals prevents reflux into the esophagus

"The client being admitted from the emergency department is diagnosed with a fecal impaction. Which nursing intervention should be implemented? "1. Administer an antidiarrheal medication every day and PRN. 2. Perform bowel training every two (2) hours. 3. Administer an oil retention enema. 4. Prepare for an upper gastrointestinal (UGI) series x-ray."

CORRECT 3 "1. An antidiarrheal medication would slow down the peristalsis in the colon, worsening the problem. 2. The client has an immediate need to evacuate the bowel, not a need for bowel training. 3. Oil retention enemas will help to soften the feces and evacuate the stool.(correct) 4. A UGI series adds barium to the already hardened stool in the colon. Barium enemas x-ray the colon; a UGI series x-rays the stomach and jejunum."

"A nurse is caring for a patient with cervical cancer. The nurse notices that the radium implant has been dislodged. Which of the following actions should the nurse take first? "1. Stay with the patient and contact radiology 2. Wrap the implant in a blanket and place it behind a lead shield 3. Pick up the implant with lon-handled forceps and place it in a lead container 4. Obtain a dosimeter reading on the patient and report it to the physician"

CORRECT 3 "1. need to secure the implant in a lead container kept in the patient's room 2. pick up implant with long-handled forceps 3. never touch implant with bare hands; forceps and container should be kept in patient's room. Correct. 4. need to place implant in a lead container"

An infant is admitted to the pediatric unit with a diagnosis of sepsis. the nurse is completing a nursing assessment. what would be the priority nursing assessment for this infant? 1. skin integrity 2. temperature 3. jaundice 4. respiratory function

Correct #4. RATIONALE: altered temerature, jaundice, and respiratory distress are all symptoms of sepsis in infancts. respiratory function is the highest priority because without an adequate airway and breathing, the client cannot maintain life. skin inetgrity is a routine assessment. STRATEGY: use the ABCs and the process of elimination to make a selection. airway and breathing typically take priority in situations of high acuity, such as sepsis.

Which of the following signs and symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm? "a. Abdominal pain. b. Absent pedal pulses. c. Chest pain. d. Lower back pain."

Correct Answer D. Lower back pain results from expansion of the aneurysm. The expansion applies pressure in the abdomen, and the pain is referred to the lower back. Abdominal pain is the most common symptom resulting from impaired circulation. Absent pedal pulses are a sign of no circulation and would occur after a ruptured aneurysm or in peripheral vascular disease. Chest pain usually is associated with coronary artery or pulmonary disease.

"The home health nurse is caring for a client with cancer and the client is complaining of acute pain. The most appropriate nursing assessment of the client's pain would include which of the following? "1. The client's pain rating 2. Nonverbal cues from the client 3. The nurse's impression of the client's pain 4. Pain relief after appropriate nursing intervention

Correct Answer: 1 Rationale: The Client's self-report is a critical component of pain assessment. The nurse should ask the client about the description of pain and listen carefully to the client's words used to describe the pain. The nurse's impression of the client's pain is not appropriate in determining the client's pain level. Nonverbal cues are important, but not the most appropriate assessment. Pain relief is also important but not related to the question being asked.

A nurse is changing the central line dressing of a client receiving Parenteral nutritional and notes that the catheter insertion site appears reddened. The nurse next asseses which of the following items? 1. Client Temperature 2. Expiration of the bag 3. Time of last dressing change. 4. Tightness of tubing connections.

Correct Answer: 1, client temp. Rationale: Redness at the catheter insertion site is a possible indication of infection. Loose connections would result in leakage not redness.The expiration and time of last dressing change are not priorities and should have been checked at the time of shift change.

What's the first intervention for a patient experiencing chest pain and an Sp02 of 89%? "A. Administer morphine. B. Administer oxygen. C. Administer sublingual nitroglycerin. D. Obtain an electrocardiogram (ECC)"

Correct answer: B Administering supplemental oxygen to the patient is the first priority. Administer oxygen to increase SpO2 to greater than 90% to help prevent further cardiac damage. Sublingual nitroglycerin and morphine are commonly administered after oxygen.

Tissue plasminogen activator (t-PA) is considered for treatment of a patient who arrives in the emergency department following onset of symptoms of myocardial infarction. Which of the following is a contraindication for treatment with t-PA? "A. Worsening chest pain that began earlier in the evening. B. History of cerebral hemorrhage. C. History of prior myocardial infarction. D. Hypertension."

Correct: B A history of cerebral hemorrhage is a contraindication to tPA because it may increase the risk of bleeding. TPA acts by dissolving the clot blocking the coronary artery and works best when administered within 6 hours of onset of symptoms. Prior MI is not a contraindication to tPA. Patients receiving tPA should be observed for changes in blood pressure, as tPA may cause hypotension.

"Which of the following items would be most beneficial when providing oral care to a patient with metastatic cancer who is at risk for oral tissue injury secondary to chemotherapy? "A. Firm-bristle toothbrush B. Hydrogen peroxide rinse C. Alcohol-based mouthwash D. 1 tsp salt in 1 L water mouth rinse"

D. (CORRECT) A salt-water mouth rinse will not cause further irritation to oral tissue that is fragile because of mucositis, which is a side effect of chemotherapy.