5 (2)

A patient recently admitted to the hospital is to receive an antibiotic intravenously for the first time for a urinary tract infection. Before checking the five rights prior to administration, what is the nurse's first action? 1 Review the clinical records and ask the patient about any known allergies. 2 Check with the pharmacy for any known allergies for this patient. 3 Check the patient's identification band for any allergies. 4 Ask the nurse who previously cared for the patient about any known allergies.

1 The clinical record should have all known hypersensitivities listed for the patient. The patient should also be asked directly about any known allergies. The pharmacy is not responsible for obtaining information on all of the patient's known allergies. Checking the patient's identification band for allergies is part of the "five rights" process at the bedside before the medication is given. Asking the previous nurse is not an appropriate safety measure before medication administration.

The nurse plans to assess a patient with type I hypersensitivity for which clinical manifestation? 1 Poison ivy 2 Autoimmune hemolytic anemia 3 Allergic asthma 4 Rheumatoid arthritis

3 Allergic asthma is a manifestation of type I hypersensitivity. Poison ivy is a type IV delayed mechanism of hypersensitivity. Autoimmune hemolytic anemia is a type II cytotoxic mechanism of hypersensitivity. Rheumatoid arthritis is a type III immune complex-mediated mechanism of hypersensitivity.

What are the side effects of radiation? (SATA) a. Altered taste sensation b. Skin changes and permanent local hair loss c. Diarrhea and tooth loss d. Weight gain and fluid retention e. Fatigue

A, B, E

What signs/symptoms does the nurse assess in a patient with dysfunctional uterine bleeding? (Select all that apply) a. Male hair pattern b. Gastric ulcers c. Thyroid enlargement d. Abdominal pain e. Abdominal masses

A, C, D, E

A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best? a. Assess medication records for steroid use. b. Facilitate a consultation with physical therapy. c. Measure the range of motion in both hips. d. Notify the health care provider immediately.

ANS: A Chronic steroid use is seen in clients with SLE and can lead to osteonecrosis (bone necrosis). The nurse should determine if the client has been taking a steroid. Physical therapy may be beneficial, but there is not enough information about the client yet. Measuring range of motion is best done by the physical therapist. Notifying the provider immediately is not warranted.

A client is started on etanercept (Enbrel). What teaching by the nurse is most appropriate? a. Giving subcutaneous injections b. Having a chest x-ray once a year c. Taking the medication with food d. Using heat on the injection site

ANS: A Etanercept is given as a subcutaneous injection twice a week. The nurse should teach the client how to self-administer the medication. The other options are not appropriate for etanercept.

1. The nurse is caring for a client diagnosed with human immune deficiency virus. The client's CD4+ cell count is 399/mm3. What action by the nurse is best? a. Counsel the client on safer sex practices/abstinence. b. Encourage the client to abstain from alcohol. c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iron meals.

ANS: A This client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she remains highly infectious and should be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of the disease. DIF: Applying/Application REF: 328 KEY: HIV/AIDS| safer sex| immune disorders MSC: IntegratedProcess:Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

A nurse works with several clients who have gout. Which types of gout and their drug treatments are correctly matched? (Select all that apply.) a. Allopurinol (Zyloprim) - Acute gout b. Colchicine (Colcrys) - Acute gout c. Febuxostat (Uloric) - Chronic gout d. Indomethacin (Indocin) - Acute gout e. Probenecid (Benemid) - Chronic gout

ANS: B, C, D, E Acute gout can be treated with colchicine and indomethacin. Chronic gout can be treated with febuxostat and probenecid. Allopurinol is used for chronic gout.

A nurse is discharging a client to a short-term rehabilitation center after a joint replacement. Which action by the nurse is most important? a. Administering pain medication before transport b. Answering any last-minute questions by the client c. Ensuring the family has directions to the facility d. Providing a verbal hand-off report to the facility

ANS: D As required by The Joint Commission and other accrediting agencies, a hand-off report must be given to the new provider to prevent error. The other options are valid responses but do not take priority.

A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like "pins and needles" and that the neck is very painful since returning from surgery. What action by the nurse is best? a. Assist the client to change positions. b. Document the findings in the client's chart. c. Encourage range of motion of the neck. d. Notify the provider immediately.

ANS: D Clients with RA can have cervical joint involvement. This can lead to an emergent situation in which the phrenic nerve is compressed, causing respiratory insufficiency. The client can also suffer a permanent spinal cord injury. The nurse needs to notify the provider immediately. Changing positions and doing range of motion may actually worsen the situation. The nurse should document findings after notifying the provider.

A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection? a. Assess the client's white blood cell count. b. Culture any drainage from the wound. c. Monitor the client's temperature every 4 hours. d. Use aseptic technique for dressing changes.

ANS: D Preventing surgical wound infection is a primary responsibility of the nurse, who must use aseptic technique to change dressings or empty drains. The other actions do not prevent infection but can lead to early detection of an infection that is already present.

8. A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem? a. Chooses high-protein food b. Has decreased oral discomfort c. Eats 90% of meals and snacks d. Has a weight gain of 2 pounds/1 month

ANS: D The weight gain is the best indicator that goals for this client problem have been met because it demonstrates that the client not only is eating well but also is able to absorb the nutrients. DIF: Evaluating/Synthesis REF: 341 KEY: HIV/AIDS| malnutrition| nutrition MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

The nurse is caring for a client who is receiving rituximab (Rituxan) for treatment of lymphoma. During the infusion, it is essential for the nurse to observe for which side effect? A.) Alopecia B.) Allergy C.) Fever D.) Chills

Allergy Allergy is the most common side effect of monoclonal antibody therapy (rituximab). Monoclonal antibody therapy does not cause alopecia. Although fever and chills are side effects of monoclonal antibody therapy, they would not take priority over an allergic response that could potentially involve the airway.

Which laboratory result is the most important in relation to the nadir? a. RBC count b. WBC count c. Platelet count d. Serum calcium level

B

When caring for a client receiving chemotherapy, the nurse plans care during the nadir of bone marrow activity to prevent which complication? A.) Drug toxicity B.) Polycythemia C.) Infection D.) Dose-limiting side effects

Infection The lowest point of bone marrow function is referred to as the nadir; risk for infection is highest during this phase. Drug toxicity can develop when drug levels exceed peak concentrations. Polycythemia refers to an increase in the number of red blood cells; typically chemotherapy causes reduction of red blood cells or anemia. Dose limiting side effects occur when the dose or frequency of chemotherapy need to be altered or held, such as in the case of severe neutropenia or neurologic dysfunction .

Which client has the highest risk for breast cancer? A.) Older adult woman with high breast density B.) Nullipara older adult woman C.) Obese older adult male with gynecomastia D.) Middle-aged woman with high breast density

Older adult woman with high breast density People at high increased risk for breast cancer include women age 65 years and older with high breast density. Nullipara women are at low increased risk for breast cancer. Men are not at high increased risk for breast cancer, but obesity can cause gynecomastia. Being middle-aged does not indicate a high increased risk for breast cancer.

Which medication does the nurse plan to administer to a client before chemotherapy to decrease the incidence of nausea and vomiting? A.) Morphine B.) Ondansetron (Zofran) C.) Naloxone (Narcan) D.) Diazepam (Valium)

Ondansetron (Zofran) Ondansetron is a 5-HT3 receptor blocker that blocks serotonin to prevent nausea and vomiting. Morphine is a narcotic analgesic or opiate; it may cause nausea. Naloxone is a narcotic antagonist used for opiate overdose. Diazepam, a benzodiazepine, is an antianxiety medication only; lorazepam, another benzodiazepine, may be used for nausea.

65. The nurse is reviewing the laboratory results for several burn patients who are approximately 24-to 36 hours postinjury. What laboratory results related to the fluid remobilization in these patients does the nurse expect to see? a. Anemia b. Metabolic alkalosis c. Hypernatremia d. Hyperkalemia

a

Which factors in the older adult increase the risk of complications from a burn injury? (SATA) a. slower healing time b. thinner skin c. increased inflammatory compliance d. increased pulmonary compliance e. . altered glucose metabolism f. history of heart failure

a b e f

The nurse is caring for a patient with 45% TBSA burns. Which are priority medical surgical concepts for this patient? (SATA) a. tissue integrity b. cellular regulation c. perfusion d. elimination e. fluid and electrolyte balance f. gas exchange

a c e

61. As a result of third-spacing, during the acute phase, which electrolyte imbalances may occur? (Select all that apply.) a. Hyperkalemia b. Hypokalemia c. Hypernatremia d. Hyponatremia e. Hypercalcemia

a, d

A patient has had a pelvic examination and needs an additional diagnostic test for possible uterine leimyomas. The niurse prepares the patient for which first-choice diagnostic test? a. Transvaginal ultrasounnd b. Laparoscopy c. Hysteroscopy d. Endometrial biopsy

a. Transvaginal ultrasounnd

46. The release of myoglobin form damaged muscle in patients with major burns can result in which potential complication? a. Paralytic ileus b. Acute kidney injury c. Limited mobility d. Hypovolemia

b

31. The nurse is caring for a firefighter who was trapped for a prolonged period of time by burning debris. During the shift, the nurse notes a progressive hoarseness, a brassy cough, and the patient reports increased difficulty with swallowing. How does the nurse interpret these changes? a. Temporary discomfort that can be treated with sips of cool fluids b. Signs of symptoms of probable carbon monoxide poisoning c. Signs indicating a pulmonary injury and possible airway obstruction d. Expected findings considering the mechanism of injury

c

34. The nurse is caring for several patients on the burn unit. Which of these patients has the most acute need for cardiac monitoring? a. Older adult woman who spilled hot water over her legs while boiling noodles b. Teenager with facial burns that occurred when he threw gasoline on a campfire c. Young women who was struck by lightning while jogging on the beach d. Middle-aged man who fell asleep while smoking and sustained burns to the chest

c

37. The student nurse is caring for a patient who has been in the burn unit for several weeks. The patient needs assistance with the bedpan to have a bowel movement, and the student nurse notes that the stool is black with a tarry appearance. What is the most important priority action at this time? a. Report this finding to the primary nurse or the instructor. b. Ask if the patient is currently taking an iron supplement. c. Test for the presence of occult blood with a hemoccult card and reagent. d. Perform a dietary assessment to determine if the stool color is related to food.

c

8. A patient was involved in a house fire and suffered extensive full-thickness burns. In the long-term, what issue may this patient have trouble with? a. Intolerance for vitamin C b. Metabolism of vitamin K c. Activation of vitamin D d. Absorption of vitamin A

c

A 55-year-old African-American client is having a visit with his health care provider. What test should the nurse discuss with the client as an option to screen for prostate cancer, even though screening is not routinely recommended? a. Complete blood count b. Culture and sensitivity c. Prostate-specific antigen d. Cystoscopy

c. Prostate-specific antigen

A client with colorectal cancer was started on 5-fluorouracil (5-FU) and is experiencing fatigue, diarrhea, and mouth ulcers. A relatively new chemotherapeutic agent, oxaliplatin (Eloxatin), has been added to the treatment regimen. What does the nurse tell the client about the diarrhea and mouth ulcers? A. "A combination of chemotherapeutic agents has caused them." B. "GI problems are symptoms of the advanced stage of your disease." C. "5-FU cannot discriminate between your cancer and your healthy cells." D. "You have these as a result of the radiation treatment."

"5-FU cannot discriminate between your cancer and your healthy cells." 5-FU cannot discriminate between cancer and healthy cells; therefore, the side effects are diarrhea, mucositis, leukopenia, mouth ulcers, and skin ulcers. The 5-FU treatment, not a combination of chemotherapy drugs, radiation, or the stage of the disease, is what is causing the client's GI problems.

The nurse is teaching post-mastectomy exercises to a client. Which statement made by the client indicates that teaching has been effective? A.) "For the pulley exercise, I'll drape a 6-foot-long rope over a shower curtain rod or over the top of a door." B.) "In rope turning, I'll hold the rope with my arms flexed." C.) "In rope turning, I'll start by making large circles." D.) "With hand wall climbing, I'll walk my hands up the wall and back down until they are at waist level."

"For the pulley exercise, I'll drape a 6-foot-long rope over a shower curtain rod or over the top of a door." To perform the pulley exercise properly, the client should drape a 6-foot-long rope over a sturdy structure. In rope turning, the client holds the end of the rope and steps back from the door until the arm is almost straight out in front. The client starts with small circles and gradually increases to larger circles as the client becomes more flexible. With hand wall climbing, the client walks the hands up the wall and then back down until they are at shoulder level.

The nurse is caring for a client who is to be discharged after a bowel resection and the creation of a colostomy. Which client statement demonstrates that additional instruction from the nurse is needed? A. "I can drive my car in about 2 weeks." B. "I should avoid drinking carbonated sodas." C. "It may take 6 weeks to see the effects of some foods on my bowel patterns." D. "Stool softeners will help me avoid straining."

"I can drive my car in about 2 weeks." The client who has had a bowel resection and colostomy should avoid driving for 4 to 6 weeks. The client should avoid drinking sodas and other carbonated drinks because of the gas they produce. He or she may not be able to see the effects of certain foods on bowel patterns for several weeks. The client should avoid straining at stool.

The home health nurse is teaching a client about the care of a new colostomy. Which client statement demonstrates a correct understanding of the instructions? A. "A dark or purplish-looking stoma is normal and should not concern me." B. "If the skin around the stoma is red or scratched, it will heal soon." C. "I need to check for leakage underneath my colostomy." D. "I should strive for a very tight fit when applying the barrier around the stoma."

"I need to check for leakage underneath my colostomy." The pouch system should be checked frequently for evidence of leakage to prevent excoriation. A purplish stoma is indicative of ischemia and necrosis. Redness or scratched skin around the stoma should be reported to prevent it from beginning to break down. An overly tight fit may lead to necrosis of the stoma.

A client with irritable bowel syndrome (IBS) is constipated. The nurse instructs the client about a management plan. Which client statement shows an accurate understanding of the nurse's teaching? A. "A drink of diet soda with dinner is OK for me." B. "I need to go for a walk every evening." C. "Maintaining a low-fiber diet will manage my constipation." D. "Watching the amount of fluid that I drink with meals is very important."

"I need to go for a walk every evening." Increased ambulation is part of the management plan for IBS, along with increased fluids and fiber and avoiding caffeinated beverages. Caffeinated beverages can cause bloating or diarrhea and should be avoided in clients with IBS. Fiber is encouraged in clients with IBS because it produces a bulky soft stool and aids in establishing regular bowel habits. At least 8 to 10 cups of fluid should be consumed daily to promote normal bowel function.

Which statement made by a client allows the nurse to recognize whether the client receiving brachytherapy for ovarian cancer understands the treatment plan? A.) "I may lose my hair during this treatment." B.) "I must be positioned in the same way during each treatment." C.) "I will have a radioactive device in my body for a short time." D.) "I will be placed in a semiprivate room for company."

"I will have a radioactive device in my body for a short time." Brachytherapy refers to short-term insertion of a radiation source. Side effects of radiation therapy are site-specific; this client is unlikely to experience hair loss from treating ovarian cancer with radiation. The client undergoing teletherapy (external beam radiation), not brachytherapy, must be positioned precisely in the same position each time. The client who is receiving brachytherapy must be in a private room.

The Certified Wound, Ostomy, and Continence Nurse is teaching a client with colorectal cancer how to care for a newly created colostomy. Which client statement reflects a correct understanding of the necessary self-management skills? A. "I will have my spouse change the bag for me." B. "If I have any leakage, I'll put a towel over it." C. "I need to call my home health nurse to come out if I have any problems." D. "I will make certain that I always have an extra bag available."

"I will make certain that I always have an extra bag available." The statement that the client will be certain to bring an extra bag is the only statement illustrating that the client is taking responsibility to care for the colostomy. Using a towel is not an acceptable or effective way to cope with leakage. It is not realistic that the home health nurse can make frequent visits for the purpose of colostomy care.

The nurse is teaching a client who has undergone a hemorrhoidectomy about a follow-up plan of care. Which client statement demonstrates a correct understanding of the nurse's instructions? A. "I should take Ex-Lax after the surgery to 'keep things moving'." B. "I will need to eat a diet high in fiber." C. "Limiting my fluids will help me with constipation." D. "To help with the pain, I'll apply ice to the surgical area."

"I will need to eat a diet high in fiber." A diet high in fiber serves as a natural stool softener and will prevent irritation to hemorrhoids caused by painful bowel movements. Stimulant laxatives are discouraged because they are habit-forming. Increased amounts of fluids are needed to prevent constipation. Moist heat (sitz baths) will be more effective with postoperative discomfort than cold applications; cold therapy is sometimes recommended and useful before surgery for inflamed hemorrhoids.

A 24-year-old male is scheduled for a minimally invasive inguinal hernia repair (MIIHR). Which client statement indicates a need for further teaching about this procedure? A. "I may have trouble urinating immediately after the surgery." B. "I will need to stay in the hospital overnight." C. "I should not eat after midnight the day of the surgery." D. "My chances of having complications after this procedure are slim."

"I will need to stay in the hospital overnight." Usually, the client is discharged 3 to 5 hours after MIIHR surgery. Male clients who have difficulty urinating after the procedure should be encouraged to force fluids and to assume a natural position when voiding. Clients undergoing MIIHR surgery must be NPO after midnight before the surgery. Most clients who have MIIHR surgery have an uneventful recovery.

A client suspected of having irritable bowel syndrome (IBS) is scheduled for a hydrogen breath test. What does the nurse tell the client about this test? A. "During the test, you will drink small amounts of an antacid as directed by the technician." B. "If you have IBS, hydrogen levels may be increased in your breath samples." C. "The test will take between 30 and 45 minutes to complete." D. "You must have nothing to drink (except water) for 24 hours before the test."

"If you have IBS, hydrogen levels may be increased in your breath samples." Excess hydrogen levels are produced in clients with IBS. This is due to bacterial overgrowth in the small intestine that accompanies the disease. The hydrogen travels to the lungs to be excreted. The client will ingest small amounts of sugar during the test, not an antacid. The test takes longer than 45 minutes. The client has breath samples taken every 15 minutes for 1 to 2 hours. The client needs to be NPO (except for water) for 12 hours before the test.

A client with malabsorption syndrome asks the nurse, "What did I do to cause this disorder to develop?" How does the nurse respond? A. "An excessive intake of alcohol is associated with it, so your substance abuse could have contributed to its development." B. "It is inherited, so it could run in your family." C. "It might be caused by a virus, so you could have gotten it almost anywhere." D. "Nothing you did could have caused it; it is the result of flattening of the mucosa of your large intestine."

"Nothing you did could have caused it; it is the result of flattening of the mucosa of your large intestine." Stating that the disorder is the result of flattening of the mucosa of the large intestine is the only statement that is physiologically accurate. Malabsorption syndrome is not associated with an excessive intake of alcohol. It is not inherited, although a genetic immune defect is present in the related disease, celiac sprue. It is not caused by a virus.

The nurse is discussing treatment options with a client newly diagnosed with breast cancer. Which statement by the client indicates a need for further teaching? A.) "Hormonal therapy is only used to prevent the growth of cancer. It won't get rid of it." B.) "I might have chemotherapy before surgery." C.) "If I get radiation, I am not radioactive to others." D.) "Radiation will remove the cancer, so I might not need surgery."

"Radiation will remove the cancer, so I might not need surgery." Typically, radiation therapy follows surgery to kill residual tumor cells. Radiation therapy plays a critical role in the therapeutic regimen and is an effective treatment for almost all sites where breast cancer can metastasize. The purpose of radiation therapy is to reduce the risk for local recurrence of breast cancer. The purpose of hormonal therapy is to reduce the estrogen available to breast tumors to stop or prevent their growth. Chemotherapy drugs destroy breast cancer cells that may be present anywhere in the body; they are typically administered after surgery for breast cancer, although neoadjuvant chemotherapy may be given to reduce the size of a tumor before surgery. The client receiving radiation therapy is radioactive only if the radiation source is dwelling inside the breast tissue.

A client with colorectal cancer is scheduled for colostomy surgery. Which comment from the nurse is most therapeutic for this client? A. "Are you afraid of what your spouse will think of the colostomy?" B. "Don't worry. You will get used to the colostomy eventually." C. "Tell me what worries you the most about this procedure." D. "Why are you so afraid of having this procedure done?"

"Tell me what worries you the most about this procedure." Asking the client about what worries him or her is the only question that allows the client to express fears and anxieties about the diagnosis and treatment. Asking the client if he or she is afraid is a closed question (i.e., it requires only a "yes" or "no" response); it closes the dialogue and is not therapeutic. Telling the client not to worry offers reassurance and is a "pat" statement, making it nontherapeutic. "Why" questions place clients on the defense and are not therapeutic because they close the conversation.

A client who has just been notified that the breast biopsy indicates a malignancy tells the nurse, "I just don't know how this could have happened to me." Which response by the nurse is best? A.) "Tell me what you mean when you say you don't know how this could have happened to you." B.) "Do you have a family history that might make you more likely to develop breast cancer?" C.) "Would you like me to help you find more information about how breast cancer develops?" D.) "Many risk factors for breast cancer have been identified, so it is difficult to determine what might have caused it."

"Tell me what you mean when you say you don't know how this could have happened to you." The client's statement that he or she does not know how this could have happened may indicate shock and denial or a request for more information. To provide appropriate care, further assessment is needed about the client's psychosocial status. The first action by the nurse in this situation is to obtain more data by asking open-ended questions. The nurse needs to further assess the client's emotional status before asking about family history of cancer or obtaining information for the client.

A male client's sister was recently diagnosed with colorectal cancer (CRC), and his brother died of CRC 5 years ago. He asks the nurse whether he will inherit the disease too. How does the nurse respond? A. "Have you asked your health care provider what he or she thinks your chances are?" B. "It is hard to know what can predispose a person to develop a certain disease." C. "No. Just because they both had CRC doesn't mean that you will have it, too." D. "The only way to know whether you are predisposed to CRC is by genetic testing."

"The only way to know whether you are predisposed to CRC is by genetic testing." Genetic testing is the only definitive way to determine whether the client has a predisposition to develop CRC. A higher incidence of the disease has been noted in families who have a history; however, it is not the responsibility of the nurse to engage in genetic counseling, and this client might not be predisposed to developing CRC. Asking the client what the health care provider thinks is an evasive response by the nurse and does not address the client's concerns.

The nurse has received in report that a client receiving chemotherapy has severe neutropenia. Which interventions does the nurse plan to implement? (Select all that apply.) A.) Assess for fever. B.) Observe for bleeding. C.) Administer pegfilgrastim (Neulasta). D.) Do not permit fresh flowers or plants in the room. E.) Do not allow the client's 16-year-old son to visit. F.) Teach the client to omit raw fruits and vegetables from the diet.

-Assess for fever -Administer pegfilgramtim (Neulasta) -Do not permit fresh flowers or plants in the room -Teach the client to omit raw fruits and vegetables from the diet Any temperature elevation in a client with neutropenia is considered a sign of infection and should be reported immediately to the health care provider. Administration of biological response modifiers, such as filgrastim (Neupogen) and pegfilgrastim (Neulasta), is indicated in neutropenia to prevent infection and sepsis. Flowers and plants may harbor organisms such as fungi or viruses and are to be avoided for the immune-suppressed client. All fruits and vegetables should be cooked well; raw fruits and vegetables may harbor organisms. Thrombocytopenia, or low platelet levels, causes bleeding, not low neutrophils (a type of white blood cell). The client is at risk for infection, not the visitors, if they are well; however, very small children, who may get frequent colds and viral infections, may pose a risk.

When caring for a client who has had a colostomy created during treatment for colon cancer, which nursing actions help support the client in accepting changes in appearance or function? (Select all that apply.) A.) Explain to the client that the colostomy is only temporary. B.) Encourage the client to participate in changing the ostomy. C.) Obtain a psychiatric consultation. D.) Offer to have a person who is coping with a colostomy visit. E.) Encourage the client and family members to express their feelings and concerns.

-Encourage the client to participate in changing the ostomy. -Offer to have a person who is coping with a colostomy visit. -Encourage the client and family members to express their feelings and concerns. Encouraging the client to participate in changing the ostomy is an appropriate way for the client to become familiar with the ostomy and its care. A visit from a person who is successfully coping with an ostomy can demonstrate to the client that many aspects of life can be the same after surgery. Offering to listen to feelings and concerns is part of a therapeutic relationship and therapeutic communication. Ostomies may be temporary for bowel rest, such as after a perforation, but are typically permanent for cancer treatment. Obtaining a psychiatric consultation may need to be done for clients with persistent depression, but would not be done immediately.

The nurse is instructing a client on how to perform breast self-examination (BSE). Which techniques does the nurse include in teaching the client about BSE? (Select all that apply.) A.) Instruct the client to keep her arm by her side while performing the examination. B.) Ensure that the setting in which BSE is demonstrated is private and comfortable. C.) Ask the client to remove her shirt. The bra may be left in place. D.) Ask the client to demonstrate her own method of BSE. E.) Use the fingertips, which are more sensitive than the finger pads, to palpate the breasts.

-Ensure that the setting in which BSE is demonstrated is private and comfortable. -Ask the client to demonstrate her own method of BSE. The setting should be private and comfortable to promote an environment conducive to learning and to prevent potential client embarrassment. Before teaching breast palpation, ask the client to demonstrate her own method, so that the nurse can assess the client's understanding of BSE. For better visualization, the arm should be placed over the head. The client should undress completely from the waist up. The finger pads, which are more sensitive than the fingertips, are used when palpating the breasts.

Which statement of the student nurse indicates inadequate understanding about precautionary measures to take while treating a patient with a history of allergic reaction during an emergency situation? 1 Intravenous fluid administration is avoided in the patient. 2 Intubation equipment and a tracheostomy set are kept at the bedside. 3 The patient is premedicated with diphenhydramine or a corticosteroid. 4 For desensitizing, an allergy-causing agent is administered subcutaneously.

1 Intravenous normal saline fluid should be administrated before starting an allergy-causing substance administration to keep the patient hydrated. After administering the intravenous fluid, the intubation equipment and a tracheostomy should be placed at the bedside for use, in case of emergency. The patient is premedicated with diphenhydramine or a corticosteroid to suppress the allergic reaction. The allergy-causing substance is then administered subcutaneously in very dilute concentrations.

The nurse is caring for a patient who is prescribed vasopressors. Which drugs may the patient be taking? 1 Norepinephrine or dopamine 2 Dexamethasone or prednisone 3 Epinephrine or ephedrine sulfate 4 Chlorpheneramine or diphenhydramine

1 Norepinephrine and dopamine are vasopressors that raise blood pressure and cardiac output in severely decompensated states. Dexamethasone and prednisone are corticosteroids and act as anti-inflammatory drugs. Epinephrine and ephedrine sulfate are sympathomimetic drugs that promote bronchodilation. Chlorpheneramine and diphenhydramine are antihistamine drugs that prevent the release of histamines. These drugs may help in the treatment of type I hypersensitivity or other types of allergies.

When preparing a patient for allergy testing, the nurse provides the patient with which instruction? 1 "Antihistamines should be discontinued 2 weeks before the test to avoid suppressing the test response." 2 "It is okay to use your fluticasone propionate nasal spray before testing." 3 "Aspirin in a low dose may be taken before testing." 4 "You can take antihistamine nasal sprays before testing."

1 Systemic glucocorticoids and antihistamines are discontinued 2 weeks before the test to avoid suppressing the test response. Nasal sprays to reduce mucous membrane swelling are permitted, except for sprays that contain an antihistamine. Allergists recommend that aspirin be withheld before testing.

A patient with a history of asthma is admitted to the clinic for allergy testing. During skin testing, the patient develops shortness of breath and stridor and becomes hypotensive. What is the most appropriate drug for the nurse to give in this situation? 1 Epinephrine 2 Fexofenadine 3 Cromolyn sodium 4 Zileuton

1 The patient is experiencing an anaphylactic reaction, and epinephrine is a first-line sympathomimetic used to treat anaphylaxis. Fexofenadine is a nonsedating antihistamine and is not a first-line drug to treat anaphylaxis. Cromolyn sodium is a mast cell-stabilizing drug; it is used to prevent symptoms of allergic rhinitis but is not useful during an acute episode. Zileuton is a leukotriene antagonist; it is also used to prevent symptoms of allergic rhinitis but is likewise not useful during an acute episode.

The nurse is assessing a patient with allergic rhinitis. What assessment finding does the nurse anticipate? 1 Runny nose with itchy, watery eyes 2 Yellow drainage from the nose 3 Glowing skin over the sinuses 4 The presence of fever

1 The patient with allergic rhinitis has a runny nose and itchy, watery eyes. The drainage from the nose is usually clear or white. When a penlight is placed on the skin over the sinuses, there is a reduced glow. The patient with allergic rhinitis does not have fever unless there is an infection present.

A patient has developed a type IV hypersensitivity reaction. Which immune cells or components are involved in this type of reaction? 1 T-cells 2 Antibodies 3 Complement 4 Self cells

1 Type IV hypersensitivity is caused by T-cell mediated reactions. These cells release chemical mediators and activate macrophages to kill antigens. Antibodies and complement play no role in type IV hypersensitivity reactions but do in type III immune-complex-mediation reactions. Self cells are present in type II cytotoxic reactions when autoantibodies are produced against these cells. The self cell is then destroyed by phagocytosis.

What is the most common cause of death in Goodpasture's syndrome? 1 Uremia 2 Liver damage 3 Destruction of neutrophils 4 Production of autoantibodies

1 Uremia, which results from kidney failure, is the most common cause of death in Goodpasture's syndrome. In uremia, nitrogenous waste products are retained in the blood and cause severe toxicity that may result in death. Liver damage, destruction of neutrophils, and production of antibodies are associated with this syndrome, but death is only caused from these factors in severe cases.

Which food items may cause anaphylaxis in some individuals? Select all that apply. 1 Peanuts 2 Shellfish 3 Eggs 4 Nuts 5 Potatoes

1, 2, 3, 4 Some food items may cause anaphylaxis in susceptible individuals. These include peanuts, shellfish, eggs, and nuts. Potatoes are not known to cause anaphylactic reactions.

Which patient condition would necessitate the nurse to wear latex-free gloves when providing care? 1 A patient with cleft palate 2 A patient with spina bifida 3 A patient with galactosemia 4 A patient with Tay-Sachs disease

2 Latex allergy is a type I hypersensitivity reaction in which the specific allergen is a processed natural latex rubber protein. Spina bifida is a birth defect in which there is incomplete closing of the backbone and membranes around the spinal cord. Allergen risk increases due to high exposure to latex, such as in patients with spina bifida, so the nurse must wear latex-free gloves. Cleft palate, galactosemia, and Tay-Sachs disease are also birth defects but are not associated with latex allergy.

What should be the immediate nursing action for a patient having an allergic reaction to penicillin who has symptoms of swollen lips and tongue, soft palate, and widespread hives with pruritus? 1 Administering oral serratiopeptidase 2 Administering intravenous epinephrine 3 Administering inhalation of salbutamol 4 Administering intramuscular theophylline

2 The patient is experiencing a penicillin-induced anaphylactic reaction, which requires immediate medical treatment. The nurse should administer epinephrine, which helps in suppressing the anaphylactic reaction. Administering oral serratiopeptidase, inhaling salbutamol, or administering intramuscular theophylline does not help in the immediate treatment of anaphylaxis.

The nursing instructor asks the student nurse to explain a type IV hypersensitivity reaction. Which statement by the student best describes type IV hypersensitivity? 1 "It is a reaction of immunoglobulin G (IgG) with the host cell membrane or antigen." 2 "The reaction of sensitized T-cells with antigen and release of lymphokines activate macrophages and induce inflammation." 3 "It results in release of mediators, especially histamine, because of the reaction of IgE antibody on mast cells." 4 "An immune complex of antigen and antibodies is formed and deposited in the walls of blood vessels."

2 The reaction of sensitized T-cells with antigen and release of lymphokines is a delayed hypersensitivity reaction, as is seen with poison ivy (type IV hypersensitivity). A reaction of IgG with the host cell membrane or antigen describes a type II hypersensitivity. A release of mediators, especially histamine, because of the reaction of IgE antibody on mast cells describes a type I hypersensitivity reaction. An immune complex of antigen and antibodies deposited in the walls of blood vessels describes a type III hypersensitivity reaction.

Which type of hypersensitivity is a cell-mediated immunity with T-lymphocyte as the reactive cell? 1 Rapid hypersensitivity 2 Delayed hypersensitivity 3 Cytotoxic hypersensitivity 4 Immune complex-mediated hypersensitivity

2 Type IV hypersensitivity is a type of cell-mediated response that is often called delayed type hypersensitivity since the reaction takes 2 to 3 days to develop. In a type IV reaction, the reactive cell is the T-lymphocyte (T-cell). Rapid hypersensitivity, cytotoxic hypersensitivity, and immune complex-mediated hypersensitivity are antibody-mediated hypersensitivity reactions.

Assessment findings reveal that a patient admitted to the hospital has a contact type I hypersensitivity to latex. Which preventive nursing intervention is best in planning care for this patient? 1 Report the need for desensitization therapy. 2 Convey the need for pharmacologic therapy to the health care provider. 3 Communicate the need for avoidance therapy to the health care team. 4 Discuss symptomatic therapy with the health care provider.

3 Contact hypersensitivities can occur with latex, pollens, foods, and environmental proteins. Avoidance therapy is the recommended nursing intervention. Desensitization therapy is administered via allergy shots when allergens have been identified and cannot easily be avoided. Medications might be indicated if signs of type I or type IV hypersensitivity exist, but this is not a preventive measure. Symptomatic therapy interventions such as an epinephrine pen, antihistamines, and corticosteroids are effective only after the hypersensitivity reaction has already occurred.

While assessing a patient, the nurse notes that the patient's vagina and buccal and nasal mucous membranes are dry. The laboratory reports indicate the presence of elevated levels of IgM rheumatoid factor. The nurse suspects what syndrome? 1 Sicca syndrome 2 Reiter's syndrome 3 Sjögren's syndrome 4 Goodpasture's syndrome

3 Dry eyes, dry nasal and buccal membranes, and vaginal dryness are the symptoms associated with Sjögren's syndrome. The presence of elevated levels of IgM rheumatoid factor in the laboratory reports indicates that the patient with this syndrome has accompanied rheumatoid arthritis. Dry buccal and nasal membranes and vaginal dryness are not associated with sicca syndrome, Reiter's syndrome, or Goodpasture's syndrome. Sicca syndrome is associated with dry eyes. Reiter's syndrome is characterized by arthritis, urethritis, and conjunctivitis. Goodpasture's syndrome is an autoimmune disorder in which autoantibodies are produced against the glomerular basement membrane and neutrophils.

A patient is being discharged from the hospital after an allergic reaction to environmental airborne allergens. Which instruction is most important for the nurse to include in this patient's discharge teaching plan? 1 Wash fruits and vegetables with mild soap and water before eating. 2 Intermittent exposure to known allergens will produce immunity. 3 Remove cloth drapes, carpeting, and upholstered furniture. 4 Be cautious when eating unprocessed honey.

3 Removing cloth drapes, carpet, and upholstery will reduce airborne pollen, dust mites, and mold. Washing fruits and vegetables pertains to food allergies. Patients do not develop immunity to known allergens by direct exposure; common interventions include avoidance therapy, desensitization therapy, and symptomatic therapy. Honey is said to help with some people with allergies to pollen only; it does not have an impact on airborne allergens.

A patient is scheduled to undergo scratch testing. Which nursing intervention can be most helpful to achieve best results of the test? 1 Avoid the use of alcohol to remove surface oils at the testing site. 2 Recommend aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) before the test. 3 Instruct the patient to discontinue antihistamines before the test. 4 Instruct the patient to discontinue non-antihistamine nasal sprays.

3 The patient should discontinue antihistamines for 2 weeks before scratch testing because antihistamines suppress the allergic response. During the test, alcohol may be applied to remove the surface oils that can interfere with the results. Aspirin or other NSAIDs may also result in a reduced allergic response and therefore should not be taken before the test. Non-antihistamine nasal sprays may be used to reduce swelling.

Which type of hypersensitivity is anaphylaxis? 1 Delayed hypersensitivity 2 Cytotoxic hypersensitivity 3 Immediate hypersensitivity 4 Immune-complex mediated hypersensitivity

3 Type 1 hypersensitivity is also known as immediate hypersensitivity. Anaphylaxis is an example of type I hypersensitivity reaction, which occurs rapidly and systemically. Anaphylaxis is due to the reaction of immunoglobulin E (IgE) antibodies on mast cells with antigen, resulting in the release of mediators, especially histamine, which causes the allergic reaction. Anaphylaxis is not an example of delayed, cytotoxic, or immune-complex mediated hypersensitivity.

A patient is diagnosed with a type I hypersensitivity. Which antibody level increases during this type of allergy? 1 Immunoglobulin G (IgG) 2 IgM 3 IgD 4 IgE

4 In a patient exposed to an allergen, elevated levels of IgE antibodies are produced. The elevated level of antibodies causes inflammation, erythema, or edema in the affected region. IgG antibodies play a crucial role in type II allergies. IgM antibodies act at the first stage of an infection caused by viruses, microorganisms, or toxins. The role of IgD antibodies is not clearly known, but they activate B-cells during infection.

A patient is diagnosed with a type I hypersensitivity. Which antibody level increases during this type of allergy? 1 Immunoglobulin G (IgG) 2 IgM 3 IgD 4 IgE

4 In a patient exposed to an allergen, elevated levels of IgE antibodies are produced. The elevated level of antibodies causes inflammation, erythema, or edema in the affected region. IgG antibodies play a crucial role in type II allergies. IgM antibodies act at the first stage of an infection caused by viruses, microorganisms, or toxins. The role of IgD antibodies is not clearly known, but they activate B-cells during infection. IgG = type II IgE = type I T-cells = type IV

The nurse is reviewing discharge teaching with a patient who suffered an anaphylactic reaction to a bee sting. Which statement by the patient indicates the need for further teaching? 1 "I must wear a medical alert bracelet stating that I am allergic to bee stings." 2 "I need to carry epinephrine with me." 3 "My spouse must learn how to give me an injection." 4 "I am immune to bee stings now that I have had a reaction."

4 No immunity develops after an anaphylactic reaction. In fact, the next reaction could be more severe. The patient should carry epinephrine at all times and always wear a medical alert bracelet that states all allergies. Someone (spouse, neighbor, or family member) must learn how to give the patient injections in case the patient is unable self-administer the injection.

Which nursing action is most appropriate for the nurse working in an allergy clinic to delegate to a nursing assistant? 1 Plan the schedule for desensitization therapy for a patient with allergies. 2 Monitor the patient who has just received skin testing for signs of anaphylaxis. 3 Educate a patient with a latex allergy about other substances with cross-sensitivity to latex. 4 Remind the patient to stay at the clinic for 30 minutes after receiving intradermal allergy testing.

4 Reminding a patient about safety policies is within the scope of practice of a nursing assistant. Planning care and assessing for complications require broader education and scope of practice and should be done by the registered nurse. Patient education is a registered nursing responsibility, which requires broader education and scope of practice.

A patient with a type I allergy is treated with antihistamines and corticosteroids. What other measure can help the patient to prevent future recurrence of allergies? 1 Epinephrine drug therapy 2 Increased fluid intake 3 Increased rest periods 4 Avoidance therapy

4 The best way to prevent future recurrence of a type I allergy is to avoid known causative allergens whenever possible. Exposure to these agents may lead to an IgE-mediated immune response. Epinephrine injections are administered only when needed; excessive use can cause serious side effects. Antihistamines may cause dryness and drowsiness; increasing fluid intake may help prevent dryness, and increasing rest periods may provide comfort. However, these measures do not prevent the recurrence of allergies.

The nurse is assessing a patient with severe pet-induced allergy. The patient has two pet dogs. What action is the most beneficial for this patient? 1 Bathe the pets frequently. 2 Keep the pets out of the bedroom. 3 Clean the rooms thoroughly. 4 Keep the pets out of the house.

4 The nurse should suggest to the patient with pet-induced allergy to keep the pets out of the house to reduce exposure to allergens. This type of avoidance therapy is most beneficial for a patient with severe pet-induced allergy. Frequent bathing of the pets can help to reduce allergens, and keeping the pets out of the bedroom and cleaning the rooms thoroughly help to remove animal hair and dander, but these won't be as effective as removing the dogs from the indoor environment. The patient would still be exposed to the allergens.

The nurse prepares to administer zafirlukast to a patient with allergic rhinitis. Zafirlukast works by which mechanism? 1 Blocking histamine from binding to receptors. 2 Preventing synthesis of mediators. 3 Preventing mast cell membranes from opening. 4 Blocking the leukotriene receptor.

4 Zafirlukast is a leukotriene antagonist that prevents the occurrence of allergic rhinitis by blocking the leukotriene receptor. Antihistamines such as diphenhydramine block histamines from binding to receptors; zafirlukast is not an antihistamine. Corticosteroids prevent synthesis of mediators; zafirlukast is not a corticosteroid. Mast cell-stabilizing drugs such as cromolyn sodium prevent mast cell membranes from opening when an allergen binds to IgE; zafirlukast is not a mast cell-stabilizing drug.

The patient with a history of asthma is prescribed a leukotriene receptor antagonist to prevent allergic rhinitis. The nurse anticipates that which drug will be prescribed? 1 Cromolyn sodium 2 Desloratadine 3 Fexofenadine 4 Zafirlukast

4 Zafirlukast is a leukotriene receptor antagonist; it works by blocking the leukotriene receptor and is used to prevent allergic rhinitis. Cromolyn sodium is a mast cell-stabilizing drug. Desloratadine and fexofenadine are non-sedating antihistamines.

A client has a urinary catheter and continuous bladder irrigation after a transurethral resection of the prostate this morning. The amount of bladder irrigation solution that has infused over the past 12 hours is 1000 mL. The amount of fluid in the urinary drainage bag is 1725 mL. The nurse records that the client has had ____ mL urinary output in the past 12 hours. (Ignatavicius & Workman, p.1505)

725 mL (Ignatavicius & Workman, p.1505)

A patient with cancer tells the nurse that she has numbness and weakness in her legs. What is the nurses best response? a. "Are you having any back pain?" b. "Have you been exercising vigorously?" c. "When was your last dose of pain medication?" d. "This is a normal response to chemotherapy."

A

At what point is a patient radioactive when receiving radiation treatment by teletherapy and is therefore a potential danger to other people? a. The patient is never radioactive b. During the mechanical delivery of gamma rays c. For the first 24-48 hours after treatment d. Until the radiation source has decayed by one half-life

A

Chemotherapy drug dosage is based on total body surface area; therefore, what assessment will the nurse perform? a. Measure the patient's height and weight b. Compare the patient's weight to a nomogram c. Calculate BMI d. Measure abdominal girth

A

The nurse is caring for several patients who are receiving chemotherapy. Which patient is the most likely to need transfer to the intensive care unit? a. Patient receiving interleukin therapy for renal cell carcinoma develops edema b. Patient receiving estrogen therapy develops calf pain with redness and swelling c. Patient receiving vascular endothelial growth factor/receptor inhibitor has high blood pressure d. Patient receiving an anti-androgen receptor developed gynecomastia

A

The nurse is responsible for teaching the immunosuppressed patient and the family about health-promoting activities. Which information is correct? a. Wash hands thoroughly with an antimicrobial soap b. Do not drink water, milk, juice, or other cold liquids c. Boil dishes or use disposables whenever possible d. Don a mask before entering the patient's personal space

A

The nurse is reviewing the medication list of an older patient who is getting chemotherapy and filgrastim (Neupogen). Which intervention is the nurse most likely to use to facilitate the purpose of the Neupogen? a. Teach patient, family, and all visitors about scrupulous hand hygiene b. Administer the Neupogen prior to chemo therapy to prevent nausea c. Teach and assess for bleeding sign such as bruising or bleeding gums d. Assess the patient for fatigue and plan for periods of uninterrupted rest

A

The patient has breast cancer with bone metastasis. Based on this information, which laboratory result would the nurse expect to see? a. Increase in serum calcium level b. Decrease in blood glucose c. Increase in platelet count d. Decrease in serum sodium level

A

What is the most typical schedule for radiation therapy? a. Small doses of radiation given on a daily basis for a set time period b. Large one-time dose of radiation given after completing chemotherapy c. Small doses of radiation given several days apart to minimize side effects d. Large doses administered monthly for a set period of months

A

Which example best illustrates appropriate prophylactic cancer surgery? a. Removal of breast tissue for strong family history of breast cancer b. Biopsy of lymph node at a site distal to the primary tumor c. Breast reconstruction after a mastectomy d. Partial removal of a tumor to provide pain relief

A

A nurse is assessing an older client for the presence of infection. The client's temperature is 97.6° F (36.4° C). What response by the nurse is best? a. Assess the client for more specific signs. b. Conclude that an infection is not present. c. Document findings and continue to monitor. d. Request that the provider order blood cultures.

A Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse should assess the client for specific signs of infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures may or may not be needed depending on the results of further assessment.

A client has been on dialysis for many years and now is receiving a kidney transplant. The client experiences hyperacute rejection. What treatment does the nurse prepare to facilitate? a. Dialysis b. High-dose steroid administration c. Monoclonal antibody therapy d. Plasmapheresis

A Hyperacute rejection starts within minutes of transplantation and nothing will stop the process. The organ is removed. If the client survives, he or she will have to return to dialysis treatment. Steroids, monoclonal antibodies, and plasmapheresis are ineffective against this type of rejection.

A client receiving muromonab-CD3 (Orthoclone OKT3) asks the nurse how the drug works. What response by the nurse is best? a. "It increases the elimination of T lymphocytes from circulation." b. "It inhibits cytokine production in most lymphocytes." c. "It prevents DNA synthesis, stopping cell division in activated lymphocytes." d. "It prevents the activation of the lymphocytes responsible for rejection."

A Muromonab-CD3 (Orthoclone OKT3) is a monoclonal antibody that works to increase the elimination of T lymphocytes from circulation. The corticosteroids broadly inhibit cytokine production in most leukocytes, resulting in generalized immunosuppression. The main action of all antiproliferatives (such as azathioprine [Imuran]) is to inhibit something essential to DNA synthesis, which prevents cell division in activated lymphocytes. Calcineurin inhibitors such as cyclosporine (Sandimmune) stop the production and secretion of interleukin-2, which then prevents the activation of lymphocytes involved in transplant rejection.

A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client? a. Assessing vaccination records for booster shot needs b. Encouraging the client to eat a nutritious diet c. Instructing the client to wash minor wounds carefully d. Teaching hand hygiene to prevent the spread of microbes

A Older adults may have insufficient antibodies that have already been produced against microbes to which they have been exposed. Therefore, older adults need booster shots for many vaccinations they received as younger people. A nutritious diet, proper wound care, and hand hygiene are relevant for all populations.

A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important? a. "Avoid large crowds and people who are ill." b. "Check over-the-counter meds for acetaminophen." c. "Take this medicine exactly as prescribed." d. "You have a higher risk of developing cancer."

A Prednisone, like all steroids, decreases immune function. The client should be advised to avoid large crowds and people who are ill. Prednisone does not contain acetaminophen. All clients should be taught to take medications exactly as prescribed. A higher risk for cancer is seen with drugs from the calcineurin inhibitor category, such as tacrolimus (Prograf).

A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ? a. Bone marrow b. Spleen c. Thymus d. Tonsils

A The B cell is the primary cell in antibody-mediated immunity and is released from the bone marrow. These cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B cells.

The RN on the medical-surgical unit receives a shift report about four clients. Which client does the nurse assess first? A. A 34-year-old who has returned to the unit after a colon resection with a new colostomy stoma, which is dark pink B. A 36-year-old admitted after a motor vehicle crash with areas of ecchymoses on the abdomen in a "lap-belt" pattern C. A 40-year-old with pneumonia who has abdominal distention and decreased bowel sounds in all quadrants D. A 51-year-old with familial adenomatous polyposis (FAP) who is scheduled for a colonoscopy

A 36-year-old admitted after a motor vehicle crash with areas of ecchymoses on the abdomen in a "lap-belt" pattern Ecchymoses in the abdominal area may indicate intraperitoneal or intra-abdominal bleeding; this client requires rapid assessment and interventions. The client who is post colon resection, the client with pneumonia, and the client with FAP do not have an urgent need for further assessment or intervention.

A newly graduated RN has just finished a 6-week orientation to the oncology unit. Which client is most appropriate to assign to the new graduate? A.) A 30-year-old with acute lymphocytic leukemia who will receive combination chemotherapy today B.) A 40-year-old with chemotherapy-induced nausea and vomiting who has had no urine output for 16 hours C.) A 45-year-old with pancytopenia who will require IV administration of erythropoietin (Procrit) D.) A 72-year-old with tumor lysis syndrome who is receiving normal saline IV at a rate of 250 mL/hr

A 45-year-old with pancytopenia who will require IV administration of erythropoietin (Procrit) A new nurse after a 6-week oncology orientation possesses the skills to care for clients with pancytopenia and with administration of medications to correct anemia. The clients with acute lymphocytic leukemia and chemotherapy-induced nausea are complex clients requiring a nurse certified in chemotherapy administration. The client with tumor lysis syndrome has complicated needs for assessment and care and should be cared for by an RN with more oncology experience.

Which client does the medical-surgical unit charge nurse assign to an LPN/LVN? A. A 41-year-old who needs assistance with choosing a site for a colostomy stoma B. A 47-year-old who needs to receive "whole gut" lavage before a colon resection C. A 51-year-old who has recently arrived on the unit after having an open herniorrhaphy D. A 56-year-old who has obstipation and a recent emesis of foul-smelling liquid

A 47-year-old who needs to receive "whole gut" lavage before a colon resection Because administration of medications is within the LPN/LVN scope of practice, this preoperative client can be assigned to the LPN/LVN. Assistance with choosing a site for a colostomy stoma is an intervention that should be provided by an RN. The recent postoperative client and the critically ill client will need assessments and interventions that can only be done by an RN.

A 22 year old patient reports abdominal pain that semms to start several days before her menstrual period. What questions does the nurse ask in order to obtain a thorough menstrual history? (Select all that apply) a. "How old were you when you started menstruation?" b. "Typically, how long does your period last?" c. "How would you describe your menstrual flow?" d. "When did you last have sexual intercourse?" e. "Would you like information about contraceptives?"

A, B, C

A postoperative client is receiving morphine for pain. For which side effects does the nurse monitor this client? (Select all that apply.) a. Hypotension b. Respiratory depression c. Constipation d. Increased intracranial pressure e. Altered bleeding times

A, B, C

A patient has had a posterior colporrhaphy. What is included in the nursing care of this patient? (select all that apply) a. Administer pain medication before a bowel movement b. Instruct to avoid straining during a bowel movement c. Resume regular activities after discharge from the hospital d. Provide sitz baths e. Promote a low-residue (low-fiber) diet

A, B, D, E

Which are steps in the process of making an antigen-specific antibody? (Select all that apply.) a. Antibody-antigen binding b. Invasion c. Opsonization d. Recognition e. Sensitization

A, B, D, E The seven steps in the process of making antigen-specific antibodies are: exposure/invasion, antigen recognition, sensitization, antibody production and release, antigen-antibody binding, antibody binding actions, and sustained immunity. Opsonization is the adherence of an antibody to the antigen, marking it for destruction.

What are the rationales for chemotherapy as a cancer treatment? (SATA) a. Increases the survival time for the patient b. Decreases the patient's risk for life-threatening complications c. Systemic treatment for cancer cells that may have escaped from the primary tumor d. Concentrates in secondary lymphoid tissues and prevents widespread metastasis e. Less expensive and safer than radiation therapy

A, C

The nurse reads in the patient's chart that the health care provider is concerned about myelo-suppression. Which laboratory results will the nurse closely monitor and report to the provider? (SATA) a. WBC count b. Serum potassium level c. RBC count d. Platelet count e. Blood glucose level

A, C, D

The student nurse is learning about the functions of different antibodies. Which principles does the student learn? (Select all that apply.) a. IgA is found in high concentrations in secretions from mucous membranes. b. IgD is present in the highest concentrations in mucous membranes. c. IgE is associated with antibody-mediated hypersensitivity reactions. d. IgG comprises the majority of the circulating antibody population. e. IgM is the first antibody formed by a newly sensitized B cell.

A, C, D, E Immunoglobulin A (IgA) is found in high concentrations in secretions from mucous membranes. Immunoglobulin E (IgE) is associated with antibody-mediated hypersensitivity reactions. The majority of the circulating antibody population consists of immunoglobulin G (IgG). The first antibody formed by a newly sensitized B cell is immunoglobulin M (IgM). Immunoglobulin D (IgD) is typically present in low concentrations.

Following a uterine embolization using a vascular closure device, what patient care would the nurse provide? (select all that apply) a. Assist the patient to ambulate 2 hours after the procedure b. Keep the patient on bedrest with the leg immobilized for 4 hours before ambulating c. Encourage the patient to drink a lot of fluids d. Assess the patients pain level and administer analgesics as needed e. Raise the head of the bed

A, D, E

The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.) a. Edema b. Pulselessness c. Pallor d. Redness e. Warmth

A, D, E The five cardinal signs of inflammation include redness, warmth, pain, swelling, and decreased function.

The nurse is teaching a group of clients with irritable bowel syndrome (IBS) about complementary and alternative therapies. What does the nurse suggest as possible treatment modalities? (Select all that apply.) A. Acupuncture B. Decreasing physical activities C. Herbs (moxibustion) D. Meditation E. Peppermint oil capsules F. Yoga

A. Acupuncture C. Herbs (moxibustion) D. Meditation E. Peppermint oil capsules F. Yoga Acupuncture is recommended as a complementary therapy for IBS. Moxibustion is helpful for some clients with IBS. Meditation, yoga, and other relaxation techniques help many clients manage stress and their IBS symptoms. Research has shown that peppermint oil capsules may be effective in reducing symptoms of IBS. Regular exercise is important for managing stress and promoting bowel elimination.

The nurse is teaching a client with a newly created colostomy about foods to limit or avoid because of flatulence or odors. Which foods are included? (Select all that apply.) A. Broccoli B. Buttermilk C. Mushrooms D. Onions E. Peas F. Yogurt

A. Broccoli C. Mushrooms D. Onions E. Peas Broccoli, mushrooms, onions, and peas often cause flatus. Buttermilk will help prevent odors. Yogurt can help prevent flatus.

A client has received an overdose of a benzodiazepine. What medication does the nurse anticipate an order for? a. Flumazenil (Romazicon) b. Naloxone (Narcan) c. Acetylcysteine (Mucomyst) d. Digoxin immune fab (Digibind)

A. Flumaxenil (Romazicon)

A client reports pain 8 hours after surgery. The client has already received an opioid within the past 2 hours. What is the nurse's best action? a. Assess the pain further. b. Administer naloxone (Narcan). c. Call the surgeon. d. Document the finding.

A. assess the pain further

The nurse is caring for a client who is reporting severe postoperative pain. The physician's order states that the client is to receive "hydromorphone hydrochloride (Dilaudid) 10-15 mg every 1-2 hours PRN pain." What is the nurse's priority action? a. Call the physician to clarify the order. b. Give the medication as ordered. c. Refuse to give the medication. d. Call the hospital pharmacist.

A. call the physician to clarify the order

The nurse is changing the client's dressing on the second postoperative day and notes a small amount of serosanguineous drainage. What is the nurse's best action? a. Cleanse the suture line and apply a sterile dressing. b. Culture the drainage and leave the incision open to air. c. Cover the incision with a transparent dressing. d. Notify the surgeon to assess the client.

A. cleanse the suture line and apply a sterile dressing

The nurse is caring for several postoperative clients on the unit. Which client does the nurse assess first? a. Client with 200 mL dark drainage from the nasogastric tube in an hour b. Client who received oral pain medication 20 minutes ago c. Client who has not yet ambulated after surgery 4 hours ago d. Client requiring discharge teaching and whose family is present

A. client with 200 mL dark drainage from the nasogastric tube in an hour

The nurse is caring for clients in the postanesthesia care unit (PACU). Which client does the nurse intervene for first? a. Client with a pulse deficit of 15 b. Client who is reporting leg pain c. Client with dementia who is confused d. Client who is reporting a headache

A. client with a pulse deficit of 15

The nurse is working in the postanesthesia care unit (PACU) and receives a client from the operating room (OR). What does the nurse assess first? a. Client's endotracheal tube b. Client's nasogastric tube c. Client's Foley catheter d. Hemovac drain at the incision site

A. client's endotracheal tube

The nurse is assisting a client to ambulate several hours after his surgery. The client coughs and says to the nurse, "I feel like something ripped in my incision." A large amount of blood is suddenly apparent on the client's gown near the incision. What action does the nurse take first? a. Ease the client to the floor and call for assistance. b. Put immediate pressure over the incision with the hands. c. Call the Rapid Response Team to assess the client. d. Lift up the gown and take off the dressing.

A. ease the client to the floor and call for assistance

A client who has just been transferred to the postanesthesia care unit (PACU) from surgery is very restless and confused. What is the nurse's first action? a. Orient the client and remain with him or her. b. Call the surgeon for an intraoperative report. c. Notify the physician on call. d. Assess the client's level of pain.

A. orient the client and remain with him or her

18. A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first? a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4° F (39.1° C) b. Client with Bruton's agammaglobulinemia who is waiting for discharge teaching c. Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion d. Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia

ANS: A A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be assessed first. The client who is post immunoglobulin infusion should have had all infusion-related vital signs and assessments completed and should be checked next. The client receiving antibiotics should be seen third, and the client waiting for discharge teaching is the lowest priority. Since discharge teaching can take time, the nurse may want to delegate this task to someone else while attending to the most seriously ill client. DIF: Applying/Application REF: 338 KEY: HIV/AIDS| immune disorders| prioritizing| fever| infection| white blood cell count MSC: IntegratedProcess:NursingProcess:Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

3. The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? a. Consistent use of Standard Precautions b. Double-gloving before body fluid exposure c. Labeling charts and armbands "HIV+" d. Wearing a mask within 3 feet of the client

ANS: A According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet of the client is part of Airborne Precautions and is not necessary with every client contact. DIF: Remembering/Knowledge REF: 332 KEY: HIV/AIDS| infection control| Standard Precautions| immune disorders MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

The nurse is working with a client who has rheumatoid arthritis (RA). The nurse has identified the priority problem of poor body image for the client. What finding by the nurse indicates goals for this client problem are being met? a. Attends meetings of a book club b. Has a positive outlook on life c. Takes medication as directed d. Uses assistive devices to protect joints

ANS: A All of the activities are appropriate for a client with RA. Clients who have a poor body image are often reluctant to appear in public, so attending public book club meetings indicates that goals for this client problem are being met.

A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching? a. Acetaminophen (Tylenol) b. Cyclobenzaprine hydrochloride (Flexeril) c. Hyaluronate (Hyalgan) d. Ibuprofen (Motrin)

ANS: A All of the drugs are appropriate to treat OA. However, the first-line drug is acetaminophen. Cyclobenzaprine is a muscle relaxant given to treat muscle spasms. Hyaluronate is a synthetic joint fluid implant. Ibuprofen is a nonsteroidal anti-inflammatory drug.

2. The nurse is presenting information to a community group on safer sex practices. The nurse should teach that which sexual practice is the riskiest? a. Anal intercourse b. Masturbation c. Oral sex d. Vaginal intercourse

ANS: A Anal intercourse is the riskiest sexual practice because the fragile anal tissue can tear, creating a portal of entry for human immune deficiency virus. DIF: Understanding/Comprehension REF: 330 KEY: HIV/AIDS| safer sex| infection| immune disorders MSC: IntegratedProcess:Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance

A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief. The client also requests the celecoxib in addition to the morphine. What action by the nurse is best? a. Consult with the health care provider about administering both drugs to the client. b. Inform the client that the celecoxib will be started when he or she goes home. c. Teach the client that, since morphine is stronger, celecoxib is not needed. d. Tell the client he or she should not take both drugs at the same time.

ANS: A Despite getting an opioid analgesic for postoperative pain, the nurse should be aware that the client may be on other medications for arthritis in other joints. The nonsteroidal anti-inflammatory drug celecoxib will also help with the postoperative pain. The nurse should consult the provider about continuing the celecoxib while the client is in the hospital. The other responses are not warranted, as the client should be restarted on this medication postoperatively.

A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement? a. "I always wear long sleeves, pants, and a hat when outdoors." b. "I try not to use cosmetics that contain any type of sunblock." c. "Since I tend to sweat a lot, I use a lot of baby powder." d. "Since I can't be exposed to the sun, I have been using a tanning bed."

ANS: A Good self-management of the skin in SLE includes protecting the skin from sun exposure, using sunblock, avoiding drying agents such as powder, and avoiding tanning beds.

A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the client for Heberden's nodules. What assessment technique is correct? a. Inspect the client's distal finger joints. b. Palpate the client's abdomen for tenderness. c. Palpate the client's upper body lymph nodes. d. Perform range of motion on the client's wrists.

ANS: A Herberden's nodules are seen in osteoarthritis and are bony nodules at the distal interphalangeal joints. To assess for this finding, the nurse inspects the client's distal fingertips. These nodules are not found in the abdomen, lymph nodes, or wrists.

12. A client has scheduled brachytherapy sessions and states that she feels as though she is not safe around her family. What is the best response by the nurse? a. You are only reactive when the radioactive implant is in place. b. To be totally safe, it is a good idea to sleep in a separate room. c. It is best to stay a safe distance from friends or family between treatments. d. You should use a separate bathroom from the rest of the family.

ANS: A In brachytherapy, the surgeon inserts an applicator into the uterus. After placement is verified, the radioactive isotope is placed in the applicator for several minutes for a single treatment. There are no restrictions for the woman to stay away from her family or the public between treatments.

The nurse is teaching a client with gout dietary strategies to prevent exacerbations or other problems. Which statement by the nurse is most appropriate? a. "Drink 1 to 2 liters of water each day." b. "Have 10 to 12 ounces of juice a day." c. "Liver is a good source of iron." d. "Never eat hard cheeses or sardines."

ANS: A Kidney stones are common in clients with gout, so drinking plenty of water will help prevent this from occurring. Citrus juice is high in ash, which can help prevent the formation of stones, but the value of this recommendation is not clear. Clients with gout should not eat organ meats or fish with bones, such as sardines.

The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further? a. Creatinine: 3.9 mg/dL b. Platelet count: 210,000/mm3 c. Red blood cell count: 5.2/mm3 d. White blood cell count: 4400/mm3

ANS: A Lupus nephritis is the leading cause of death in clients with SLE. The creatinine level is very high and the nurse needs to perform further assessments related to this finding. The other laboratory values are normal.

6. A nurse is caring for four postoperative clients who each had a total abdominal hysterectomy. Which client should the nurse assess first upon initial rounding? a. Client who has had two saturated perineal pads in the last 2 hours b. Client with a temperature of 99 F and blood pressure of 115/73 mm Hg c. Client who has pain of 4 on a scale of 0 to 10 d. Client with a urinary catheter output of 150 mL in the last 3 hours

ANS: A Normal vaginal bleeding should be less than one saturated perineal pad in 4 hours. Two saturated pads in such a short time could indicate hemorrhage, which is a priority. The other clients also have needs, but the client with excessive bleeding should be assessed first.

A client in the orthopedic clinic has a self-reported history of osteoarthritis. The client reports a low-grade fever that started when the weather changed and several joints started "acting up," especially both hips and knees. What action by the nurse is best? a. Assess the client for the presence of subcutaneous nodules or Baker's cysts. b. Inspect the client's feet and hands for podagra and tophi on fingers and toes. c. Prepare to teach the client about an acetaminophen (Tylenol) regimen. d. Reassure the client that the problems will fade as the weather changes again.

ANS: A Osteoarthritis is not a systemic disease, nor does it present bilaterally. These are manifestations of rheumatoid arthritis. The nurse should assess for other manifestations of this disorder, including subcutaneous nodules and Baker's cysts. Podagra and tophi are seen in gout. Acetaminophen is not used for rheumatoid arthritis. Telling the client that the symptoms will fade with weather changes is not accurate.

2. The nurse is educating a client on the prevention of toxic shock syndrome (TSS). Which statement by the client indicates a lack of understanding? a. I need to change my tampon every 8 hours during the day. b. At night, I should use a feminine pad rather than a tampon. c. If I dont use tampons, I should not get TSS. d. It is best if I wash my hands before inserting the tampon.

ANS: A Tampons need to be changed every 3 to 6 hours to avoid infection by such organisms as Staphylococcus aureus. All of the other responses are correct: use of feminine pads at night, not using tampons at all, and washing hands before tampon insertion are all strategies to prevent TSS. DIF: Applying/Application REF: 1485

5. A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states Whew! I was really worried about that result What action by the nurse is most important? a. Assess the client's sexual activity and patterns. b. Express happiness over the test result. c. Remind the client about safer sex practices. d. Tell the client to be retested in 3 months.

ANS: A The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to making antibodies to HIV. This period of time is known as the window period and can last up to 36 months. The nurse needs to assess the client's sexual behavior further to determine the proper response. The other actions are not the most important, but discussing safer sex practices is always appropriate. DIF: Applying/Application REF: 336 KEY: HIV/AIDS| safer sexual practices| nursing assessment| immune disorders MSC: IntegratedProcess:NursingProcess:Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

14. A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The client's partner is listed as the emergency contact, but the client's mother insists that she should be listed instead. What action by the nurse is best? a. Contact the social worker to assist the client with advance directives. b. Ignore the mother; the client does not want her to be involved. c. Let the client know, gently, that nurses cannot be involved in these disputes. d. Tell the client that, legally, the mother is the emergency contact.

ANS: A The client should make his or her wishes known and formalize them through advance directives. The nurse should help the client by contacting someone to help with this process. Ignoring the mother or telling the client that nurses cannot be involved does not help the situation. Legal statutes vary by state; as more states recognize gay marriage, this issue will continue to evolve. DIF: Applying/Application REF: 336 KEY: HIV/AIDS| autonomy| advocacy| referrals| LGBTQ MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

A client is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important? a. Have adequate help to transfer the client. b. Provide socks so the client can slide easier. c. Tell the client full weight bearing is allowed. d. Use a footstool to elevate the client's leg.

ANS: A The client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure there is adequate help to transfer the client while preventing falls. Slippery socks will encourage a fall. Elevating the leg greater than 90 degrees is not allowed.

15. A client with human immune deficiency virus infection is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important? a. Consult with the pharmacy about drug interactions. b. Ensure that the client understands the new medications. c. Give the new drugs without considering the old ones. d. Schedule all medications at standard times.'

ANS: A The drug regimen for someone with HIV/AIDS is complex and consists of many medications that must be given at specific times of the day, and that have many interactions with other drugs. The nurse should consult with a pharmacist about possible interactions. Client teaching is important but does not take priority over ensuring the medications do not interfere with each other, which could lead to drug resistance or a resurgence of symptoms. DIF: Applying/Application REF: 339 KEY: HIV/AIDS| immune disorder| antiretrovirals| HAART MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best? a. Assess the client's culture more thoroughly. b. Discuss options for performing duties. c. See if the client will call a community meeting. d. Suggest the client give up the role of elder.

ANS: A The nurse needs a more thorough understanding of the client's culture, including the meaning of illness and the ramifications of the elder not being able to perform traditional duties. This must be done prior to offering any possible solutions. If the nurse does not understand the consequences of what is suggested, the client may simply be unwilling to listen or participate in problem solving. The other options may be reasonable depending on the outcome of a better cultural understanding.

13. A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the "AIDS guy" and wondering how the client contracted the disease. What action by the nurse is best? a. Confront the staff members about unethical behavior. b. Ignore the behavior; they will stop on their own soon. c. Report the behavior to the unit's nursing management. d. Tell the client that other staff members are talking about him or her.

ANS: A The professional nurse should be able to confront unethical behavior assertively. The staff should not be talking about clients unless they have a need to do so for client care. Ignoring the behavior may be more comfortable, but the nurse is abdicating responsibility. The behavior may need to be reported, but not as a first step. Telling the client that others are talking about him or her does not accomplish anything. DIF: Applying/Application REF: 344 KEY: HIV/AIDS| communication| advocacy| caring| patient-centered care MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The client's surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best? a. Assess neurovascular status in both legs. b. Elevate the affected leg and apply ice. c. Prepare to administer pain medication. d. Try to place the affected leg in abduction.

ANS: A This client has manifestations of hip dislocation, a critical complication of this surgery. Hip dislocation can cause neurovascular compromise. The nurse should assess neurovascular status, comparing both legs. The nurse should not try to move the extremity to elevate or abduct it. Pain medication may be administered if possible, but first the nurse should thoroughly assess the client.

12. A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best? a. Assess the client for support systems. b. Determine if a clergy member would help. c. Explain legal requirements to tell sex partners. d. Offer to tell the family for the client.

ANS: A This client needs the assistance of support systems. The nurse should help the client identify them and what role they can play in supporting him or her. A clergy member may or may not be welcome. Legal requirements about disclosing HIV status vary by state. Telling the family for the client is enabling, and the client may not want the family to know. DIF: Applying/Application REF: 343 KEY: HIV/AIDS| nursing assessment| psychosocial response| support| caring MSC: IntegratedProcess:Caring NOT: Client Needs Category: Psychosocial Integrity

A nurse is teaching a client with psoriatic arthritis about the medication golimumab (Simponi). What information is most important to include? a. "Avoid large crowds or people who are ill." b. "Stay upright for 1 hour after taking this drug." c. "This drug may cause your hair to fall out." d. "You may double the dose if pain is severe."

ANS: A This drug has a Food and Drug Administration black box warning about opportunistic or other serious infections. Teach the client to avoid large crowds and people who are ill. The other instructions do not pertain to golimumab.

What action by the perioperative nursing staff is most important to prevent surgical wound infection in a client having a total joint replacement? a. Administer preoperative antibiotic as ordered. b. Assess the client's white blood cell count. c. Instruct the client to shower the night before. d. Monitor the client's temperature postoperatively.

ANS: A To prevent surgical wound infection, antibiotics are given preoperatively within an hour of surgery. Simply taking a shower will not help prevent infection unless the client is told to use special antimicrobial soap. The other options are processes to monitor for infection, not prevent it.

19. An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug? a. "Truvada does not reduce the need for safe sex practices." b. "This drug has been taken off the market due to increases in cancer." c. "Truvada reduces the number of HIV tests you will need." d. "This drug is only used for postexposure prophylaxis."

ANS: A Truvada is a new drug used for pre-exposure prophylaxis and appears to reduce transmission of human immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not reduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3 months. This drug has not been taken off the market and is not used for postexposure prophylaxis. DIF: Understanding/Comprehension REF: 332 KEY: HIV/AIDS| immune disorders| vaccinations| patient education MSC: IntegratedProcess:Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A nurse is caring for a client with systemic sclerosis. The client's facial skin is very taut, limiting the client's ability to open the mouth. After consulting with a registered dietitian for appropriate nutrition, what other consultation should the nurse facilitate? a. Dentist b. Massage therapist c. Occupational therapy d. Physical therapy

ANS: A With limited ability to open the mouth, dental hygiene may be lacking. The nurse should encourage the client to see a dentist. The other referrals are not related to the mouth.

2. The nurse is giving discharge instructions to a client who had a total abdominal hysterectomy. Which statements by the client indicate a need for further teaching? (Select all that apply.) a. I should not have any problems driving to see my mother, who lives 3 hours away. b. Now that I have time off from work, I can return to my exercise routine next week. c. My granddaughter weighs 23 pounds, so I need to refrain from picking her up. d. I will have to limit the times that I climb our stairs at home to morning and night. e. For 1 month, I will need to refrain from sexual intercourse.

ANS: A, B Driving and sitting for extended periods of time should be avoided until the surgeon gives permission. For 2 to 6 weeks, exercise participation should also be avoided. All of the other responses demonstrate adequate knowledge for discharge. The client should not lift anything heavier than 10 pounds, should limit stair climbing, and should refrain from sexual intercourse.

A client with fibromyalgia is in the hospital for an unrelated issue. The client reports that sleep, which is always difficult, is even harder now. What actions by the nurse are most appropriate? (Select all that apply.) a. Allow the client uninterrupted rest time. b. Assess the client's usual bedtime routine. c. Limit environmental noise as much as possible. d. Offer a massage or warm shower at night. e. Request an order for a strong sleeping pill.

ANS: A, B, C, D Clients with fibromyalgia often have sleep disturbances, which can be exacerbated by the stress, noise, and unfamiliar environment of the hospital. Allowing uninterrupted rest time, adhering to the client's usual bedtime routine as much as possible, limiting noise and light, and offering massages or warm showers can help. The client does not need a strong sleeping pill unless all other options fail and the client requests something for sleep. At that point a mild sleeping agent can be tried.

MULTIPLE RESPONSE 1. A student nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.) a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly. d. Opportunistic infections and cancer are leading causes of death. e. People with stage 1 HIV disease are not infectious to others.

ANS: A, B, C, D In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do not function well. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two leading causes of death in clients with HIV infection. People infected with HIV are infectious in all stages of the disease. DIF: Remembering/Knowledge REF: 327 KEY: HIV/AIDS| immune disorders| inflammation MSC: IntegratedProcess:Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

3. A nurse is traveling to a third-world country with a medical volunteer group to work with people who are infected with human immune deficiency virus (HIV). The nurse should recognize that which of the following might be a barrier to the prevention of perinatal HIV transmission? (Select all that apply.) a. Clean drinking water b. Cultural beliefs about illness c. Lack of antiviral medication d. Social stigma e. Unknown transmission routes

ANS: A, B, C, D Treatment and prevention of HIV is complex, and in third-world countries barriers exist that one might not otherwise think of. Mothers must have access to clean drinking water if they are to mix formula. Cultural beliefs about illness, lack of available medications, and social stigma are also possible barriers. Perinatal transmission is well known to occur across the placenta during birth, from exposure to blood and body fluids during birth, and through breast-feeding. DIF: Analyzing/Analysis REF: 332 KEY: HIV/AIDS| infection control| culture| patient-centered care MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Psychosocial Integrity

3. The nurse is taking the history of a 24-year-old client diagnosed with cervical cancer. What possible risk factors would the nurse assess? (Select all that apply.) a. Smoking b. Multiple sexual partners c. Poor diet d. Nulliparity e. Younger than 18 at first intercourse

ANS: A, B, C, E Smoking, multiple sexual partners, poor diet, and age less than 18 for first intercourse are all risk factors for cervical cancer. Nulliparity is a risk factor for endometrial cancer.

2. Which findings are AIDS-defining characteristics? (Select all that apply.) a. CD4+ cell count less than 200/mm3 or less than 14% b. Infection with Pneumocystis jiroveci c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) d. Presence of HIV wasting syndrome e. Taking antiretroviral medications

ANS: A, B, D A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 or less than 14% (even if the total CD4+ count is above 200 cells/mm3) or an opportunistic infection such as Pneumocystis jiroveci and HIV wasting syndrome. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics. DIF: Remembering/Knowledge REF: 328 KEY: HIV/AIDS| immune disorders MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.) a. Grab bars to reach high items b. Long-handled bath scrub brush c. Soft rocker-recliner chair d. Toothbrush with built-up handle e. Wheelchair cushion for comfort

ANS: A, B, D Grab bars, long-handled bath brushes, and toothbrushes with built-up handles all provide modifications for daily activities, making it easier for the client with RA to complete ADLs independently. The rocker-recliner and wheelchair cushion are comfort measures but do not help increase independence.

A client has been diagnosed with fibromyalgia syndrome but does not want to take the prescribed medications. What nonpharmacologic measures can the nurse suggest to help manage this condition? (Select all that apply.) a. Acupuncture b. Stretching c. Supplements d. Tai chi e. Vigorous aerobics

ANS: A, B, D There are many nonpharmacologic means for controlling the symptoms of fibromyalgia, including acupuncture, stretching, tai chi, low-impact aerobics, swimming, biking, strengthening, massage, stress management, and hypnosis. Dietary supplements and vigorous aerobics are not recommended.

A home health care nurse is visiting a client discharged home after a hip replacement. The client is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client? (Select all that apply.) a. Buy and install an elevated toilet seat. b. Install grab bars in the shower and by the toilet. c. Step into the bathtub with the affected leg first. d. Remove all throw rugs throughout the house. e. Use a shower chair while taking a shower.

ANS: A, B, D, E Buying and installing an elevated toilet seat, installing grab bars, removing throw rugs, and using a shower chair will all promote safety for this client. The client is still on partial weight bearing, so he or she cannot step into the bathtub leading with the operative side. Stepping into a bathtub may also require the client to bend the hip more than the allowed 90 degrees.

A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.) a. "Avoid acetaminophen in over-the-counter medications." b. "It may take several weeks to become effective on pain." c. "Pregnancy and breast-feeding are not affected by MTX." d. "Stay away from large crowds and people who are ill." e. "You may find that folic acid, a B vitamin, reduces side effects."

ANS: A, B, D, E MTX is a disease-modifying antirheumatic drug and is used as a first-line drug for RA. MTX can cause liver toxicity, so the client should be advised to avoid medications that contain acetaminophen. It may take 4 to 6 weeks for effectiveness. MTX can cause immunosuppression, so avoiding sick people and crowds is important. Folic acid helps reduce side effects for some people. Pregnancy and breast-feeding are contraindicated while on this drug.

The nurse is working with clients who have connective tissue diseases. Which disorders are correctly paired with their manifestations? (Select all that apply.) a. Dry, scaly skin rash - Systemic lupus erythematosus (SLE) b. Esophageal dysmotility - Systemic sclerosis c. Excess uric acid excretion - Gout d. Footdrop and paresthesias - Osteoarthritis e. Vasculitis causing organ damage - Rheumatoid arthritis

ANS: A, B, E A dry, scaly skin rash is the most frequent dermatologic manifestation of SLE. Systemic sclerosis can lead to esophageal motility problems. Vasculitis leads to organ damage in rheumatoid arthritis. Gout is caused by hyperuricemia; the production of uric acid exceeds the excretion capability of the kidneys. Footdrop and paresthesias occur in rheumatoid arthritis.

6. A postmenopausal client is experiencing low back and pelvic pain, fatigue, and bloody vaginal discharge. What laboratory tests would the nurse expect to see ordered for this client if endometrial cancer is suspected? (Select all that apply.) a. Cancer antigen-125 (CA-125) b. White blood cell (WBC) count c. Hemoglobin and hematocrit (H&H) d. International normalized ratio (INR) e. Prothrombin time (PT)

ANS: A, C Serum tumor markers such as CA-125 assess for metastasis, especially if elevated. H&H would evaluate the possibility of anemia, a common finding with postmenopausal bleeding with endometrial cancer. WBC count is not indicated since there are no signs of infection. The INR and PT are coagulation tests to measure the time it takes for a fibrin clot to form. They are used to evaluate the extrinsic pathway of coagulation in clients receiving oral warfarin.

7. A client with acquired immune deficiency syndrome and esophagitis due to Candida fungus is scheduled for an endoscopy. What actions by the nurse are most appropriate? (Select all that apply.) a. Assess the client's mouth and throat. b. Determine if the client has a stiff neck. c. Ensure that the consent form is on the chart. d. Maintain NPO status as prescribed. e. Percuss the client's abdomen.

ANS: A, C, D Oral Candida fungal infections can lead to esophagitis. This is diagnosed with an endoscopy and biopsy. The nurse assesses the client's mouth and throat beforehand, ensures valid consent is on the chart, and maintains the client in NPO status as prescribed. A stiff neck and abdominal percussion are not related to this diagnostic procedure. DIF: Applying/Application REF: 334 KEY: HIV/AIDS| nursing assessment| informed consent| NPO| endoscopy MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

An older client returning to the postoperative nursing unit after a hip replacement is disoriented and restless. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply an abduction pillow to the client's legs. b. Assess the skin under the abduction pillow straps. c. Place pillows under the heels to keep them off the bed. d. Monitor cognition to determine when the client can get up. e. Take and record vital signs per unit/facility policy.

ANS: A, C, E The UAP can apply an abduction pillow, elevate the heels on a pillow, and take/record vital signs. Assessing skin is the nurse's responsibility, although if the UAP notices abnormalities, he or she should report them. Determining when the client is able to get out of bed is also a nursing responsibility.

1. A 28-year-old client is diagnosed with endometriosis and is experiencing severe symptoms. Which actions by the nurse are the most appropriate at this time? (Select all that apply.) a. Reduce the pain by low-level heat. b. Discuss the high risk of infertility with this diagnosis. c. Relieve anxiety by relaxation techniques and education. d. Discuss in detail the side effects of laparoscopic surgery. e. Suggest resources such as the Endometriosis Association.

ANS: A, C, E With endometriosis, pain is the predominant symptom, with anxiety occurring because of the diagnosis. Interventions should be directed to pain and anxiety relief, such as low-level heat, relaxation techniques, and education about the pathophysiology and possible treatment of endometriosis. The nurse could suggest resources to give more information about the diagnosis. Discussion of the possibility of infertility and side effects of laparoscopic surgery is premature and may increase the anxiety.

4. A client with acquired immune deficiency syndrome (AIDS) is hospitalized with Pneumocystis jiroveci pneumonia and is started on the drug of choice for this infection. What laboratory values should the nurse report to the provider as a priority? (Select all that apply.) a. Aspartate transaminase, alanine transaminase: elevated b. CD4+ cell count: 180/mm3 c. Creatinine: 1.0 mg/dL 3 d. Platelet count: 80,000/mm e. Serum sodium: 120 mEq/L

ANS: A, D, E The drug of choice to treat Pneumocystis jiroveci pneumonia is trimethoprim with sulfamethoxazole (Septra). Side effects of this drug include hepatitis, hyponatremia, and thrombocytopenia. The elevated liver enzymes, low platelet count, and low sodium should all be reported. The CD4+ cell count is within the expected range for a client with an AIDS-defining infection. The creatinine level is normal. DIF: Analyzing/Analysis REF: 340 KEY: HIV/AIDS| laboratory values| antibiotics| immune disorders MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

16. A client with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition? a. Auscultating the lungs b. Assessing mucous membranes c. Listening to bowel sounds d. Performing a neurologic examination

ANS: B Cryptosporidiosis can cause extreme loss of fluids and electrolytes, up to 20 L/day. The nurse should assess signs of hydration/dehydration as the priority, including checking the client's mucous membranes for dryness. The nurse will perform the other assessments as part of a comprehensive assessment. DIF: Applying/Application REF: 334 KEY: HIV/AIDS| nursing assessment| fluids and electrolytes MSC: IntegratedProcess:NursingProcess:Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

6. A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first? a. Ask the client about travel to any foreign countries. b. Assess the client for adherence to the drug regimen. c. Determine if the client has any new sexual partners. d. Request information about new living quarters or pets.

ANS: B Adherence to the complex drug regimen needed for HIV treatment can be daunting. Clients must take their medications on time and correctly at a minimum of 90% of the time. Since this client's viral load has increased dramatically, the nurse should first assess this factor. After this, the other assessments may or may not be needed. DIF: Applying/Application REF: 338 KEY: HIV/AIDS| nursing assessment| immune disorders| medications MSC: IntegratedProcess:NursingProcess:Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client who reports jaw pain when eating b. Client with a red, hot, swollen right wrist c. Client who has a puffy-looking area behind the knee d. Client with a worse joint deformity since the last visit

ANS: B All of the options are possible manifestations of RA. However, the presence of one joint that is much redder, hotter, or more swollen that the other joints may indicate infection. The nurse needs to see this client first.

The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the client's blood glucose readings have been elevated. What question by the nurse is most appropriate? a. "Are you compliant with following the diabetic diet?" b. "Have you been taking glucosamine supplements?" c. "How much exercise do you really get each week?" d. "You're still taking your diabetic medication, right?"

ANS: B All of the topics are appropriate for a client whose blood glucose readings have been higher than usual. However, since this client also has OA, and glucosamine can increase blood glucose levels, the nurse should ask about its use. The other questions all have an element of nontherapeutic communication in them. "Compliant" is a word associated with negative images, and the client may deny being "noncompliant." Asking how much exercise the client "really" gets is accusatory. Asking if the client takes his or her medications "right?" is patronizing.

14. A 20-year-old client is interested in protection from the human papilloma virus (HPV) since she may become sexually active. Which response from the nurse is the most accurate? a. You are too old to receive an HPV vaccine. b. Either Gardasil or Cervarix can provide protection. c. You will need to have three injections over a span of 1 year. d. The most common side effect of the vaccine is itching at the injection site.

ANS: B Current HPV vaccines are Gardasil and Cervarix, which should be given before the first sexual contact to protect against the highest risk HPV types associated with cervical cancer. The client is not too old since it is recommended that young women up to 26 years should receive an HPV vaccine. The entire series consists of three injections over 6 months, not 1 year. Local pain and redness surrounding the injection site are very common, but this does not include itching.

A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply? a. Heating pad b. Ice packs c. Splints d. Wax dip

ANS: B Ice is best for acute inflammation. Heat often helps with joint stiffness. Splinting helps preserve joint function. A wax dip is used to provide warmth to the joint which is more appropriate for chronic pain and stiffness.

9. The nurse is doing preoperative teaching for a client who is scheduled for removal of cervical polyps in the office. Which statement by the client indicates a correct understanding of the procedure? a. I hope that I do not have cancer of the cervix. b. There should be little or no discomfort during the procedure. c. There may be a lot of bleeding after the polyp is removed. d. This may prevent me from having any more children.

ANS: B Polyp removal is a simple office procedure with the client feeling no pain. The other responses are incorrect. Cervical polyps are the most common benign growth of the cervix. Cautery is used to stop any bleeding, and there is no evidence that cervical polyps have a relationship to childbearing.

A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acute exacerbation. The client is in the clinic for a follow-up visit and is distraught about the possibility of another hospitalization disrupting the family. What action by the nurse is best? a. Explain to the client that SLE is an unpredictable disease. b. Help the client create backup plans to minimize disruption. c. Offer to talk to the family and educate them about SLE. d. Tell the client to remain compliant with treatment plans.

ANS: B SLE is an unpredictable disease and acute exacerbations can occur without warning, creating chaos in the family. Helping the client make backup plans for this event not only will decrease the disruption but will give the client a sense of having more control. Explaining facts about the disease is helpful as well but does not engage the client in problem solving. The family may need education, but again this does not help the client to problem-solve. Remaining compliant may help decrease exacerbations, but is not as powerful an intervention as helping the client plan for such events.

10. A client has recently been diagnosed with stage III endometrial cancer and asks the nurse for an explanation. What response by the nurse is correct about the staging of the cancer? a. The cancer has spread to the mucosa of the bowel and bladder. b. It has reached the vagina or lymph nodes. c. The cancer now involves the cervix. d. It is contained in the endometrium of the cervix.

ANS: B Stage III of endometrial cancer reaches the vagina or lymph nodes. Stage I is confined to the endometrium. Stage II involves the cervix, and stage IV spreads to the bowel or bladder mucosa and/or beyond the pelvis.

A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly anemic and the surgeon states the client may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important? a. Administer preoperative medications as prescribed. b. Ensure that a consent for transfusion is on the chart. c. Explain to the client how anemia affects healing. d. Teach the client about foods high in protein and iron.

ANS: B The preoperative nurse should ensure that all valid consents are on the chart, including one for blood transfusions if this may be needed. Administering preoperative medications is important for all preoperative clients and is not specific to this client. Teaching in the preoperative area should focus on immediate concerns.

3. A client is admitted to the emergency department with toxic shock syndrome. Which action by the nurse is the most important? a. Administer IV fluids to maintain fluid and electrolyte balance. b. Remove the tampon as the source of infection. c. Collect a blood specimen for culture and sensitivity. d. Transfuse the client to manage low blood count.

ANS: B The source of infection should be removed first. All of the other answers are possible interventions depending on the clients symptoms and vital signs, but removing the tampon is the priority.

An older client is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9 g/dL, hematocrit: 32%. What intervention by the nurse is most appropriate? a. Instruct the client to avoid large crowds. b. Prepare to administer epoetin alfa (Epogen). c. Teach the client about foods high in iron. d. Tell the client that all laboratory results are normal.

ANS: B This client is anemic, which needs correction prior to surgery. While eating iron-rich foods is helpful, to increase the client's red blood cells, hemoglobin, and hematocrit within 2 months, epoetin alfa is needed. This colony-stimulating factor will encourage the production of red cells. The client's white blood cell count is normal, so avoiding infection is not the priority.

10. A client has a primary selective immunoglobulin A deficiency. The nurse should prepare the client for self-management by teaching what principle of medical management? a. "Infusions will be scheduled every 3 to 4 weeks." b. "Treatment is aimed at treating specific infections." c. "Unfortunately, there is no effective treatment." d. "You will need many immunoglobulin A infusions."

ANS: B Treatment for this disorder is vigorous management of infection, not infusion of exogenous immunoglobulins. The other responses are inaccurate. DIF: Understanding/Comprehension REF: 345 KEY: Immune disorders| patient education MSC: IntegratedProcess:Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? (Select all that apply.) a. It affects single joints only. b. Antibodies lead to inflammation. c. It consists of an autoimmune process. d. Morning stiffness is rare. e. Permanent damage is inevitable.

ANS: B, C RA is a chronic autoimmune systemic inflammatory disorder leading to arthritis-type symptoms in the joints and other symptoms that can be seen outside the joints. Antibodies are created that lead to inflammation. Clients often report morning stiffness. Permanent damage can be avoided with aggressive, early treatment.

4. A client is scheduled to start external beam radiation therapy (EBRT) for her endometrial cancer. Which teaching by the nurse is accurate? (Select all that apply.) a. You will need to be hospitalized during this therapy. b. Your skin needs to be inspected daily for any breakdown. c. It is not wise to stay out in the sun for long periods of time. d. The perineal area may become damaged with the radiation. e. The technician applies new site markings before each treatment.

ANS: B, C, D EBRT is usually performed in ambulatory care and does not require hospitalization. The client needs to know to evaluate the skin, especially in the perineal area, for any breakdown, and avoid sunbathing. The technician does not apply new site markings, so the client needs to avoid washing off the markings that indicate the treatment site.

6. A client with acquired immune deficiency syndrome is in the hospital with severe diarrhea. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assessing the client's fluid and electrolyte status b. Assisting the client to get out of bed to prevent falls c. Obtaining a bedside commode if the client is weak d. Providing gentle perianal cleansing after stools e. Reporting any perianal abnormalities

ANS: B, C, D, E The UAP can assist the client with getting out of bed, obtain a bedside commode for the client's use, cleanse the client's perianal area after bowel movements, and report any abnormal observations such as redness or open areas. The nurse assesses fluid and electrolyte status. DIF: Applying/Application REF: 341 KEY: HIV/AIDS| delegation| hygiene| elimination| patient safety| unlicensed assistive personnel (UAP) MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all that apply.) a. Anorexia b. Felty's syndrome c. Joint deformity d. Low-grade fever e. Weight loss

ANS: B, C, E Late manifestations of RA include Felty's syndrome, joint deformity, weight loss, organ involvement, osteoporosis, extreme fatigue, and anemia, among others. Anorexia and low-grade fever are both seen early in the course of the disease.

5. A client with acquired immune deficiency syndrome has oral thrush and difficulty eating. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply oral anesthetic gels before meals. b. Assist the client with oral care every 2 hours. c. Offer the client frequent sips of cool drinks. d. Provide the client with alcohol-based mouthwash. e. Remind the client to use only a soft toothbrush.

ANS: B, C, E The UAP can help the client with oral care, offer fluids, and remind the client of things the nurse (or other professional) has already taught. Applying medications is performed by the nurse. Alcohol-based mouthwashes are harsh and drying and should not be used. DIF: Applying/Application REF: 341 KEY: HIV/AIDS| delegation| unlicensed assistive personnel (UAP)| oral care MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

8. A client has a recurrent Bartholin cyst. What is the nurses priority action? a. Apply an ice pack to the area. b. Administer a prophylactic antibiotic. c. Obtain a fluid sample for laboratory analysis. d. Suggest moist heat such as a sitz bath.

ANS: C A major cause of an obstructed duct forming a cyst is infection. The laboratory specimen is a priority since a culture is needed in order to prescribe sensitive antibiotics. Comfort measures can then be used, such as ice packs and moist heat.

A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed? a. Assess the distal circulation in 30 minutes. b. Change the settings based on range of motion. c. Raise the lower siderail on the affected side. d. Remind the client to do quad-setting exercises.

ANS: C Because the client's leg is strapped into the CPM, if it falls off the bed due to movement, the client's leg (and new joint) can be injured. The nurse should instruct the UAP to raise the siderail to prevent this from occurring. Assessment is a nursing responsibility. Only the surgeon, physical therapist, or specially trained technician adjusts the CPM settings. Quad-setting exercises are not related to the CPM machine.

A client has fibromyalgia and is prescribed duloxetine hydrochloride (Cymbalta). The client calls the clinic and asks the nurse why an antidepressant drug has been prescribed. What response by the nurse is best? a. "A little sedation will help you get some rest." b. "Depression often accompanies fibromyalgia." c. "This drug works in the brain to decrease pain." d. "You will have more energy after taking this drug."

ANS: C Duloxetine works to increase the release of the neurotransmitters serotonin and norepinephrine, which reduces the pain from fibromyalgia. The other answers are inaccurate.

4. A 55-year-old post-menopausal woman is assessed by the nurse with a history of dyspareunia, backache, pelvis pressure, urinary tract infections, and a frequent urinary urgency. Which condition does the nurse suspect? a. Ovarian cyst b. Rectocele c. Cystocele d. Fibroid

ANS: C Dyspareunia, backache, pelvis pressure, urinary tract infections, and urinary urgency are all symptoms of a cystocelea protrusion of the bladder through the vaginal wall. Ovarian cysts are rare after menopause. A rectocele is associated with constipation, hemorrhoids, and fecal impaction. Fibroids are associated with heavy bleeding.

A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important? a. "Be sure you get enough sleep at night." b. "Eat plenty of high-protein, high-iron foods." c. "Notify your provider at once if you get a fever." d. "Weigh yourself every day on the same scale."

ANS: C Fever is the classic sign of a lupus flare and should be reported immediately. Rest and nutrition are important but do not take priority over teaching the client what to do if he or she develops an elevated temperature. Daily weights may or may not be important depending on renal involvement.

17. A client with HIV/AIDS asks the nurse why gabapentin (Neurontin) is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best? a. "Gabapentin can be used as an antidepressant too." b. "I have no idea why you should be taking this drug." c. "This drug helps treat the pain from nerve irritation." d. "You are at risk for seizures due to fungal infections."

ANS: C Many classes of medications are used for neuropathic pain, including tricyclic antidepressants such as gabapentin. It is not being used as an antidepressant or to prevent seizures from fungal infections. If the nurse does not know the answer, he or she should find out for the client. DIF: Understanding/Comprehension REF: 341 KEY: HIV/AIDS| neuropathic pain| tricyclic antidepressants| pain| pharmacologic pain management MSC: IntegratedProcess:Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)? a. Avoid contact sports. b. Get plenty of calcium. c. Lose weight if needed. d. Engage in weight-bearing exercise.

ANS: C Obesity can lead to OA, and if the client is overweight, losing weight can help prevent OA or reduce symptoms once it occurs. Arthritis can be caused by contact sports, but this is less common than obesity. Calcium and weight-bearing exercise are both important for osteoporosis.

The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement? a. Needs multiple dental fillings b. Over age 85 c. Severe osteoporosis d. Urinary tract infection

ANS: C Osteoporosis is a contraindication to joint replacement because the bones have a high risk of shattering as the new prosthesis is implanted. The client who needs fillings should have them done prior to the surgery. Age greater than 85 is not an absolute contraindication. A urinary tract infection can be treated prior to surgery.

4. A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first? a. Initiate Droplet Precautions for the client. b. Notify the provider about the CD4+ results. c. Place the client under Airborne Precautions. d. Use Standard Precautions to provide care.

ANS: C Since this client's CD4+ cell count is low, he or she may have anergy, or the inability to mount an immune response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next the nurse notifies the provider about the low CD4+ count and requests alterative testing for TB. Droplet Precautions are not used for TB. Standard Precautions are not adequate in this case. DIF: Applying/Application REF: 334 KEY: HIV/AIDS| Transmission-Based Precautions| infection control| immune disorders MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

A nurse is discharging a client after a total hip replacement. What statement by the client indicates good potential for self-management? a. "I can bend down to pick something up." b. "I no longer need to do my exercises." c. "I will not sit with my legs crossed." d. "I won't wash my incision to keep it dry."

ANS: C There are many precautions clients need to take after hip replacement surgery, including not bending more than 90 degrees at the hips, continuing prescribed exercises, not crossing the legs, and washing the incision daily and patting it dry.

After a total knee replacement, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the client's pulses are 2+/4+ bilaterally; the skin is pale pink, warm, and dry; and the client is unable to dorsiflex or plantarflex the affected foot. What action does the nurse perform next? a. Document the findings and monitor as prescribed. b. Increase the frequency of monitoring the client. c. Notify the surgeon or anesthesia provider immediately. d. Palpate the client's bladder or perform a bladder scan.

ANS: C With the femoral nerve block, the client should still be able to dorsiflex and plantarflex the affected foot. Since this client has an abnormal finding, the nurse should notify either the surgeon or the anesthesia provider immediately. Documentation is the last priority. Increasing the frequency of assessment may be a good idea, but first the nurse must notify the appropriate person. Palpating the bladder is not related.

5. The nurse is teaching a client who is undergoing brachytherapy about what to immediately report to her health care provider. Which signs and symptoms would be included in this teaching? (Select all that apply.) a. Constipation for 3 days b. Temperature of 99 F c. Abdominal pain d. Visible blood in the urine e. Heavy vaginal bleeding

ANS: C, D, E Health teaching for a client having brachytherapy should emphasize reporting abdominal pain, visible blood in the urine, and heavy vaginal bleeding. Severe diarrhea (not constipation), urethral burning, extreme fatigue, and a fever over 100 F should also be reported.

The nurse is caring for a client with systemic sclerosis (SSc). What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Collaborate with a registered dietitian for appropriate foods. b. Inspect the skin and note any areas of ulceration. c. Keep the room at a comfortably warm temperature. d. Place a foot cradle at the end of the bed to lift sheets. e. Remind the client to elevate the head of the bed after eating.

ANS: C, D, E The client with SSc should avoid cold temperatures, which may lead to vasospasms and Raynaud's phenomenon. The UAP can adjust the room temperature for the client's comfort. Keeping the sheets off the feet will help prevent injury; the UAP can apply a foot cradle to the bed to hold the sheets up. Because of esophageal problems, the client should remain in an upright position for 1 to 2 hours after meals. The UAP can remind the client of this once he or she has been taught. The other actions are performed by the registered nurse.

9. A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposi's sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important? a. Adhering to Standard Precautions b. Assessing tolerance to dressing changes c. Performing hand hygiene before and after care d. Disposing of soiled dressings properly

ANS: D All of the actions are important, but due to the infectious nature of this illness, ensuring proper disposal of soiled dressings is vital. DIF: Applying/Application REF: 342 KEY: HIV/AIDS| wound care| dressings| infection control MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

11. The client is emotionally upset about the recent diagnosis of stage IV endometrial cancer. Which action by the nurse is best? a. Let the client alone for a long period of reflection time. b. Ask friends and relatives to limit their visits. c. Tell the client that an emotional response is unacceptable. d. Create an atmosphere of acceptance and discussion.

ANS: D Discussion of a clients concerns about the presence of cancer and the potential for recurrence will provide emotional support and allay fears. Coping behaviors are encouraged with the support of friends and relatives. An emotional response should be accepted.

The nurse is caring for a client using a continuous passive motion (CPM) machine and has delegated some tasks to the unlicensed assistive personnel (UAP). What action by the UAP warrants intervention by the nurse? a. Checking to see if the machine is working b. Keeping controls in a secure place on the bed c. Placing padding in the machine per request d. Storing the CPM machine under the bed after removal

ANS: D For infection control (and to avoid tripping on it), the CPM machine is never placed on the floor. The other actions are appropriate.

An older client has returned to the surgical unit after a total hip replacement. The client is confused and restless. What intervention by the nurse is most important to prevent injury? a. Administer mild sedation. b. Keep all four siderails up. c. Restrain the client's hands. d. Use an abduction pillow.

ANS: D Older clients often have trouble metabolizing anesthetics and pain medication, leading to confusion or restlessness postoperatively. To prevent the hip from dislocating, the nurse should use an abduction pillow since the client cannot follow directions at this time. Sedation may worsen the client's mental status and should be avoided. Using all four siderails may be considered a restraint. Hand restraints are not necessary in this situation.

13. A client has just returned from a total abdominal hysterectomy and needs postoperative nursing care. What action can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess heart, lung, and bowel sounds. b. Check the hemoglobin and hematocrit levels. c. Evaluate the dressing for drainage. d. Empty the urine from the urinary catheter bag.

ANS: D The UAP is able to empty the urinary output from the catheter. The nurse would assess the heart, lung, and bowel sounds; check the hemoglobin and hematocrit levels; and evaluate the drainage on the dressing.

5. The nurse is caring for a postoperative client following an anterior colporrhaphy. What action can be delegated to the unlicensed assistive personnel (UAP)? a. Reviewing the hematocrit and hemoglobin results b. Teaching the client to avoid lifting her 4-year-old grandson c. Assessing the level of pain and any drainage d. Drawing a shallow hot bath for comfort measures

ANS: D The UAP is able to provide comfort through a bath. The registered nurse should review any laboratory results, complete any teaching, and assess pain and discharge.

7. A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? a. Administer sleeping medication. b. Perform most activities for the client. c. Increase the client's oxygen during activity . d. Pace activities, allowing for adequate rest.

ANS: D This client has two major reasons for fatigue: decreased oxygenation and systemic illness. The nurse should not do everything for the client but rather let the client do as much as possible within limits and allow for adequate rest in between. Sleeping medications may be needed but not as the first step, and only with caution. Increasing oxygen during activities may or may not be warranted, but first the nurse must try pacing the client's activity. DIF: Applying/Application REF: 340 KEY: HIV/AIDS| immune disorders| rest and sleep| fatigue MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

1. Which action would the nurse teach to help the client prevent vulvovaginitis? a. Wipe back to front after urination. b. Cleanse the inner labial mucosa with soap and water. c. Use feminine hygiene sprays to avoid odor. d. Wear loose cotton underwear.

ANS: D To prevent vulvovaginitis, the client should wear cotton underwear. The client should wipe front to back after urination, not back to front. The client should cleanse the inner labial mucosa with water only, and avoid using feminine hygiene sprays.

The nurse in the rheumatology clinic is assessing clients with rheumatoid arthritis (RA). Which client should the nurse see first? a. Client taking celecoxib (Celebrex) and ranitidine (Zantac) b. Client taking etanercept (Enbrel) with a red injection site c. Client with a blood glucose of 190 mg/dL who is taking steroids d. Client with a fever and cough who is taking tofacitinib (Xeljanz)

ANS: D Tofacitinib carries a Food and Drug Administration black box warning about opportunistic infections, tuberculosis, and cancer. Fever and cough may indicate tuberculosis. Ranitidine is often taken with celecoxib, which can cause gastrointestinal distress. Redness and itchy rashes are frequently seen with etanercept injections. Steroids are known to raise blood glucose levels.

11. An HIV-positive client is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate? a. Initiate Contact Precautions. b. Place the client on Airborne Precautions. c. Place the client on Droplet Precautions. d. Use Standard Precautions consistently.

ANS: D Toxoplasma gondii infection is an opportunistic infection that poses no threat to immunocompetent health care workers. Use of Standard Precautions is sufficient to care for this client. DIF: Applying/Application REF: 334 KEY: HIV/AIDS| infection control| Standard Precautions MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

7. A client has undergone a vaginal hysterectomy with a bilateral salpingo-oophorectomy. She is concerned about a loss of libido. What intervention by the nurse would be best? a. Suggest increasing vitamins and supplements daily. b. Discuss the value of a balanced diet and exercise. c. Reinforce that weight gain may be inevitable. d. Teach that estrogen cream inserted vaginally may help.

ANS: D Use of vaginal estrogen cream and gentle dilation can help with vaginal changes and loss of libido. Weight gain and masculinization are misperceptions after a vaginal hysterectomy. Vitamins, supplements, a balanced diet, and exercise are helpful for healthy living, but are not necessarily going to increase libido.

A client has a possible connective tissue disease and the nurse is reviewing the client's laboratory values. Which laboratory values and their related connective tissue diseases (CTDs) are correctly matched? (Select all that apply.) a. Elevated antinuclear antibody (ANA) - Normal value; no connective tissue disease b. Elevated sedimentation rate - Rheumatoid arthritis c. Lowered albumin - Indicative only of nutritional deficit d. Positive human leukocyte antigen B27 (HLA-B27) - Reiter's syndrome or ankylosing spondylitis e. Positive rheumatoid factor - Possible kidney disease

ANS: D, E The HLA-B27 is diagnostic for Reiter's syndrome or ankylosing spondylitis. A positive rheumatoid factor can be seen in autoimmune CTDs, kidney and liver disease, or leukemia. An elevated ANA is indicative of inflammatory CTDs, although a small minority of healthy adults also have this finding. An elevated sedimentation rate indicates inflammation, whether from an infection, an injury, or an autoimmune CTD. Lowered albumin is seen in nutritional deficiencies but also in chronic infection or inflammation.

A client who is undergoing chemotherapy for breast cancer reports problems with concentration and memory. Which nursing intervention is indicated at this time? A.) Explain that this occurs in some clients and is usually permanent. B.) Inform the client that a small glass of wine may help her relax. C.) Protect the client from infection. D.) Allow the client an opportunity to express her feelings.

Allow the client an opportunity to express her feelings. Although no specific intervention for this side effect is known, therapeutic communication and listening may be helpful to the client. Evidence regarding problems with concentration and memory loss with chemotherapy is not complete, but the current thinking is that this process is usually temporary. The client should be advised to avoid the use of alcohol and recreational drugs at this time because they also impair memory. Chemotherapeutic agents are implicated in central nervous system function in this scenario, not infection.

Aside from chemotherapeutic agents, what other medications does the nurse expect to administer to a client with advanced colorectal cancer for relief of symptoms? A. Analgesics and antiemetics B. Analgesics and benzodiazepines C. Steroids and analgesics D. Steroids and anti-inflammatory medications

Analgesics and antiemetics Clients with advanced colorectal cancer and metastasis also receive drugs such as analgesics and antiemetics for relief of symptoms, specifically pain and nausea. Benzodiazepines, steroids, and anti-inflammatory medications are not routinely requested for these clients.

A male client in a long-term care facility is 2 days postoperative after an open repair of an indirect inguinal hernia. Which nursing action does the RN delegate to unlicensed assistive personnel (UAP)? A. Assessing the client's incision for signs of infection B. Assisting the client to stand to void C. Instructing the client in how to deep-breathe D. Monitoring the client's pain level

Assisting the client to stand to void Assisting the client with activities is part of the UAP role. Assessment of the client's incision and pain level requires broader education and scope of practice and should be done by licensed nursing personnel. Client teaching—even about something as fundamental as taking "deep breaths"—likewise requires broader education and scope of practice and should be done by licensed nursing personnel.

A client is struggling with body image after breast cancer surgery. Which behavior indicates to the nurse that the client is maladaptive? A.) Avoiding eye contact with staff B.) Saying, "I feel like less of a woman" C.) Requesting a temporary prosthesis immediately D.) Saying, "This is the ugliest scar ever"

Avoiding eye contact with staff Avoiding eye contact may be an indication of decreased self-image. The client stating that she feels like less of a woman or that her scar is ugly illustrates an expected emotional state; by verbalizing her frustration, the client suggests a willingness to discuss and express feelings. Requesting a prosthesis can be a sign of healing and working through body image changes.

Each chemotherapeutic agent has a specific nadir. What is important to do when giving combination therapy? a. Give two agents with similar nadirs b. Avoid giving agents with similar nadirs at the same time c. Allow for one agent's nadir to recover before giving another agent d. Give two agents from the same drug class

B

The nurse hears in report that the patient has cachexia. Which assessment will the nurse plan to perform? a. Ability to ambulate independently b. Appetite and nutritional intake c. Mental status and cognition d. Sensation and pulses in extremities

B

The nurse is caring for a patient who must receive an IV chemotherapy infusion. What is the most important intervention related to extravasation? a. Identify the specific antidote and make sure it is readily available b. Frequently monitor the access site to prevent leakage of large volumes c. Advocate that an implanted port be established prior to administration d. Check institutional policy to see if warm or cold compresses are prescribed

B

The patient is having nausea and vomiting, so the nurse checks the medication orders for an antiemetic. The orders indicate to give Avandement (rosiglitazone maleate and metformin hydrochloride) as needed for nausea and vomiting. What should the nurse do? a. Give the Avademenet as ordered and observe for symptom relief b. Contact the provider for clarification because Avadement is not an antiemetic c. Check the MAR for the last time of Avadement d. Assess the patient for delayed nausea before giving the Avadement

B

What instructions will the nurse give to the UAP regarding the hygienic care of a patient with neutropenia? a. Do not enter the room unless absolutely necessary and then minimize time spent in the room b. Mouth care and washing of the axillary and perianal regions must be done during the shift c. If the patient seems very tired, assist with toileting, but defer all other aspects of hygienic care d.Assists the patient to perform hygienic care according to the standard routine for all patients

B

Which cancer patient is the most likely candidate for palliative surgery? a. Needs extensive cosmetic repair after treatment of neck cancer b. Has continuous vomiting because tumor is obstructing the GI tract c. Has suspicious skin lesion that requires further investigation d. Has been treated for cancer and is currently asymptomatic

B

Which cancer patient is the most likely candidate for reconstructive surgery? a. Has severe back pain and decreased sensation in the lower extremities b. Has significant scarring of the face and neck after completing treatments c. Requires lymph node removal for possible metastasis of primary tumor d. Has leukemia that is not responding to transfusion therapy

B

Which patient with cancer has the greatest risk for infection? a. Recently diagnosed with breast cancer b. Has leukemia with neutropenia c. Has lung cancer with a persistent cough d. Diagnosed with prostate cancer 3 years ago

B

Which word best describes the purpose of cytoreductive surgery for cancer? a. Prevention b. Control c. Cure d. Restore

B

A student nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the student learn? (Select all that apply.) a. Basophils are only involved in the general inflammatory process. b. Eosinophils increase during allergic reactions and parasitic invasion. c. Macrophages can participate in many episodes of phagocytosis. d. Monocytes turn into macrophages after they enter body tissues. e. Neutrophils can only take part in one episode of phagocytosis.

B, C, D, E Eosinophils do increase during allergic and parasitic invasion. Macrophages participate in many episodes of phagocytosis. Monocytes turn into macrophages after they enter body tissues. Neutrophils only take part in one episode of phagocytosis. Basophils are involved in both the general inflammatory response and allergic or hypersensitivity responses.

The healthcare provider informs the nurse that it is likely that the patient's cancer has invaded the bone marrow. Based on this information, the nurse will be vigilant for which signs and symptoms? (SATA) a. Nausea and vomiting b. Fatigue and weakness c. Decreasing WBC counts d. Confusion with memory loss e. Bruising or other bleeding signs

B, C, E

One hour after admission to the postanesthesia care unit (PACU), the postoperative client has become very restless. What is the nurse's first action? a. Assess for bladder distention. b. Assess the oxygen saturation level. c. Call the surgeon to assess the client. d. Administer pain medication as ordered.

B. assess the oxygen saturation level

The nurse assesses a client who has just been brought to the postanesthesia care unit (PACU). In the operating room, the client's blood pressure was 136/80 mm Hg; it is now 110/80 mm Hg. Urine output was 40 mL/hr and is now 10 mL/hr. Which action by the nurse is best? a. Awaken the client and encourage oral fluids. b. Increase the IV of 0.9 NS as ordered to 100 mL/hr. c. Put the client in Trendelenburg position. d. Assess the client's levels of consciousness and pain.

B. increase the IV of 0.9 NS as ordered to 100 mL/hr

What does the nurse advise a client diagnosed with irritable bowel syndrome (IBS) to take during periods of constipation? A. Bulk-forming laxatives B. Saline laxatives C. Stimulant laxatives D. Stool-softening agents

Bulk-forming laxatives For treatment of constipation-predominant IBS, bulk-forming laxatives are generally taken at mealtimes with a glass of water. Saline and stimulant laxatives are not used for the treatment of constipation-predominant IBS. Stool-softening agents are not effective.

A patient is on a newer protocol, dose-dense chemotherapy. Which factor is most likely to contribute to patient noncompliance if the nurse fails to educate the patient and the family? a. Treatment is expensive and less likely to be covered by insurance b. Length of therapy is prolonged and progress is slow to manifest c. Side effects are likely to be more intense and unpleasant d. Administration is painful and pain does not respond to medications

C

A patient is taking oprelvekin (Neumega). Which assessment data finding indicates that the therapy is working? a. Weight has increased by 2 pounds b. Nausea and vomiting are relieved c. Platelet count is increasing d. Hemoglobin level is normalizing

C

A patient with advanced breast cancer reports severe back pain and leg weakness. Based on these symptoms, what does the nurse suspect? a. Tumor lysis syndrome b. Lower back cancer c. Spinal cord compression d. Bladder tumor

C

A patient with lymphoma reports severe facial swelling, tightness of the gown collar, and epistaxis. Which complication does the nurse suspect? a. Tumor lysis syndrome b. Cancer-induced hypercalcemia c. Superior vena cava syndrome d. Congestive heart failure

C

An older adult is having frequent and severe chemotherapy induced nausea and vomiting (CINV) which seems to be anticipatory and acute. Which assessment is the most important to make? a. Fears and feelings associated with chemotherapy b. Patient's self-management of distressing symptoms c. Signs of dehydration or electrolyte imbalance d. Willingness to try complementary or alternative techniques

C

How does the nurse apply the "inverse square law" in caring for a patient with cancer who is treated with a radiation implant? a. Assists the health care provider to calculate the radiation dose b. Reminds the unlicensed assistive personnel (UAP's) to wear dosimeter film badge for protection c. Stands at a distance from the patient as much as possible d. Monitors condition of the skin after therapy with gamma rays

C

The charge nurse sees an order for IV chemotherapy. According to the Oncology Nursing Society, who should the charge nurse assign to administer the medication? a. Any nurse who studied pharmacology and has IV therapy training b. Advanced practice nurse who specializes in oncology education c. Registered nurse who completed an approved chemotherapy course d. Licensed practical nurse with years of experience in giving medications

C

The nurse hears in report that the patient is distressed by the prospect of developing alopecia. Which question is the nurse most likely to ask to assess the patient's concerns? a. "Would you like additional information about side effects of chemotherapy?" b. "What questions do you have about hair and skin care products?" c. "How would losing your hair affect your life and activities?" d. "How would you feel about talking to someone who experienced hair loss?"

C

A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider? a. Blood urea nitrogen (BUN) of 18 mg/dL b. Cloudy, foul-smelling urine c. Creatinine of 3.9 mg/dL d. Urine output of 340 mL/8 hr

C A creatinine of 3.9 mg/dL is high, indicating possible dysfunction of the kidney. This is a possible sign of rejection. The BUN is normal, as is the urine output. Cloudy, foul-smelling urine would probably indicate a urinary tract infection.

The nurse is preparing a client for discharge. The client has a large draining wound. What is the nurse's best action? a. Arrange a nurse to come to the house to change the dressing after discharge. b. Have the client come back to the clinic daily to have the dressing changed. c. Teach the client and family how to change the dressing. d. Apply a hydrocolloid dressing and change once a week.

C. teach the client and family how to change the dressing

The nurse case manager is discussing community resources with a client who has colorectal cancer and is scheduled for a colostomy. Which referral is of greatest value to this client initially? A. Certified Wound, Ostomy, and Continence Nurse (CWOCN) B. Home health nursing agency C. Hospice D. Hospital chaplain

Certified Wound, Ostomy, and Continence Nurse (CWOCN) A CWOCN (or an enterostomal therapist) will be of greatest value to the client because the client is scheduled to receive a colostomy. The client is newly diagnosed, so it is not yet known whether home health nursing will be needed. A referral to hospice may be helpful for a terminally ill client. Referral to a chaplain may be helpful later in the process of adjusting to the disease.

Which finding alarms the nurse when caring for a client receiving chemotherapy who has a platelet count of 17,000/mm3? A.) Increasing shortness of breath B.) Diminished bilateral breath sounds C.) Change in mental status D.) Weight gain of 4 pounds in 1 day

Change in mental status A change in mental status could result from spontaneous bleeding; in this case, a cerebral hemorrhage may have developed. Increasing shortness of breath is typically related to anemia, not to thrombocytopenia. Diminished breath sounds may be related to many factors, including poor respiratory excursion, infection, and atelectasis, which is not related to thrombocytopenia. A large weight gain in a short period may be related to kidney or heart failure; bleeding is the major complication of thrombocytopenia.

Which client being cared for on the medical-surgical unit will be best to assign to a nurse who has floated from the intensive care unit (ICU)? A.) Recent radical mastectomy client requiring chemotherapy administration B.) Modified radical mastectomy client needing discharge teaching C.) Stage III breast cancer client requesting information about radiation and chemotherapy D.) Client with a Jackson-Pratt drain who just arrived from the postanesthesia care unit after a quadrantectomy

Client with a Jackson-Pratt drain who just arrived from the postanesthesia care unit after a quadrantectomy A nurse working in the ICU would be familiar with postoperative monitoring and care of clients with Jackson-Pratt drains. The recent radical mastectomy client requires chemotherapy, so it is more appropriate to assign her to nurses who are familiar with teaching, monitoring, and providing chemotherapy for clients with breast cancer. The modified radical mastectomy client who requires discharge teaching, and the stage III breast cancer client requiring information about radiation and chemotherapy are more appropriate to assign to nurses who are familiar with breast cancer.

The RN working on an oncology unit has just received report on these clients. Which client should be assessed first? A.) Client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature B.) Client with lymphoma who will need administration of an antiemetic before receiving chemotherapy C.) Client with metastatic breast cancer who is scheduled for external beam radiation in 1 hour D.) Client with xerostomia associated with laryngeal cancer who needs oral care before breakfast

Client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature Neutropenia poses high risk for life-threatening sepsis and septic shock, which develop and progress rapidly in immune-suppressed people; the nurse should see the client with chemotherapy-induced neutropenia first. The client with lymphoma and the client with metastatic breast cancer are not in distress and can be assessed later. The client with dry mouth (xerostomia) can be assessed later, or the nurse can delegate mouth care to unlicensed assistive personnel.

Iggy Ch.56 p. 1157 A 56-year-old woman returns from the postanesthesia care unit (PACU) after an open colon resection and colostomy for ascending colon cancer. She has IV fluids running at 100 mL/hr and is receiving morphine PCA. An NGT is in place connected to low suction, and she is NPO. Her abdominal dressing is dry and intact, and her oxygen saturation is 95% on 2 L/min of oxygen via nasal cannula. She is allowed out of bed to the bathroom or chair today. You are assigned to care for this patient for the rest of the day shift. 4. The patient's husband asks you about his wife's prognosis regarding her cancer survival. What is your best response at this time?

Colon cancer for many patients is highly curable. Survivability depends on many factors, including stage of the cancer at the time of discovery and treatment.

A client has been diagnosed with breast cancer. Which client-chosen treatment option requires the nurse to discuss with the client the necessity of considering additional therapy? A.) Chemotherapy B.) Complementary and alternative medicine (CAM) C.) Hormonal therapy D.) Neoadjuvant therapy

Complementary and alternative medicine (CAM) No proven benefit has been found with using CAM alone as a cure for breast cancer. The nurse must ensure that the client's choices can be safely integrated with conventional treatment for breast cancer. Chemotherapy is usually used for stage II or higher breast cancer and may or may not be used as a single treatment option. The purpose of hormonal therapy is to reduce the estrogen available to breast tumors to stop or prevent their growth; it may or may not be used with other treatment options. A large tumor is sometimes treated with chemotherapy, called neoadjuvant therapy, to shrink the tumor before it is surgically removed; an advantage of this therapy is that cancers can be removed by lumpectomy rather than mastectomy.

A client with a bowel obstruction is ordered a nasogastric (NG) tube. After the nurse inserts the tube, which nursing intervention is the highest priority for this client? A. Attaching the tube to high continuous suction B. Auscultating for bowel sounds and peristalsis while the suction runs C. Connecting the tube to low intermittent suction D. Flushing the tube with 30 mL of normal saline every 24 hours

Connecting the tube to low intermittent suction The NG tube should be attached to intermittent low suction unless otherwise requested by the health care provider. Continuous suction is rarely used because it can injure the gastric mucosa of the client's stomach. Bowel sounds should not be auscultated with suction on and running. The tube should be flushed every 4 hours, minimally.

The nurse works at an institution where pharmacogenomics is incorporated in to the care of cancer patients. How does this newer approach impact nursing care? a. Nurse is likely to see fewer cancers that are linked to a genetic etiology b. Targeted chemotherapy selection will eliminate side effects c. Prophylactic treatment of first degree family members is likely to increase d. Patients' risk for the more dangerous side effects is decreased

D

The patient has thyroid cancer and will be treated with injection of the radionuclide iodine-131 (brachytherapy). Which guideline is the most relevant to correctly instructing the UAP about assisting the patient with hygiene and activities of daily living? a. Oncology Nursing Society practice guidelines b. American Cancer Society treatment guidelines c. Institutional evidence-based policies for infection control d. Institutional policies for handling body fluids and wastes

D

A client had surgical repair of a fractured ankle under local anesthesia and is being transferred from the postanesthesia care unit (PACU) to the surgical floor. Once admitted, what is the nurse's priority action? a. Assess pressure points for breakdown. b. Assess the client's pain. c. Insert an IV for antibiotic therapy. d. Assess a full set of vital signs.

D. assess a full set of vitals

The nurse is assessing clients in the postanesthesia care unit (PACU). A client is shivering and has a temperature of 95.4° F (35.2° C). What is the nurse's best action? a. Get the client warm blankets. b. Elevate the head of the bed. c. Auscultate the client's lungs. d. Assess the client's oxygen saturation.

D. assess the client's oxygen saturation

A client is being transferred to the postanesthesia care unit (PACU) after surgery. The client has an endotracheal tube (ET) in place. On assessment, the client has oxygen saturation of 95%, respiratory rate of 14 breaths/min, and asymmetric chest wall expansion. What is the nurse's best action? a. Attempt to awaken the client. b. "Bag" the client with a resuscitation bag. c. Increase the client's fraction of inspired oxygen (FIO2). d. Auscultate lung sounds bilaterally.

D. auscultate lung sounds bilaterally

A postsurgical client's urinary output via the Foley catheter is 30 mL in 3 hours. What is the nurse's first action? a. Increase the IV infusion rate. b. Assess the client's skin turgor. c. Weigh the client. d. Check the patency of the catheter.

D. check the patency of the catheter

Postoperatively, a client has a heart rate of 120 beats/min, with dysrhythmias noted on the ECG monitor and a respiratory rate of 34 breaths/min, and is very difficult to arouse. Which action by the nurse is most appropriate? a. Accompany the client to the postanesthesia care unit (PACU). b. Keep the client in the surgical suite. c. Call a code or the Rapid Response Team. d. Transfer the client to the intensive care unit (ICU).

D. transfer the client to the intensive care unit (ICU)

The nurse is caring for several clients on the postoperative unit. Which client does the nurse determine has the highest risk of respiratory complications after general anesthesia? a. Older woman taking a calcium channel blocker for hypertension b. Middle-aged man with a deviated nasal septum c. Middle-aged woman taking St. John's wort daily for depression d. Young adult with a body mass index of 40

D. young adult with a body mass index of 40

Which manifestation of an oncologic emergency requires the nurse to contact the health care provider immediately? A.) New onset of fatigue B.) Edema of arms and hands C.) Dry cough D.) Weight gain

Edema of arms and hands Edema of the arms and hands indicates worsening compression of the superior vena cava consistent with superior vena cava syndrome. The compression must be relieved immediately, often with radiation therapy, because death can result without timely intervention. New onset of fatigue may likely be an early manifestation of hypercalcemia, which usually develops slowly, but because it is an early manifestation, this is not the priority. Dry cough is not a manifestation that is specific to an oncologic emergency; however, it may be a side effect of chemotherapy. Weight gain could be an early sign of syndrome of inappropriate antidiuretic hormone; although this should be addressed, it is an early sign so it is not the priority.

A client with a family history of colorectal cancer (CRC) regularly sees a health care provider for early detection of any signs of cancer. Which laboratory result may be an indication of CRC in this client? A. Decrease in liver function test results B. Elevated carcinoembryonic antigen C. Elevated hemoglobin levels D. Negative test for occult blood

Elevated carcinoembryonic antigen Carcinoembryonic antigen may be elevated in many clients diagnosed with CRC. Liver involvement may or may not occur in CRC. Hemoglobin will likely be decreased with CRC, not increased. An occult blood test is not reliable to affirm or rule out CRC.

A client with colorectal cancer had colostomy surgery performed yesterday. The client is very anxious about caring for the colostomy and states that the health care provider's instructions "seem overwhelming." What does the nurse do first for this client? A. Encourages the client to look at and touch the colostomy stoma B. Instructs the client about complete care of the colostomy C. Schedules a visit from a client who has a colostomy and is successfully caring for it D. Suggests that the client involve family members in the care of the colostomy

Encourages the client to look at and touch the colostomy stoma The initial intervention is to get the client comfortable looking at and touching the stoma before providing instructions on its care. Instructing the client about colostomy care will be much more effective after the client's anxiety level has stabilized. Talking with someone who has gone through a similar experience may be helpful to the client only after his or her anxiety level has stabilized. The client has begun to express feelings regarding the colostomy and its care; it is too soon to involve others. The client must get comfortable with this body image change first.

Which potential side effects does the nurse include in the teaching plan for a client undergoing radiation therapy for laryngeal cancer? (Select all that apply.) A.) Fatigue B.) Changes in color of hair C.) Change in taste D.) Changes in skin of the neck E.) Difficulty swallowing

Fatigue Change in taste Changes in skin of the neck Difficulty swallowing Radiation therapy to any site produces fatigue in most clients, and may cause clients to report changes in taste. Radiation side effects are site-specific; the larynx is in the neck, so changes in the skin of the neck may occur. Dysphagia (difficulty swallowing) may occur from radiation to the throat area. Chemotherapy, which causes alopecia, may cause changes in the color or texture of hair; this does not normally occur with radiation therapy.

A client is receiving chemotherapy treatment for breast cancer and asks for additional support for managing the associated nausea and vomiting. Which complementary therapy does the nurse suggest? A.) Ginger B.) Journaling C.) Meditation D.) Yoga

Ginger It has long been believed that ginger helps alleviate nausea and vomiting. Current studies are being done on the effect of ginger on chemotherapy-induced nausea. Journaling is good for reducing anxiety, stress, and fear. Meditation helps reduce stress, improve mood, improve quality of sleep, and reduce fatigue. Yoga has been shown to improve physical functioning, reduce fatigue, improve sleep, and improve one's overall quality of life.

The oncology nurse is caring for a group of clients receiving chemotherapy. The client with which sign/symptom is displaying bone marrow suppression? A.) Hemoglobin of 7.4 and hematocrit of 21.8 B.) Potassium level of 2.9 mEq/L and diarrhea C.) 250,000 platelets/mm3 D.) 5000 white blood cells/mm3

Hemoglobin of 7.4 and hematocrit of 21.8 Bone marrow suppression causes anemia, leukopenia, and thrombocytopenia; the client with a hemoglobin of 7.4 and hematocrit of 21.8 has anemia demonstrated by low hemoglobin and hematocrit. The client with diarrhea and a potassium level of 2.9 mEq/L has hypokalemia and electrolyte imbalance. The client with 250,000 platelets/mm3 and the client with 5000 white blood cells/mm3 demonstrate normal values.

.What is the mechanism of action for the chemotherapeutic drug cetuximab (Erbitux)? A. It destroys the cancer's cell wall, which will kill the cell. B. It decreases blood flow to rapidly dividing cancer cells. C. It stimulates the body's immune system and stunts cancer growth. D. It blocks factors that promote cancer cell growth.

It blocks factors that promote cancer cell growth. Cetuximab, a monoclonal antibody, may be given for advanced disease. This drug works by binding to a protein (epidermal growth factor receptor) to slow cell growth. The medication does not destroy the cancer's cell walls and does not stimulate the body's immune system or stunt cancer growth in that manner. The treatment does not decrease blood flow to rapidly dividing cancer cells.

Iggy Ch.56 p. 1157 A 56-year-old woman returns from the postanesthesia care unit (PACU) after an open colon resection and colostomy for ascending colon cancer. She has IV fluids running at 100 mL/hr and is receiving morphine PCA. An NGT is in place connected to low suction, and she is NPO. Her abdominal dressing is dry and intact, and her oxygen saturation is 95% on 2 L/min of oxygen via nasal cannula. She is allowed out of bed to the bathroom or chair today. You are assigned to care for this patient for the rest of the day shift. 3. While the patient was in the bathroom, her oxygen saturation level decreased to 88%. What is your best action at this time?

It is common for a patient's oxygen saturation to decrease upon initial physical activity after surgery. Maintain patient safety, allowing her time to sit on the toilet. If possible, escort her safely from the bathroom back to bed. Continually assess oxygenation. When it is feasible, take the patient's vital signs. Reassure her that you will remain with her to decrease concerns of anxiety which may affect oxygenation. If oxygen saturation does not improve or vital signs are unstable, contact the patient's surgeon.

A premenopausal client diagnosed with breast cancer will be receiving hormonal therapy. The nurse anticipates that the health care provider will request which medication for this client? A.) Anastrozole (Arimdex) B.) Fulvestrant (Faslodex) C.) Leuprolide (Lupron) D.) Trastuzumab (Herceptin)

Leuprolide (Lupron) Leuprolide is used in premenopausal women whose main estrogen source is the ovaries and who may benefit from luteinizing hormone-releasing hormone agonists that inhibit estrogen synthesis. Anastrozole is an aromatase inhibitor that is used in postmenopausal women whose main source of estrogen is not the ovaries, but rather body fat. Fulvestrant is a second-line hormonal therapy for postmenopausal women with advanced breast cancer. Trastuzumab is not a hormone and is used for targeted therapy for breast cancer.

Which option for prevention and early detection of breast cancer is the option of choice for a client with a high genetic risk? A.) Breast self-examination (BSE) beginning at 20 years of age B.) Hormone replacement therapy (HRT) combining estrogen and progesterone C.) Magnetic resonance imaging (MRI) and mammography every year beginning at age 30 D.) Prophylactic mastectomy

Magnetic resonance imaging (MRI) and mammography every year beginning at age 30 The American Cancer Society recommends that high-risk women (>20% lifetime risk) have an MRI and mammogram every year beginning at age 30. BSE is an option for everyone, not just those at high genetic risk for breast cancer. Use of HRT containing both estrogen and progestin increases risk; risk diminishes after 5 years of discontinuation. With a prophylactic mastectomy, there is a small risk that breast cancer will develop in residual breast glandular tissue because no mastectomy reliably removes all mammary tissue.

The nurse is caring for a client receiving chemotherapy who reports anorexia. Which measure does the nurse use to best monitor for cachexia? A.) Monitor weight B.) Trend red blood cells and hemoglobin and hematocrit C.) Monitor platelets D.) Observe for motor deficits

Monitor weight Cachexia results in extreme body wasting and malnutrition; severe weight loss is expected. Anemia and bleeding tendencies result from bone marrow suppression secondary to invasion of bone marrow by a cancer or a side effect of chemotherapy. Motor deficits result from spinal cord compression.

A client diagnosed with irritable bowel syndrome (IBS) is discharged home with a variety of medications for IBS symptoms. Upon returning to the clinic, the client states, "Most of my symptoms have improved, except for the diarrhea." What does the nurse anticipate will be prescribed for this client? A. Antidiarrheal agent B. Muscarinic receptor antagonist C. Serotonin antagonist D. Tricyclic antidepressant

Muscarinic receptor antagonist A muscarinic (M3) receptor antagonist can also inhibit intestinal motility. Antidiarrheal agents and serotonin antagonists are not the most effective choices for this client. A tricyclic antidepressant is not going to be effective for this client's diarrhea.

Which assessment finding indicates to the nurse that a client is at high risk for a malignant breast lesion? A.) A 1-cm freely mobile rubbery mass discovered by the client B.) Ill-defined painful rubbery lump in the outer breast quadrant C.) Backache and breast fungal infection D.) Nipple discharge and dimpling

Nipple discharge and dimpling Nipple discharge and dimpling are high-risk assessment findings for a malignant breast lesion. On clinical examination, fibroadenomas are oval, freely mobile, rubbery masses usually discovered by the woman herself; their size varies from smaller than 1 cm in diameter to as large as 15 cm in diameter. Although the immediate fear is breast cancer, the risk of its occurring within a fibroadenoma is very small. Breast pain and tender lumps or areas of thickening in the breasts are typical symptoms of a fibrocystic breast condition; the lumps are rubbery, ill-defined, and commonly found in the upper outer quadrant of the breast. Many large-breasted women develop fungal infection under the breasts, especially in hot weather, because it is difficult to keep this area dry and exposed to air. Backaches from the added weight are also common.

A client with an intestinal obstruction has pain that changes from a "colicky" intermittent type to constant discomfort. What does the nurse do first? A. Administers medication for pain B. Changes the nasogastric suction level from "intermittent" to "constant" C. Positions the client in high-Fowler's position D. Prepares the client for emergency surgery

Prepares the client for emergency surgery The change in pain type could be indicative of perforation or peritonitis and will require immediate surgical intervention. Pain medication may mask the client's symptoms but will not address the root cause. A change in the nasogastric suction rate will not resolve the cause of the client's pain and could be particularly ineffective if a nonvented tube is in use. A high-Fowler's position will have no effect on an intestinal perforation or peritonitis, which this client is likely experiencing.

When caring for the client with chemotherapy-induced mucositis, which intervention will be most helpful? A.) Administering a biological response modifier B.) Encouraging oral care with commercial mouthwash C.) Providing oral care with a disposable mouth swab D.) Maintaining NPO until the lesions have resolved

Providing oral care with a disposable mouth swab The client with mucositis would benefit most from oral care; mouth swabs are soft and disposable and therefore clean and appropriate to provide oral care. Biological response modifiers are used to stimulate bone marrow production of immune system cells; mucositis or sores in the mouth will not respond to these medications. Commercial mouthwashes should be avoided because they may contain alcohol or other drying agents that may further irritate the mucosa. Keeping the client NPO is not necessary because nutrition is important during cancer treatment; a local anesthetic may be prescribed for comfort.

After an abdominoperineal resection, a 75-year-old client is referred to a home health agency. Which staff member does the nurse manager assign to perform the initial assessment on this client? A. LPN/LVN who has worked with many home health clients after colostomy surgeries B. LPN/LVN with 20 years of experience in the home health agency C. RN who is new to the agency with 5 years experience in the emergency department D. Social worker who is experienced with case management of older clients

RN who is new to the agency with 5 years experience in the emergency department Clients with medical or surgical diagnoses have complex physiologic needs that should be assessed by an RN. For this reason, Medicare requires that the initial assessment must be done by an RN, although LPN/LVNs and social workers are likely to be part of the health care team.

A client who recently had a mastectomy requests a volunteer to visit her home to help with recovery. Which community resource does the nurse recommend? A.) National Breast Cancer Coalition B.) Reach to Recovery C.) Susan G. Komen for the Cure D.) Young Survival Coalition

Reach to Recovery The American Cancer Society's program Reach to Recovery provides volunteers who visit clients in the hospital or at home. They bring personal messages of hope; informational materials on breast cancer recovery; and a soft, temporary breast form. The National Breast Cancer Coalition is an organization dedicated to ending breast cancer through action and advocacy. Susan G. Komen for the Cure is an organization that supports breast cancer research. The Young Survival Coalition is an organization dedicated to educating the medical, research, breast cancer, and legislative communities about breast cancer, as well as serving as a point of contact for young women living with breast cancer. None of these other community resources provide volunteers to visit the home.

A client who has just been discharged from the hospital after a modified radical mastectomy is referred to a home health agency. Which nursing action is most appropriate to delegate to an experienced home health aide? A.) Assessing the safety of the home environment B.) Developing a plan to decrease lymphedema risk C.) Monitoring pain level and analgesic effectiveness D.) Reinforcing the guidelines for hand and arm care

Reinforcing the guidelines for hand and arm care Reinforcement of previously taught information about hand and arm care should be done by all caregivers. Assessment, developing a care plan, and monitoring pain level and analgesic effectiveness are not within the scope of practice of a home health aide and should be done by licensed nursing staff.

The nurse is caring for a client with end-stage ovarian cancer who needs clarification on the purpose of palliative surgery. Which outcome should the nurse teach the client is the goal of palliative surgery? A.) Cure of the cancer B.) Relief of symptoms or improved quality of life C.) Allowing other therapies to be more effective D.) Prolonging the client's survival time

Relief of symptoms or improved quality of life The focus of palliative surgery is to improve quality of life during the survival time. Curative surgery removes all cancer cells, visible and microscopic. Debulking is a procedure that removes some cancerous tissue, allowing other therapies to be more effective. Many therapies, such as surgery, chemotherapy, and biotherapy, increase the client's chance of cure and survival, but palliation improves quality of life.

After an automobile crash, a client is admitted to the emergency department with possible abdominal trauma. Which health care provider request does the nurse implement first? A. Insert a nasogastric tube and connect it to intermittent suction. B. Obtain a complete blood count and coagulation panel. C. Start an IV line and infuse normal saline at 200 mL/hr. D. Arrange for a computed tomography (CT) scan of the abdomen.

Start an IV line and infuse normal saline at 200 mL/hr. After the initial airway, breathing, and circulation assessment is completed, the most immediate concerns are the high risks for hemorrhage and shock. To rapidly treat for these possible complications, IV access and infusion of fluids are necessary as the priority intervention. Inserting a nasogastric tube, laboratory studies, and arranging a CT scan are secondary to establishing IV access and instilling fluids.

A client asks the nurse, "Can you tell me some foods to include in my diet so that I can reduce my chances of getting colorectal cancer?" Which dietary selection does the nurse suggest? A. Steak with pasta B. Spaghetti with tomato sauce C. Steamed broccoli with turkey D. Tuna salad with wheat crackers

Steamed broccoli with turkey Steamed broccoli with turkey contains low-fat meat and no refined carbohydrates. Animal fat from red meats is carcinogenic, and pasta is high in refined carbohydrates, which are known to contribute to colon cancer. Spaghetti and wheat crackers also contain large amounts of refined carbohydrates.

A client who has undergone breast surgery is struggling with issues concerning her sexuality. What is the best way for the nurse to address the client's concerns? A.) Allow the client to bring up the topic first. B.) Remind the client to avoid sexual intercourse for 2 months after the surgery. C.) Suggest that the client wear a bra or camisole during intercourse. D.) Teach the client that birth control is a priority.

Suggest that the client wear a bra or camisole during intercourse. Clients may prefer to lay a pillow over the surgical site or wear a bra or camisole to prevent contact with the surgical site during intercourse. The client may be embarrassed to discuss the topic of sexuality, so the nurse must be sensitive to possible concerns and approach the subject first. Sexual intercourse can be resumed after surgery whenever the client is comfortable. Sexually active clients receiving chemotherapy or radiotherapy must use birth control because of the therapy's teratogenic effects, but this is not necessary for clients who have had surgery only.

A 21-year-old with a stab wound to the abdomen has come to the emergency department. Once stabilized, the client is admitted to the medical-surgical unit. What does the admitting nurse do first for this client? A. Administer pain medication. B. Assess skin temperature and color. C. Check on the amount of urine output. D. Take vital signs.

Take vital signs. Assessment of vital signs should be done first to determine the adequacy of the airway and circulation. Vital signs initially reveal the most about the client's condition. The client should not be medicated for pain until his or her alertness level is determined. Skin temperature and color are not specifically indicative of the client's overall condition. If the client is in shock, urine output will be scant and will not be an accurate assessment variable.

Which statement about the early detection of breast masses is correct? A.) Clinical breast examinations should be done yearly starting at age 20. B.) Detection of breast cancer before or after axillary node invasion yields the same survival rate. C.) Mammography as a baseline screening is recommended by the American Cancer Society at 30 years of age. D.) The goal of screening for breast cancer is early detection.

The goal of screening for breast cancer is early detection. The purpose of screening is early detection of cancer before it spreads. It is recommended that the clinical breast examination be part of a periodic health assessment at least every 3 years for women in their 20s and 30s, and every year for asymptomatic women who are at least 40 years of age. Detection of breast cancer before axillary node invasion increases the chance of survival. The American Cancer Society recommends screening with mammography annually beginning at age 40.

The nurse corrects the nursing student when caring for a client with neutropenia secondary to chemotherapy in which circumstance? A.) The student scrubs the hub of IV tubing before administering an antibiotic. B.) The nurse overhears the student explaining to the client the importance of handwashing. C.) The student teaches the client that symptoms of neutropenia include fatigue and weakness. D.) The nurse observes the student providing oral hygiene and perineal care.

The student teaches the client that symptoms of neutropenia include fatigue and weakness. Symptoms of neutropenia include low neutrophil count, fever, and signs and symptoms of infection; the student should be corrected. Asepsis with IV lines is an appropriate action. Handwashing is an essential component of client care, especially when the client is at risk for neutropenia. Hygiene and perineal care help prevent infection and sepsis.

A client is being evaluated in the emergency department for a possible small bowel obstruction. Which signs and/or symptoms does the nurse expect to assess? A. Cramping intermittently, metabolic acidosis, and minimal vomiting B. Intermittent lower abdominal cramping, obstipation, and metabolic alkalosis C. Metabolic acidosis, upper abdominal distention, and intermittent cramping D. Upper abdominal distention, metabolic alkalosis, and great amount of vomiting

Upper abdominal distention, metabolic alkalosis, and great amount of vomiting A small bowel obstruction is characterized by upper or epigastric abdominal distention, metabolic alkalosis, and a great amount of vomiting. Intermittent lower abdominal cramping, metabolic acidosis, and minimal vomiting are all symptoms of a large bowel obstruction.

Iggy Ch.56 p. 1157 A 56-year-old woman returns from the postanesthesia care unit (PACU) after an open colon resection and colostomy for ascending colon cancer. She has IV fluids running at 100 mL/hr and is receiving morphine PCA. An NGT is in place connected to low suction, and she is NPO. Her abdominal dressing is dry and intact, and her oxygen saturation is 95% on 2 L/min of oxygen via nasal cannula. She is allowed out of bed to the bathroom or chair today. You are assigned to care for this patient for the rest of the day shift. 2. At 5 PM, the patient states that she needs to go to the bathroom. Will you delegate this activity to the nursing technician? Why or why not?

You should accompany the patient to the bathroom during this initial ambulation. This provides you, as the nurse, with assessment information about the patient's ability to transfer, her steadiness and gait, and her response to initial ambulation. This information will help you determine whether you should delegate future transfers or ambulation needs (e.g., going to the bathroom) to the nursing technician.

Iggy Ch.56 p. 1157 A 56-year-old woman returns from the postanesthesia care unit (PACU) after an open colon resection and colostomy for ascending colon cancer. She has IV fluids running at 100 mL/hr and is receiving morphine PCA. An NGT is in place connected to low suction, and she is NPO. Her abdominal dressing is dry and intact, and her oxygen saturation is 95% on 2 L/min of oxygen via nasal cannula. She is allowed out of bed to the bathroom or chair today. You are assigned to care for this patient for the rest of the day shift. 1. Upon the patient's admission to your unit at 1100 (11 AM), should you delegate taking the patient's vital signs to an experienced nursing technician? Why or why not?

You should initially, and in the early hours after surgery, assess vital signs to establish a baseline and to monitor initial recovery. After you have deemed that the patient is stable and progressing normally, delegation of vital signs can be assigned to an experienced nursing technician, with the understanding that you must follow all Nurse Practice Acts related to appropriate delegation. You must communicate the task that is to be performed (vital signs checks), the frequency of the task (e.g., every 15 minutes, hourly, and so on), and the method by which the task should be accomplished (manual vs. automated monitoring for blood pressure, and so on). You should also clarify that you need the experienced nursing technician to report his or her findings back to you in a specific time frame (e.g., every 15 minutes, hourly, and so on). It is important that you follow up with the experienced nursing technician regularly to obtain a report of the vital signs that were taken, so that you can make appropriate nursing decisions based on that data.

14. A patient sustained a superficial-thickness burn over a large area of the body. The patient is crying with discomfort and is very concerned about the long-term effects. What does the nurse tell the patient to expect? a. "Healing should occur in 3 to 6 days with no scarring or complications." b. "The pain should be less because more of the nerve endings were destroyed." c. "The wound will appear red an dry with some white areas." d. "The leathery eschar will have to be removed before healing can occur."

a

33. The nurse is caring for a burn patient who was stabilized by and transferred from a small rural hospital. The patient develops a new complaint of shortness of breath. On auscultation, the nurse hears crackles throughout the lung fields. What does the nurse suspect is causing this patient's symptoms? a. Pulmonary fluid overload due to fluid resuscitation b. Exposure to carbon monoxide that was undiagnosed c. Fat emboli secondary to extensive injury d. Excessive oxygen therapy at the first facility

a

36. The nursing student notes on the care plan that the burn patient she is caring for is at risk for organ ischemia. Based on the student's knowledge of the pathophysiology of burns, which etiology does the nursing student select? a. Related to hypovolemia and hypotension b. Related to fluid overload and peripheral edema c. Related to prolonged resuscitation and hypoxia d. Related to direct blunt trauma to the kidneys

a

38. A patient who lives in a rural community sustained severe burns during a house fire at 10 AM. The rural emergency medical services (EMS) started a peripheral IV at 11:00 AM at a keep-vein-open (KVO) rate. The patient was admitted to the hospital at 1:00 PM. In calculating the fluid replacement, at what time is the fluid for the first 8-hour period completed? a. 6:00 PM b. 7:00 PM c. 8:00 PM d. 9:00 PM

a

44. The priority expected outcome during the resuscitation phase of a burn injury is to maintain which factor? a. The airway b. Cardiac output c. Fluid replacement d. Patient comfort

a

5. The nurse is reviewing the hemoglobin and hematocrit results for a patient recently admitted for a severe burn. Which result is most likely related to vascular dehydration? a. Hematocrit of 58% b. Hemoglobin of 14 g/dL c. Hematocrit 42% d. Hemoglobin of 10 g/dL

a

52. The nurse is applying a dressing to cover a burn on a patient's left leg. What technique does the nurse use? a. Consider the depth of the injury and amount of drainage, and work distal to proximal. b. Change the dressing every 4 hours or when the drainage leaks through the dressing. c. Consider the patient's mobility and the area of injury, and work proximal to distal. d. Use multiple gauze layers and roller gauze to pad and protect the joint areas.

a

55. The nurse is educating a patient who has sustained burns to the dominant hand. What kind of active range-of-motion exercises does the nurse instruct the patient to perform? a. Exercise the hand, thumb, and fingers every hour while awake. b. Exercise the fingers and thumb at least three times a day. c. Use the hands to perform activities of daily living. d. Squeeze a soft rubber ball several times a day.

a

66. Local tissue resistance to electricity varies in different parts of the body. Which tissue has the most resistance? a. Skin epidermis b. Tendons and muscle c. Fatty tissue d. Nerve tissue and blood vessels

a

67. A patient was rescued from a burning house and treated with oxygen. Initially, the patient has audible wheezing and wheezing on auscultation, but after approximately 30 minutes the wheezing stopped. The patient now demonstrates substernal retractions and anxiety. What action does the nurse take at this time? a. Recognize an impending airway obstruction and prepare for immediate intubation. b. Continue to monitor the patient's respiratory status and initiate pulse oximetry. c. Document this finding as evidence of improvement and continue to observe. d. Stay with and encourage the patient to remain calm and breathe deeply.

a

69. A patient has sustained a burn to the right ankle. The provider has applied the initial dressing to the ankle, and the nurse assists the patient into bed and positions the ankle to prevent contracture. What is the correct position the nurse uses? a. Dorsiflexion b. Adduction c. External rotation d. Hyperextension

a

70. A patient has sustained a severe burn greater than 30% TBSA. What is the best way to assess renal function in this patient? a. Measure urine output and compare this value with fluid intake. b. Weigh the patient every day and compare that to the dray weight. c. Note the amount of edema and measure abdominal girth. d. Assist the patient with a urinal or bedpan every 2 hours.

a

72. The provider has ordered an escharotomy for a patient because of constriction around the patient's chest. The nurse is teaching the patient and family about the procedure. Which statement by the family indicates a need for additional teaching? a. "He doesn't do well under general anesthesia." b. "He'll be awake for the procedure." c. "He will receive medication for sedation and pain." d. "We could stay with him at the bedside during the procedure."

a

73. The nurse is caring for a firefighter who was brought in for burns around the face and upper chest. Airway maintenance for this patient with respiratory involvement includes what action? a. Monitoring for signs and symptoms of upper airway edema during fluid resuscitation b. Inserting a nasopharyngeal or oropharyngeal airway when the patient's airway is completely obstructed c. Obtaining an order for as-needed (prn) oxygen per nasal cannula d. Frequently suctioning the mouth with Yankauer suction

a

83. A patient has been depressed and withdrawn since her injury and has expressed that "life will never be the same." Which nursing intervention best promotes a positive image for this burn patient? a. Discussing the possibility of reconstructive surgery with the patient b. Allowing the patient to choose a colorful scarf to cover the burned area c. Playing cards or board games with the patient d. Encouraging the patient to consider how fortunate she is to be alive

a

84. A 28-year-old male patient sustained second-and third-degree burns on his legs (30%) when his clothing caught fire while he was burning leaves. He was hosed down by his neighbor and has arrived at the ED in severe discomfort. What is the priority problem for this patient at this time? a. Acute pain related to damaged or exposed nerve endings b. Decreased fluid volume related to electrolyte imbalance c. Potential for inadequate oxygenation d. Diminished self-image related to the appearance of legs

a

A patient was burned on the forearm after tripping and falling against a wood-burning stove. There are currently severe small blisters over the burn area. What does the nurse advise the patient to do about the blisters? a. Leave the blisters intact because they protect the wound from infection. b. Use a sterile needle to open a tiny hole in each blister to drain the fluid. c. Allow blisters to increase in size; then open them to prevent immunosuppression. d. Leave the blisters intact unless the pain and pressure increase.

a

Iggy Study Guide Ch.56 24. The nurse is teaching a patient about how to control gas and odor from a colostomy. Which information does the nurse include? a. Do not chew gum. b. Place an aspirin in the colostomy. c. Do not consume buttermilk. d. Do not eat parsley.

a

A client has undergone transurethral resection of the prostate (TURP). Which interventions does the nurse incorporate in this client's postoperative care? (Select all that apply.) a) Administer antispasmodic medications. b) Encourage the client to urinate around the catheter if pressure is felt. c) Perform intermittent urinary catheterization every 4 to 6 hours. d) Place the client in a supine position with his knees flexed. e) Assist the client to mobilize as soon as permitted. (Chp 72, elsevier resources)

a) Administer antispasmodic medications. e) Assist the client to mobilize as soon as permitted. Antispasmodic drugs can be administered to decrease the bladder spasms that may occur due to catheter use. Assisting the client to a chair as soon as permitted postoperatively will help to decrease the risk of complications from immobility. An indwelling catheter and continuous bladder irrigation are in place for about 24 hours after TURP. The client should not try to void around the catheter, which causes the bladder muscles to contract and may result in painful spasms. Intermittent urinary catheterization is not necessary. Typically, the catheter is taped to the client's thigh, so he should keep his leg straight. (Chp 72, elsevier resources)

The RN working in the hospital emergency department is assigned to care for these four clients. Which client does the nurse attend to first? a) Adolescent with an erection for "10 or 11 hours" who is reporting severe pain b) Young adult with a swollen, painful scrotum who has a recent history of mumps infection c) Middle-aged adult discharged 2 days ago after a transurethral resection of the prostate who has increased hematuria d) Older adult with a history of benign prostatic hyperplasia and palpable bladder distention (Chp 72, elsevier resources)

a) Adolescent with an erection for "10 or 11 hours" who is reporting severe pain The client who has had an erection for "10 or 11 hours" has symptoms of priapism, which is considered a urologic emergency because the circulation to the penis may be compromised and the client may not be able to void with an erect penis. The client with a swollen, painful scrotum; the client with hematuria; and the client with a history of benign prostatic hyperplasia do not require the nurse's immediate attention since these are not medical emergencies. (Chp 72, elsevier resources)

A client with prostate cancer asks the nurse for more information and counseling. Which resources does the nurse suggest? (Select all that apply.) a) American Cancer Society's Man to Man program b) Us TOO International c) American Prostate Cancer Society d) National Prostate Cancer Coalition e) Client's church, synagogue, or place of worship (Chp 72, elsevier resources)

a) American Cancer Society's Man to Man program b) Us TOO International d) National Prostate Cancer Coalition e) Client's church, synagogue, or place of worship The American Cancer Society's Man to Man program helps the client and partner cope with prostate cancer by providing one-on-one education, personal visits, education presentations, and the opportunity to engage in open and candid discussions. Us TOO International is a prostate cancer support group that is sponsored by the Prostate Cancer Education and Support Network. The National Prostate Cancer Coalition provides prostate cancer information. The client's church, synagogue, or place of worship is a community support service that may be important for many clients. There is no such organization as the American Prostate Cancer Society. (Chp 72, elsevier resources)

After returning from transurethral resection of the prostate, the client's urine in the continuous bladder irrigation system is a burgundy color. Which client needs does the nurse anticipate after the surgeon sees the client? (Select all that apply.) a) Antispasmodic drugs b) Emergency surgery c) Forced fluids d) Increased intermittent irrigation e) Monitoring for anemia (Chp 72, elsevier resources)

a) Antispasmodic drugs e) Monitoring for anemia Although not a common occurrence, bleeding may occur in the postoperative period. Venous bleeding is more common than arterial bleeding. The surgeon may apply traction on the catheter for a few hours to control the venous bleeding. Traction on the catheter is uncomfortable and increases the risk for bladder spasms, so analgesics or antispasmodics are usually prescribed. Hemoglobin and hematocrit should be monitored and trended for indications of anemia. Emergency surgery and increased intermittent irrigation would be indicated for an arterial bleed, which would be a brighter red color. Forced fluids are indicated after the catheter is removed. (Chp 72, elsevier resources)

A client with benign prostatic hyperplasia is being discharged with alpha-adrenergic blockers. Which information is important for the nurse to include when teaching the client about this type of pharmacologic management? (Select all that apply.) a) Avoid drugs used to treat erection problems. b) Be careful when changing positions. c) Keep all appointments for follow-up laboratory testing. d) Hearing tests will need to be conducted periodically. e) Take the medication in the afternoon. (Chp 72, elsevier resources)

a) Avoid drugs used to treat erection problems. b) Be careful when changing positions. c) Keep all appointments for follow-up laboratory testing. Drugs used to treat erectile dysfunction can worsen side effects, such as hypotension. Alpha-adrenergic blockers may cause orthostatic hypotension and can cause liver damage, so it is important to keep appointments for follow-up laboratory testing. These drugs do not affect hearing. Alpha-adrenergic blockers should be taken in the evening to decrease the risk of problems related to hypotension. (Chp 72, elsevier resources)

When is the best time for the nurse to begin discharge planning and a community-based plan of care for a client with prostate cancer? a) Before surgery b) After surgery c) 2 days before being discharged d) The day of discharge (Chp 72, elsevier resources)

a) Before surgery Planning should begin as early as possible, on admission and before surgery. After surgery is not the correct time to begin planning. Planning should begin earlier than 2 days before discharge. (Chp 72, elsevier resources)

A young adult with testicular cancer is admitted for unilateral orchiectomy and retroperitoneal lymph node dissection. Which nursing action is best for the nurse to delegate to unlicensed assistive personnel (UAP)? a) Encourage the client to cough and deep-breathe after surgery. b) Discuss reproductive options with the client and significant other. c) Teach about the availability of a gel-filled silicone testicular prosthesis. d) Evaluate the client's understanding of chemotherapy and radiation treatment. (Chp 72, elsevier resources)

a) Encourage the client to cough and deep-breathe after surgery. Although teaching about routine postoperative client actions such as coughing and deep-breathing should be done by licensed nurses, reminding clients to perform these activities can be delegated to UAP. Client education and evaluation are more complex skills that should be done by licensed nurses. (Chp 72, elsevier resources)

The nurse is caring for a client with erectile dysfunction who has not had success with other treatment modalities. The nurse anticipates that the health care provider will recommend which treatment for this client? a) Penile implants b) Penile injections c) Transurethral suppository d) Vacuum constriction device (Chp 72, elsevier resources)

a) Penile implants Penile implants (prostheses), which require surgery, are used when other modalities fail. Devices include semi-rigid, flexible, or hydraulic inflatable and multi-component or one-piece instruments. Penile injections are tried before using the option of last resort. Transurethral suppository is tried before using the option of last resort. A vacuum constriction device is easy to use, and is often the first option that is tried. (Chp 72, elsevier resources)

19. The nurse is assessing a patient with a burn wound to the back and chest area. Which assessment findings are consistent with a superficial-thickness burn wound? (Select all that apply.) a. Redness b. Pain c. Mild edema d. Moisture e. Eschar

a, b, c

30. The nurse is caring for several patients on the burn unit. Which patients have the greatest risk for developing respiratory problems? (Select all that apply.) a. Patient who was in a storage room where chemicals caught fire b. Patient who was working in an area where steam escaped from a pipe c. Patient who sustained a circumferential burn to the chest area d. Patient who was burned when a firecracker exploded prematurely e. Patient who was found unconscious in a slow-burning house fire

a, b, c, e

54. The nurse is monitoring the nutritional status of a burn patient. Which indicators will the nurse use? (Select all that apply.) a. Amount of food the patient eats b. Weight to height ratio c. Serum albumin d. Amount of water the patient drinks e. Blood glucose f. Serum potassium

a, b, c, e

59. What does the process of full-thickness wound healing include? (Select all that apply.) a. Healing occurs by wound contraction. b. Eschar must be removed. c. Large blisters are protective and left undisturbed. d. Skin grafting may be necessary. e. Fasciotomy may be needed to relieve pressure and allow normal blood flow.

a, b, d, e

63. A patient with burn injuries is being discharged from the hospital. What important points does the nurse include in the discharge teaching? (Select all that apply.) a. Signs and symptoms of infection b. Drug regimens and potential medication side effects c. Definition of full-thickness burns d. Correct application and care of pressure garments e. Comfort measures to reduce scarring f. Dates for follow-up appointments

a, b, d, f

12. A patient comes to the clinic to be treated for burns from a barbeque fire. Although the patient does not appear to be in any respiratory distress, the nurse suspects an inhalation injury after observing which findings? (Select all that apply.) a. Burns to the face b. Bright cherry-red color to lips c. Singed nose hairs d. Edema of the nasal septum e. Black carbon particles around the mouth f. Sweet, sugary smell to the breath

a, c, d, e

47. A burn patient in the fluid resuscitation phase is experiencing dyspnea. What are the priority interventions for this patient? (Select all that apply.) a. Elevate the head of bed to 45 degrees. b. Maintain patient in the supine position. c. Notify the Rapid Response Team d. Administer an analgesic to calm the patient. e. Apply humidified oxygen.

a, c, e

51. The student nurse is preparing to assist with hydrotherapy for a burn patient. The supervising nurse instructs the student to obtain the necessary equipment before beginning the procedure. What equipment does the student nurse obtain? (Select all that apply.) a. Scissors and forceps b. Hydrogen peroxide c. Mild soap or detergent d. Pressure dressings e. Washcloths and gauze sponges f. Chlorhexidine sponges

a, c, e

Iggy Study Guide Ch.56 18. Which findings does the nurse expect of a postoperative colostomy patient? (Select all that apply.) a. Reddish-pink, moist stoma b. Small amount of bleeding c. Large amount of stoma swelling d. Mucocutaneous separartion e. Smooth, intact peristomal skin

a,b,e

Iggy Study Guide Ch.56 50. What are the major focus areas for interventions aimed at treating malabsorption syndromes? (Select all that apply.) a. Avoiding substances that aggravate malabsorption b. Use of complementary and alternative therapies c. Supplementation of nutrients d. Assessment and supplementation of coping strategies e. Curative radiation therapy

a,c

Iggy Study Guide Ch.56 13. The nurse is providing teaching about ways to reduce the risk for colorectal cancer (CRC). which dietary suggestions will the nurse be sure to include? (Select all that apply.) a. Low fat b. Low protein c. HIgh fiber d. HIgh in red meat e. Low in refined carbohydrates

a,c,e

Iggy Study Guide Ch.56 48. Which laboratory results are expected with malabsorption syndrome resulting in hypochromic microcytic anemia? (Select all that apply.) a. Low mean corpuscular hemoglobin (MCH) b. High serum vitamin A level c. Elevated fecal fat content d. Increased mean corpuscular volume (MVC) e. Decreased serum cholesterol level f. Low mean corpuscular hemoglobin concentration (MCHC)

a,f

A patient reports the sensation of feeling as if "something is falling out" along with painful intercourse, backache, and a feeling of heaviness or pressure in the pelvis. Which question does the nurse ask to assess for a cystole? a. "Are you having a urinary frequency or urgency?" b. "Do you feel constipated?" c. "Have you had problems with hemorrhoids?" d. "Have you had any heavy vaginal bleeding?"

a. "Are you having a urinary frequency or urgency?"

The patient reports itching, change in vaginal discharge, and an order. The nurse suspects that the patient has vulvovaginitis. Based on knowledge about the common causes of vulvovaginitis, which question would the nurse ask? a. "Have you recently been taking antibiotics?" b. "Have you been swimming in a lake or pond?" c. "Do you consistently wipe from front to back?" d. "Do you use tampons or menstrual pads?"

a. "Have you recently been taking antibiotics?"

A 34-year-old client comes to the clinic with concerns about an enlarged left testicle and heaviness in his lower abdomen. Which diagnostic test would the nurse expect to be ordered to confirm testicular cancer? a. Alpha-fetoprotein (AFP) b. Prostate-specific antigen (PSA) c. Prostate acid phosphatase (PAP) d. C-reactive protein (CRP)

a. Alpha-fetoprotein (AFP)

A patient with swelling int he perineal area is diagnosed with a Bartholin cyst. Nonsurgical management is recommended. What does the nurse instruct the patient to do? a. Apply moist heat (e.g Sitz bath or hot wet packs) to the vulva b. Return immediately to the clinic if the cyst ruptures c. Contact all sexual partners about the need for treatment d. Change the dressing at least three times a day

a. Apply moist heat (e.g Sitz bath or hot wet packs) to the vulva

The nurse is conducting a history on a male client to determine the severity of symptoms associated with prostate enlargement. Which finding is cause for prompt action by the nurse? a. Cloudy urine b. Urinary hesitancy c. Post-void dribbling d. Weak urinary stream

a. Cloudy urine

A client is interested in learning about the risk factors for prostate cancer. Which factors does the nurse include in the teaching? (Select all that apply.) a. Family history of prostate cancer b. Smoking c. Obesity d. Advanced age e. Eating too much red meat f. Race

a. Family history of prostate cancer d. Advanced age e. Eating too much red meat f. Race

The nurse is caring for a patient who has hysteroscopic surgery. The patient reports severe lower abdominal pain, she appears pale and has trouble focusing on the nurse's questions about the pain. VS show T: 98.6 F, P: 120/min, R 24/min, BP 103/60. Which complication does the nurse suspect? a. Hemorrhage b. Embolism c. Fluid overload d. Incomplete suppression of menstruation

a. Hemorrhage

A patient with a fever, myalgia, sore throat, and sun-burn like rash is admitted with the diagnosis of toxic shock syndrome. What additional clinical manifestation should the nurse assess for? a. Hypotension b. vaginal bleeding c. Bradycardia d. Polyuria

a. Hypotension

A current treatment of nonemergent dysfunctional bleeding includes which medication? a. Oral or patch contraceptives b. Tamoxifen (Nolvadex) c. Magnesium supplement d. Cisplatin (Platinol)

a. Oral or patch contraceptives

A client is diagnosed with metastatic prostate cancer. The client asks the nurse the purpose of his treatment with the luteinizing hormonereleasing hormone (LH-RH) agonist leuprolide (Lupron) and the bisphosphonate pamidronate (Aredia). Which statement by the nurse is most appropriate? a. The treatment reduces testosterone and prevents bone fractures. b. The medications prevent erectile dysfunction and increase libido. c. There is less gynecomastia and osteoporosis with this drug regimen. d. These medications both inhibit tumor progression by blocking androgens.

a. The treatment reduces testosterone and prevents bone fractures.

The nurse is teaching a client with benign prostatic hyperplasia (BPH). What statement indicates a lack of understanding by the client? a. There should be no problem with a glass of wine with dinner each night. b. I am so glad that I weaned myself off of coffee about a year ago. c. I need to inform my allergist that I cannot take my normal decongestant. d. My normal routine of drinking a quart of water during exercise needs to change.

a. There should be no problem with a glass of wine with dinner each night.

10. The nurse is caring for several patients who have sustained burns. The patient with which initial injury is the least likely to experience severe pain when a sharp stimulus is applied? a. Severe sunburn after lying in the sun for several hours b. Deep full-thickness burn from an electrical accident c. Partial-thickness burn from picking up a hot pan d. Deep partial-thickness burn after a motorcycle accident

b

11. The nurse is reviewing arterial blood gas (ABG) results for a patient with 35% TBSA burn in the resuscitation phase: pH is 7.26; Pco2 is 36 mm Hg; and HCO3- is 19 mEq/L. What condition does the nurse suspect the patient has? a. Metabolic alkalosis b. Metabolic acidosis c. Respiratory acidosis d. Respiratory alkalosis

b

13. The nurse is caring for a burn patient who received rigorous fluid resuscitation in the ED for hypotension and hypovolemic shock. In assessing renal function for the first 24 hours, what finding does the nurse anticipate? a. Output will be approximately equal to fluid intake. b. Output will be decreased compared to fluid intake. c. Urine will have a very low specific gravity and a pale-yellow color. d. Output will be managed with diuretics.

b

15. The nurse is caring for a patient brought to the ED after bending over the engine of his car when it explode in his face. What is the priority for this patient? a. Initiate fluid resuscitation b. Secure the airway c. Manage pain and discomfort d. Prevent infection

b

17. For which patient would the rule of nines method of calculating burn size be most appropriate? a. Child who weighs at least 50 pounds b. Adult whose weight is proportionate to height c. Adult who weighs under 300 pounds d. Child whose weight is proportionate to height

b

20. The nurse observes peeling of dead skin on the legs of a patient with a superficial-thickness burn wound. What is the most accurate description of this assessment finding? a. Blanching b. Desquamation c. Slough d. Fluid shift

b

29. What is the primary reason to prevent infection with burn injuries? a. Prevent extensive scar formation b. Avoid sepsis c. Avert worsening of pain d. Avoid fever and inflammation

b

35. A patient is transported to the ED for severe and extensive burns that occurred while he was trapped in a burning building. The patient is severely injured with respiratory distress and the resuscitation team must immediately begin multiple interventions. Which task is delegated to unlicensed assistive personnel (UAP)? a. Position the patient's head to open the airway and assist with intubation. b. Assist the respiratory therapist to maintain a seal during bag-valve-mask ventilation. c. Prepare the intubation equipment and set up the oxygen flowmeter. d. Elevate the head of the bed to achieve a high-Fowler's position.

b

41. A patient was admitted to the burn unit approximately 6 hours ago after being rescued from a burning building. In the ED, he reported a dry, irritated throat "from breathing in the fumes," but otherwise had no airway complaints. During the shift, the nurse notes that the patient has suddenly developed marked stridor. The nurse anticipates preparing the patient for which emergency procedure? a. Bronchoscopy b. Intubation c. Needle thoracotomy d. Escharotomy

b

43. A patient in the burn intensive care unit is receiving vecuronium (Norcuron). What is the priority nursing intervention for this patient? a. Have emergency intubation equipment at the bedside. b. Ensure that all the equipment alarms are on and functional. c. Closely monitor the patient's urinary output every hour. d. Ensure that daily drug levels and electrolyte values are obtained.

b

53. The nurse has just received a phone report on a burn patient being transferred from the burn intensive care unit to the step-down burn unit. Which of these tasks are appropriate to delegate to UAP in order to prepare the room? a. Place sterile sheets and a sterile pillowcase on the bed. b. Place a new disposable stethoscope in the room. c. Clear a space in the corner for the patient's flowers. d. Hang a sign on the door to prohibit entry of visitors.

b

56. A burn patient must have pressure dressings applied to prevent contractures and reduce scarring. For maximum effectiveness, what procedure pertaining to the pressure garments is implemented? a. Changed every 24 to 48 hours to prevent infection b. Worn at least 23 hours a day until the scar tissue matures c. Removed for hygiene and during sleeping d. Applied with aseptic technique

b

60. Which statement about the third spacing or capillary leak syndrome in a patient with severe burns is accurate? a. It usually happens in the first 36 to 48 hours. b. It is a leak of plasma fluids into the interstitial space. c. It is present only in the burned tissues. d. It can usually be prevented with diuretics.

b

62. Because of the fluid shifts in burn patients, what effects on cardiac output does the nurse expect to see? a. An initial increase, then normalized in 24 to 48 hours. b. Depressed up to 36 hours after the burn c. Improved with fluid restriction d. Responsive to diuretics as evidenced by urinary output

b

76. A patient with a burn injury had an autograft. The nurse learns in report that the donor site is on the upper thigh. What type of wound does the nurse expect to find at donor site? a. Stage 1 b. Partial thickness c. Full thickness d. Stage 4

b

77. To prevent the complication of Curling's ulcer, what does the nurse anticipate the provider will order? a. Nasogastric tube insertion b. H2 histamine blockers c. Abdominal assessment every 4 hours d. Systemic antibiotic

b

9. During shift report, the nurse learns that a new patient was admitted for an inhalation injury. Auscultation of the lungs has revealed wheezing over the mainstem bronchi since admission. During the nurse's assessment of the patient, the wheezing sounds are absent. What does the nurse do next? a. Document these findings because they indicate that the patient is improving. b. Assess for respiratory distress because of potential airway obstruction. c. Obtain an order to discontinue oxygen therapy because it is no longer needed. d. Encourage use of incentive spirometry to prevent atelectasis.

b

Iggy Study Guide Ch.56 16. After colostomy surgery, which intervention does the nurse employ? a. Cover the stoma with a dry, sterile dressing. b. Apply a pouch system as soon as possible. c. Make a hole in the pouch for gas to escape. d. Watch for the colostomy to start functioning on day 1.

b

Iggy Study Guide Ch.56 23. A patient with a colostomy may safely include which food item in the diet? a. Burritos b. Yogurt c. Cabbage d. Carbonated beverages

b

Iggy Study Guide Ch.56 49. Which diagnostic test measures urinary excretion of vitamin B12 for diagnosis of pernicious anemia and other malabsorption syndromes? a. Bile acid breath test b. Schilling test c. Hydrogen breath test d. D-xylose absorption test

b

The nurse is providing care for a burn patient who recently received a graft. On assessment of the patient's wound, redness, and swelling as well as some foul-swelling drainage is noted. What does the nurse suspect? a. partial thickness burn b. local infectionof burn wound c. failure of the graft d. systemic sepsis

b

Which are expected outcomes when evaluating the care of a patient with burn injuries? (SATA) a. Patients infection was treated rapidly b. patients airway remained patent c. patients pain was decreased or relieved d. patient's perception of self is positive e. patient's weight loss was only 10% f. patient's wounds are all in the process of healinh

b c d

A client with prostate cancer asks why he must have surgery instead of radiation, even if his cancer is the least-invasive type. What is the nurse's best response? a) "It is because your cancer growth is large." b) "Surgery is the most common intervention to cure the disease." c) "Surgery slows the spread of cancer." d) "The surgery is to promote urination." (Chp 72, elsevier resources)

b) "Surgery is the most common intervention to cure the disease." Because some localized prostate cancers are resistant to radiation, surgery is the most common intervention for a cure. The size of the tumor is not likely to be why the client is having surgery. A bilateral orchiectomy (removal of both testicles) is palliative surgery that slows the spread of cancer by removing the main source of testosterone. A transurethral resection of the prostate is done to promote urination for clients with advanced disease; it is not used as a curative treatment. (Chp 72, elsevier resources)

A client is having a radical prostatectomy. Which preoperative teaching specific to this surgery does the nurse emphasize? a) Incentive spirometry b) Kegel exercises c) Pain control d) Penile implants (Chp 72, elsevier resources)

b) Kegel exercises Kegel perineal exercises may reduce the severity of urinary incontinence after radical prostatectomy. The client is taught to contract and relax the perineal and gluteal muscles in several ways. Incentive spirometry and pain control are important for everyone who undergoes surgery; neither is specific to radical prostatectomy. Penile implants are not important to discuss during preoperative teaching; however, they may be necessary to discuss later. (Chp 72, elsevier resources)

Why is prostate cancer screening often emphasized to the African-American population in the United States? a) Metastasis of prostate cancer is higher. b) Prostate cancer occurs at an earlier age. c) Prostate-specific antigen (PSA) is not sensitive to prostate disease. d) Clinical presentation is different. (Chp 72, elsevier resources)

b) Prostate cancer occurs at an earlier age. In the United States, prostate cancer affects African-American men the most and at an earlier age. There is no difference in prostate cancer metastasis, PSA sensitivity, or clinical presentation of prostate cancer in the African-American population as compared to other populations. (Chp 72, elsevier resources)

A client had an orchiectomy and laparoscopic radical retroperitoneal lymph node dissection this morning. What is the nurse's priority for care? a) assess the client's pain level and provide pain management b) ensure that the client's urinary catheter is draining clear yellow urine c) observe the client's incision for redness, swelling, and drainage d) apply oxygen therapy via nasal cannula at 2 L/min (Ignatavicius & Workman, p. 1515)

b) ensure that the client's urinary catheter is draining clear yellow urine (Ignatavicius & Workman, p. 1515)

A client had a transurethral resection of the prostate (TURP) with continuous bladder irrigation yesterday. The staff nurse notes that the urinary drainage is bright red and thick. What is the nurse's best action? a) notify the charge nurse as soon as possible b) increase the rate of bladder irrigation c) document the assessment in the medical record d) prepare the patient for a blood transfusion (Ignatavicius & Workman, p. 1506)

b) increase the rate of bladder irrigation (Ignatavicius & Workman, p. 1506)

18. Which criterion describes a full-thickness burn wound? (Select all that apply.) a. The wound is red and moist and blanches easily. b. There is destruction to the epidermis and dermis. c. There are no skin cells for regrowth. d. The burned tissue is avascular. e. The burn wound will not be painful.

b, c, d

68. The nurse is caring for a young woman who sustained burns on the upper extremities and anterior chest while attempting to put out a kitchen grease fire. Which laboratory results does the nurse expect to see during the resuscitation phase? (Select all that apply.) a. Potassium level of 3.2 mEq/L b. Glucose level of 180 mg/dL c. Hematocrit of 49% d. pH of 7.20 e. Sodium level of 139 mEq/L

b, c, d

78. Several patients are transported from an industrial fire to a local ED. Which factors increase the risk of death for these patients? (Select all that apply.) a. Male gender b. Age greater than 60 years c. Burn greater than 40% TBSA d. Presence of an inhalation injury e. Presence of contact burns

b, c, d

3. The home health nurse is visiting an older couple for the initial visit. In observing the household, the nurse identifies several behaviors and environmental factors to address. Which identified factors increase the risk for burns and/or household fires? (Select all that apply.) a. Several potholders hanging within easy reach of the stove b. Ashtray with old cigarette butts on the bedside table c. Space heater very close to the bed d. Single smoke detector in the kitchen e. Back exit hall of the house used as a storage space

b, c, d, e

82. Which feelings are most typically expressed by the burn patient? (Select all that apply.) a. Suspicion b. Regression c. Apathy d. Denial e. Suicidal ideations f. Anger

b, d, f

A patient who is very upset asks the nurse "My doctor says I have endometriosis. What does it mean?" What is the nurse's best response? a. "It is an early warning sign of endometrial cancer, but you still need more testing." b. "A special type of tissue, called endometrial tissue, is outside of your uterus." c. "It's a special tissue which grows rapidly, but it is not dangerous." d. "It is a type of infection and inflammation of the endometrial tissue."

b. "As special type of tissue, called endometrial tissue, is outside of your uterus."

A patient had an anterior colporrhaphy and is returning to the clinic for the follow-up appointment. Which patient statement indicates that the procedure has achieved the desired therapeutic outcome? a. "The abdominal pain is almost gone." b. "I have good control over my urination." c. "I am no longer having that constipated feeling." d. "My vaginal bleeding has resolved."

b. "I have good control over my urination."

Which woman is at greatest risk for dysfunctional uterine bleeding? a. 20 yo housewife who has one child b. 45 yo attorney with a stressful life c. 30 yo nurse who smoked for 10 years d. 25 yo teacher who rarely exercises

b. 45 yo attorney with a stressful life

The nurse is administering sulfamethoxazole-trimethoprim (Bactrim) to a client diagnosed with bacterial prostatitis. Which finding causes the nurse to question this medication for this client? a. Urinary tract infection b. Allergy to sulfa medications c. Hematuria d. Elevated serum white blood cells

b. Allergy to sulfa medications

A patient tells the nurse that she was told that she had a "chocolate" cyst. Which assessment is the nurse most likely to perform? a. Ask for description of the vaginal discharge b. Assess onset and description of pain c. Assess for family history of cervical cancer d. Ask about personal or family history of renal disease

b. Assess onset and description of pain

A patient with uterine leiomyomas reports a feeling a pelvic pressure, constipation, and urinary retention. She says "I can't button my pants anymore." What does the nurse assess for to further evaluate the patients symptoms? a. Check the lower extremities for fluid retention b. Assess the abdomen for distention or enlargement c. Measure the fluid intake and urine output d. Inspect the perineal area for bleeding or discharge

b. Assess the abdomen for distention or enlargement

A patient is diagnosed with uterine leiomyomas. What does the nurse expect to see in the documentation for this patient as the chief presenting symptoms? a. Foul smelling vaginal discharge b. Heavy vaginal bleeding c. Intermittent abdominal pain d. Urinary incontinence

b. Heavy vaginal bleeding

A patient with cancer has also been diagnosed with uterine leiomyomas. Which procedure does the nurse prepare the patient for? a. Myoectomy b. Hysterectomy c. Emdometrial ablation d. Magnetic resonance-guided focused ultrasound surgery

b. Hysterectomy

A 36 yo patient is diagnosed with dysfunctional uterine bleeding. During the pelvic exam, the health care provider determines that the bleeding is acute and heavy. What is the nurse's priority action? a. Prepare the patient for immediate transport to the operating room b. Prepare to administer combination hormonal therapy c. Anticipate an order for a hormonal contraceptive patch d. Prepare to administer injectable medroxyprogesterone acetate (Depo-Provera)

b. Prepare to administer combination hormonal therapy

What is the primary treatment for dysfunctional uterine bleeding in perimenopausal women? a. Intravaginal estrogen therapy b. Progestin or combination hormone therapy c. Laparoscopic myomectomy d. Magneic resonance-guided focused ultrasound

b. Progestin or combination hormone therapy

A patient is admitted with toxic shock syndorme. What organism is frequently associated with this syndrome when it occurs as a menstrually related infection? a. E. coli b. S. aureus c. Haemophilus influenzae d. Beta-hemolytic streptococcus

b. S. aureus

A 70-year-old client returned from a transurethral resection of the prostate 8 hours ago with a continuous bladder irrigation. The nurse reviews his laboratory results as follows: Sodium 128 mEq/L Hemoglobin 14 g/dL Hematocrit 42% Red blood 4.5 cell count What action by the nurse is the most appropriate? a. Consider starting a blood transfusion. b. Slow down the bladder irrigation if the urine is pink. c. Report the findings to the surgeon immediately. d. Take the vital signs every 15 minutes.

b. Slow down the bladder irrigation if the urine is pink.

The nurse is teaching self care management to a 39 year old woman who had an abdominal hysterectomy. Which point would be emphasized to avoid complications of this surgery? a. Bathe and douche daily to prevent infection b. Take temperature twice a day for the first 3 days after surgery c. Resume typical exercise routines as soon as possible d. Gently massage calves if tenderness or swelling occurs

b. Take temperature twice a day for the first 3 days after surgery

A client has returned from a transurethral resection of the prostate with a continuous bladder irrigation. Which action by the nurse is a priority if bright red urinary drainage and clots are noted 5 hours after the surgery? a. Review the hemoglobin and hematocrit as ordered. b. Take vital signs and notify the surgeon immediately. c. Release the traction on the three-way catheter. d. Remind the client not to pull on the catheter.

b. Take vital signs and notify the surgeon immediately.

A patient has undergone a total hysterectomy with vaginal repair, The nurse advises her about careful intercourse and which OTC product to decrease sexual discomfort related to intercourse? a. Hydrocortisone cream b. Water-based lubricants c. Petroleum jelly d. Vitamin A and D ointment

b. Water-based lubricants

16. The nurse is caring for a patient who sustained carbon monoxide poisoning while working on his car engine in an enclosed space. What assessment finding does the nurse anticipate? a. Patient will be cyanotic because of hypoxia. b. Blood gas value of PaO2 will be very low. c. Patient will report a headache. d. Patient will report a dry and irritated throat.

c

2. The nurse is caring for a patient who has 30% total body surface area (TBSA) burn. During the first 12 to 36 hours, the nurse carefully monitors the patient for which status changes related to capillary leak syndrome? a. Bradycardia and pitting edema b. Hypertension and decreased urine output c. Tachycardia and hypotension d. Respiratory depression and lung crackles

c

22. Which type of burn destroys the sweat glands, resulting in decreased excretory ability? a. Superficial b. Partial thickness c. Full thickness d. Deep full thickness

c

24. An adult patient is admitted to the burn unit after being burned in a house fire. Assessment reveals burns to the entire face, back of the head, anterior torso, and circumferential burns to both arms. Using the rule of nines, what is the extent of the burn injury? a. 18% b. 24% c. 45% d. 54%

c

39. A patient in the burn intensive care unit weighed 80 kg (preburn weight). The provider orders titration of IV fluid to achieve 0.5 mL/kg/hr urine output. What is the minimal hourly urine output for this patient? a. 30 mL/hr b. 35 mL/hr c. 40 mL/hr d. 45 mL/hr

c

40. A burn patient with which condition is most likely to have mannitol (Osmitrol) ordered as part of the drug therapy? a. Peripheral edema associated with burns on the lower extremities b. Inhalation burns around the mouth causing mucosal swelling c. Electrical burn and myoglobin in the urine d. Smoke inhalation and superficial burns to the forearms

c

42. A patient was admitted for burns to the upper extremities after being trapped in a burning structure. The patient is also at risk for inadequate oxygenation related to inhalation of smoke and superheated fumes. Which diagnostic test best monitors this patient's gas exchange? a. Complete blood count b. Myoglobin level c. Carboxyhemoglobin level d. Chest x-ray

c

45. Which statement about the resuscitation phase of a burn injury is accurate? a. It occurs in the prehospital timeframe. b. It continues about 4 hours after the burn. c. It continues for about 48 hours after the burn. d. It continues until the patient is stable.

c

48. The vasodilating effects of carbon monoxide in patients with carbon monoxide poisoning cause what clinical manifestations? a. Cyanosis around the lips b. Generalized pallor c. Cherry-red skin color d. Mottled skin color

c

57. The family reports that the burn patient is unable to perform self-care measures, so someone has been "doing everything for her." The nurse finds that the patient has the knowledge and the physical capacity to independently perform self-care. What is the nurse's best response? a. "What can your family do to help you feel better and stronger?" b. "You should be doing these things for yourself to increase your self-esteem." c. "What has been happening since you were discharged from the hospital?" d. "Let's review the principles of self-care that you learned in the hospital."

c

6. The nurse is performing a morning assessment on a patient admitted for serious burns to the extremities. For what reason does the nurse assess the patient's abdomen? a. To perform a daily full head-to-toe assessment b. To assess for nausea and vomiting related to pain medication c. TO assess for a paralytic ileus secondary to reduced blood flow d. To monitor increased motility that may result in cramps and diarrhea

c

64. A patient has sustained significant burns which have created a hypermetabolic state. In planning care for this patient, what does the nurse consider? a. Increased retention of sodium b. Decreased secretion of catecholamines c. Increased caloric needs d. The decrease in core temperature

c

74. At what point does fluid mobilization occur in patients with burns? a. After the scar tissue is formed and fluids are no longer being lost. b. Within the first 4 hours after the burns were sustained. c. After 36 hours when the fluid is reabsorbed from the interstitial tissue. d. Immediately after the burns occur.

c

75. The nurse is caring for a patient with chronic pain associated with an old burn injury. Which nonpharmacologic intervention does the nurse use to help relieve the patient's pain? a. Nitrous oxide b. Cool room temperature to reduce discomfort c. Massaging nonburned areas d. Intravenous narcotics due to delayed tissue absorption

c

80. Which drug therapy reduces the risk of wound infection for burn patients? a. Large doses of oral antifungal medications every 4 hours b. Silver nitrate solution covered by dry dressings applied every 4 hours c. Silver sulfadiazine (Silvadene) on full-thickness injuries every 4 hours d. Broad-spectrum antibiotics given intravenously

c

Iggy Study Guide Ch.56 15. Which test is definitive for the diagnosis of CRC? a. Carinoembryonic antigen (CEA) b. Barium swallow c. Colonoscopy with biopsy d. Fecal occult blood test (FOBT)

c

Over a period of 4 days the patient developed an elevated temperature associated with disorientation and lethargy. Lab values include a normal platelet level. Which type of infection does the nurse suspect? a .viral b. fungal c. gram positive bacteria d. gram negative bacteria

c

With which male client does the nurse conduct prostate screening and education? a) Young adult with a history of urinary tract infections b) Client who has sustained an injury to the external genitalia c) Adult who is older than 50 years d) Sexually active client (Chp 72, elsevier resources)

c) Adult who is older than 50 years A man who is 50 years or older is at higher risk for prostate cancer. A history of urinary tract infections, injury to the external genitalia, and sexual activity are not risk factors for prostate cancer. (Chp 72, elsevier resources)

Which assessment finding causes the nurse to suspect that a client may have testicular cancer? a) Hematuria b) Penile discharge c) Painless testicular lump d) Sudden increase in libido (Chp 72, elsevier resources)

c) Painless testicular lump A painless lump or swelling in the testicles is the most common manifestation of testicular cancer. Hematuria is not a symptom of testicular cancer, but could be indicative of other conditions such as bladder cancer. Penile discharge is not a symptom of testicular cancer, but could be indicative of another condition. A sudden increase in libido is not a symptom of testicular cancer. (Chp 72, elsevier resources)

The potential problem of grief is most relevant to a client after which procedure? a) Cystoscopy b) Transurethral microwave therapy c) Radical prostatectomy d) Sperm banking (Chp 72, elsevier resources)

c) Radical prostatectomy A radical prostatectomy may lead to erectile dysfunction, which could present a potential problem of grief at loss of function. Cystoscopy, a test to view the interior of the bladder, the bladder neck, and the urethra, does not affect sexuality. Transurethral microwave therapy is a minimally invasive procedure involving high temperatures that heat and destroy excess prostate tissue, and does not affect sexuality. The process of sperm banking would not result in a diagnosis of altered self-image; however, the diagnosis leading to the necessity of sperm banking might cause this. (Chp 72, elsevier resources)

Which method is a common complementary and alternative therapy for benign prostatic hyperplasia (BPH)? a) Acupuncture b) Calcium supplements c) Serenoa repens d) Yoga (Chp 72, elsevier resources)

c) Serenoa repens Serenoa repens (saw palmetto), a plant extract, is often used by men with early to moderate BPH. They believe that this agent relieves their symptoms and prefer this treatment over prescription drugs or surgery. (It should be noted, however, that studies on the effectiveness of Serenoa repens have not shown that it is effective.) Acupuncture, calcium, and yoga are not common alternative therapies for BPH. (Chp 72, elsevier resources)

the nurse is caring for several patients who had total abdominal hysterectomies. All patients are coming to the clinic for their 6-wk followup appointment. Which patient demeanor is the strongest indicator that there is a need for psychological referral? a. Quiet and withdrawn but asks appropriate questions b. Tense and impatient but answers questions correctly c. Disheveled and lackluster and displays a lack of interest in questions d. Cheerful and distractible and answers questions with excessive detail

c. Disheveled and lackluster and displays a lack of interest in questions

A 25-year-old client has recently been diagnosed with testicular cancer and is scheduled for radiation therapy. Which intervention by the nurse is best? a. Ask the client about his support system of friends and relatives. b. Encourage the client to verbalize his fears about sexual performance. c. Explore with the client the possibility of sperm collection. d. Provide privacy to allow time for reflection about the treatment.

c. Explore with the client the possibility of sperm collection.

what is the priority nursing care most commonly see preoperatively and postperatively in a patient with leiomyomas? a. Preventing infection b. Managing severe pain c. Monitoring for bleeding d. Assessing for and managing anxiety

c. Monitoring for bleeding

The nurse sees that a patient has been advised by the health care provider to apply lindane (Kwell) to the affected area. What is a self-care measure for this patient to ensure that the symptoms do not return after using the medications. a. Wash the area daily with hydrogen peroxide b. Take a sitz bath for 30 minutes several times a day c. Wash clothes, linens, and disinfect the home environment d. Remove any irritants or allergens (e.g. change detergents)

c. Wash clothes, linens, and disinfect the home environment

21. Which type of burn wound damages the epidermis, dermis, fascia, and tissues? a. Superficial b. Partial-thickness c. Full thickness d. Deep full thickness

d

23. During the early phase of a burn injury there is a drastic increase in capillary permeability. What does this physiologic change place the patient at risk for? a. Acute kidney injury b. Fluid overload c. Increased cardiac output d. Hypovolemic shock

d

25. What is the most effective intervention for preventing transmission of infection to a burn patient? a. Use of personal protective equipment (PPE) for anyone entering the patient's room b. Maintaining reverse isolation during the resuscitation phase c. Equipment designated for patient use d. Performing hand hygiene correctly and when appropriate

d

50. A burn patient refuses to eat. The potential problem of weight loss related to increased metabolic rate and reduced calorie intake is identified for this patient. What method does the nurse use to correctly weigh this patient? a. Weigh once a week after morning hygiene and compare to previous weight. b. Weigh daily at the same time of day and compare to preburn weight. c. Use a bed scale and subtract the estimated weight of linens. d. Weigh daily without dressings or splints and compare to preburn weight.

d

58. A patient who sustained severe burns to the face with significant scarring and disfigurement will soon be discharged from the hospital. Which intervention is best to help the patient make the transition into the community? a. Discuss cosmetic surgery that could occur over the next several years. b. Focus on the positive aspects of going home and being with family. c. Teach the family to perform all aspects of care for the patient. d. Encourage visits from friends and short public appearances before discharge.

d

7. The nurse is interviewing and assessing an electrician who was brought to the emergency department (ED) after being "electrocuted." Bystanders report that he was holding onto the electrical source "for a long time." The patient is currently alert with no respiratory distress. During the interview, what does the nurse assess for? a. Knowledge of electrical safety b. Burn marks on the dominant hand c. Injuries based on reports of pain d. Entrance and exit wounds

d

81. A patient has sustained a relatively large burn. The nurse anticipates that the patient's nutritional requirements may exceed how many kcal/day? a. 1500 b. 2000 c. 3000 d. 5000

d

85. Which patient has the highest risk for a fatal burn injury? a. 4-year-old child b. 32-year-old man c. 45-year-old woman d. 77-year-old man

d

Iggy Study Guide Ch.56 22. The nurse is teaching a patient about colostomy care. Which information does the nurse include in the teaching plan? a. The stoma will enlarge within 6 to 8 weeks of surgery. b. Use a moisturizing soap to cleanse the area around the stoma. c. Place the colostomy bag on the skin when the skin sealant is still damp. d. An antifungal cream or powder can be used if a fungal rash develops.

d

Iggy Study Guide Ch.56 47. What is the classic symptom of malabsorption syndrome? a. Unintentional weight loss b. Decreased libido c. Bloating with flatus d. Chronic diarrhea

d

The nurse is educating a group of young men about testicular self-examination (TSE). Which statement by a member of the group indicates teaching has been effective? a) "I will examine my testicles right before taking a shower." b) "I should squeeze each testicle in my hand to feel any lumps." c) "I should only report any large lumps to my health care provider." d) "I will look and feel for any lumps or changes to my testes." (Chp 72, elsevier resources)

d) "I will look and feel for any lumps or changes to my testes." With early detection by monthly TSE and treatment, testicular cancer can be successfully cured. In TSE, the client should look and feel for any lumps or changes to the testes. Any lumps that are detected should be immediately reported. A TSE should be performed immediately following a shower. The client should gently roll each testicle between the thumb and forefinger. All lumps should be reported to the provider, no matter the size. (Chp 72, elsevier resources)

The nurse is teaching a client about taking sildenafil (Viagra) for erectile dysfunction. Which statement by the client indicates a need for further teaching? a) "I should have sex within an hour after taking the drug." b) "I should avoid alcohol when on the drug or it might not work well." c) "I can expect to maybe get a stuffy nose or headache when I take the drug." d) "If I have chest pain during sex, I should take a nitroglycerin tablet." (Ignatavicius & Workman, p. 1513)

d) "If I have chest pain during sex, I should take a nitroglycerin tablet." (Ignatavicius & Workman, p. 1513)

A client receiving external beam radiation therapy calls the nurse to report rectal urgency, cramping, and passing of mucus and blood. What is the nurse's best response? a) "This is an emergency. Go directly to the emergency department." b) "This is normal and will resolve as soon as the treatment stops." c) "Avoid caffeine and continue drinking plenty of water and other fluids." d) "Limit spicy or fatty foods, caffeine, and dairy products." (Chp 72, elsevier resources)

d) "Limit spicy or fatty foods, caffeine, and dairy products." The client's symptoms indicate that he is experiencing radiation proctitis, a common complication of external beam radiation therapy. The nurse's instructions to limit spicy or fatty foods, caffeine, and dairy products describe what the client should do to alleviate these symptoms. The client's symptoms do not indicate an emergency, but they should be reported to the health care provider. The client's symptoms should resolve 4 to 6 weeks after the treatment stops. Avoiding caffeine and drinking water and other fluids describe what the client should do if he is experiencing radiation cystitis, which he is not. (Chp 72, elsevier resources)

The issue that is often foremost in the minds of men who have been diagnosed with prostate cancer and must be addressed by the nurse is the alteration of which factor? a) Comfort because of surgical pain b) Mobility after treatment c) Nutrition because of radiation side effects d) Sexual function after treatment (Chp 72, elsevier resources)

d) Sexual function after treatment Altered sexual function is one of the biggest concerns of men after cancer treatment. Comfort, mobility, and nutrition are important, but are typically not the foremost concern in the minds of men with prostate cancer. (Chp 72, elsevier resources)

Hormone treatment for prostate cancer works by which action? a) Decreases blood flow to the tumor b) Destroys the tumor c) Shrinks the tumor d) Suppresses growth of the tumor (Chp 72, elsevier resources)

d) Suppresses growth of the tumor Hormone therapy, particularly antiandrogen drugs, inhibits tumor progression by blocking the uptake of testicular and adrenal androgens at the prostate tumor site. Antiandrogens may be used alone or in combination with luteinizing hormone-releasing hormone agonists for a total androgen blockade (hormone ablation). Hormone treatment for prostate cancer does not decrease blood flow to the tumor, destroy the tumor, or shrink the tumor. (Chp 72, elsevier resources)

Which woman is at greater risk for developing pelvic organ prolapse? a. 16 yo adolescent caring for her first child b. 25 yo who became sexually active at age 15 c. 34 yo who has a history of endometriosis d. 48 yo obese mother of four children

d. 48 yo obese mother of 4 children

What self management strategy would the nurse recommend to a patient to prevent vovaginitis? a. Wear nylon underwear b. Douche daily to remove vaginal secretions c. Apply antiseptic cream daily to perineal area d. Avoid wearing tight fitting clothing

d. Avoid wearing tight fitting clothing

A 20-year-old woman is being evaluated for possible toxic syndrome. What question would the nurse ask? a. "How many pads do you use on heavy flow days?" b. "Have you ever used intravaginal estrogen therapy?" c. "Do you have a history of multiple sexual partners?" d. "Do you use internal contraceptives?"

d. Do you use internal contraceptives

A patient has excessive bleeding from the uterine fibroids. Which therapy stops the blood flow to the fibroids? a. An infusion of conjugated estrogens b. Dilation and curettage c. Topical vaginal estrogen therapy d. Endometrial ablation

d. Endometrial ablation

An obese 57 yo patient describes excessive menstrual bleeding that occurs approximately every 10 days. The nurse educates the patient for which diagnostic test that is used to evaluate for endometrial cancer? a. Bimanual pelvic examination b. Transvaginal ultrasound c. Sonohysterography d. Endometrial biopsy

d. Endometrial biopsy

What disease is strongly associated with prolonged exposure to estrogen without the protective effects of progesterone? a. Endometriosis b. Uterien cancer c. Leiomyomas d. Endometrial cancer

d. Endometrial cancer

A nurse and an unlicensed assistive personnel (UAP) are caring for a client with an open radical prostatectomy. Which comfort measure could the nurse delegate to the UAP? a. Administering an antispasmodic for bladder spasms b. Managing pain through patient-controlled analgesia c. Applying ice to a swollen scrotum and penis d. Helping the client transfer from the bed to the chair

d. Helping the client transfer from the bed to the chair

For a patient with endometriosis, which supplement might offer relief of the muscle cramping? a. Vitamin C b. Vitamin D c. Potassium d. Magnesium

d. Magnesium

A client is diagnosed with benign prostatic hyperplasia and seems sad and irritable. After assessing the clients behavior, which statement by the nurse would be the most appropriate? a. The urine incontinence should not prevent you from socializing. b. You seem depressed and should seek more pleasant things to do. c. It is common for men at your age to have changes in mood. d. Nocturia could cause interruption of your sleep and cause changes in mood.

d. Nocturia could cause interruption of your sleep and cause changes in mood.

Which factors are used to determine a cancer patient's absorbed radiation dose? (SATA) a. Intensity of radiation exposure b. Proximity of radiation source to the cells c. Duration of the exposure d. Age of the patient e. Previous radiation therapy

A, B, C

27. A patient has severe burns to the anterior surface of the body from a short exposure to high temperatures at a worksite furnace. Which area of the body is most vulnerable to a deep burn injury? a. Anterior chest b. Upper arms c. Palmar surface of hands d. Eyelids

d

A patient is ordered a scratch test to determine the cause of hives. What does the nurse teach the patient about the procedure? 1 Antihistamines must be discontinued for 2 weeks before the test. 2 All types of nasal sprays must be avoided for 1 week before the test. 3 A drop of sera is placed over the scratched area. 4 Normal saline drops are used as positive control.

1 Antihistamines and systemic glucocorticoids should be discontinued for 2 weeks before a scratch test. This prevents suppression of an allergic response during the test. The patient is allowed to use nasal sprays that reduce mucous membrane swelling as it does not interfere with the test. Small drops of sera containing known allergens are placed on the skin, and the skin is scratched through the drop with a bifurcated skin testing needle. Normal saline drops are used as negative control while histamine drops are used as positive control.

A patient who experienced an anaphylactic reaction is hypotensive and has a rapid, weak, and irregular pulse. What is the priority nursing intervention? 1 Elevate the legs and feet. 2 Administer metaproterenol. 3 Administer diphenhydramine. 4 Report the findings to the primary health care provider.

1 As the patient is hypotensive and has a rapid, weak, and irregular pulse, the priority nursing intervention in this situation is to elevate the legs and feet, leaving the head of the bed elevated to about 10 degrees. The nurse administers beta-adrenergic agonist metaproterenol to decrease mucus secretion if a patient has bronchospams. Diphenhydramine is an antihistamine agent administered if the patient has symptoms of angioedema and urticaria. The nurse should report the findings to the primary health care provider after elevating the legs and feet, as it is an emergency situation.

A patient is ordered desensitization therapy for allergy. What does the nurse tell the patient about desensitization therapy? 1 The allergen is administered in increasing doses. 2 The course is recommended for 1 year. 3 Therapy involves intramuscular injections. 4 Side effects include dry mouth and increased blood pressure.

1 Desensitization therapy involves the administration of an allergen in increasing doses. The course is generally recommended for 5 years. Small amounts of allergen are injected subcutaneously. The side effects of decongestants, not desensitization therapy, include dry mouth and increased blood pressure.

A patient has developed serum sickness. What is the most likely cause? 1 Antibiotic therapy 2 Antipyretic drugs 3 Antihistamine therapy 4 Corticosteroid therapy

1 Serum sickness is a group of symptoms that occurs after receiving serum or certain drugs. Serum sickness is often caused by penicillin or other antibiotics. Antipyretic drugs may be useful in treating the fever that accompanies serum sickness. Antihistamines and corticosteroids are also useful to treat symptoms.

A patient is diagnosed with Sjögren's syndrome. Which viruses are thought to be responsible for this disorder? Select all that apply. 1 Epstein-Barr virus (EBV) 2 Human immunodeficiency virus type 1 (HIV 1) 3 Human immunodeficiency virus type 2 (HIV 2) 4 Human T-cell lymphotrophic virus type 1 (HTLV 1) 5 Human T-cell lymphotrophic virus type 2 (HTLV 2)

1, 2, 4 EBV, HIV-1, and HTLV-1 are three viruses thought to be responsible for Sjögren's syndrome because these can trigger autoimmune response in the host cells. It is not clear whether HIV-2 and HTLV-2 can also lead to this syndrome.

A patient is undergoing a skin test for allergies. Which symptoms are associated with an anaphylactic reaction? Select all that apply. 1 Red blotches 2 Itching and urticaria 3 High blood pressure 4 Diarrhea and vomiting 5 Erythema and angioedema

1, 2, 5 Red blotches, itching, urticaria, erythema, and angioedema are the common symptoms associated with anaphylactic reactions. During this reaction, vasodilation occurs and blood is lost from the vascular system; therefore, the patient becomes hypotensive, not hypertensive. Diarrhea and vomiting are not directly related to this reaction.

A patient is suffering with type I hypersensitivity. Which questions does the nurse ask during the assessment? Select all that apply. 1 "Do you have any food or drug allergies?" 2 "What is your favorite food and beverage?" 3 "Have you undergone a transplantation surgery before?" 4 "Do you have any family members with a type I allergy?" 5 "When did this problem begin and how long does each episode last?"

1, 4, 5 In order to identify the causative allergen, the nurse asks if the patient has any allergy to some foods, drugs, or other chemical compounds. The exposure to such compounds can result in mild to severe type I reactions. This type of hypersensitivity can be a hereditary problem; therefore, asking about family history of the disease will be useful. In order to understand the severity of the disease, information about onset and duration can be beneficial. Rather than asking about favorite foods or beverages, the nurse should inquire about any allergies to food items or beverages. Transplantation-related problems are associated with autoimmunity, not with type I hypersensitivity.

A patient is admitted to the hospital with suspected Goodpasture's syndrome. Which findings does the nurse expect to observe? 1 Bradycardia 2 Hemoptysis 3 Increased urine output 4 Weight loss

2 Hemoptysis (bloody sputum) is a manifestation of Goodpasture's syndrome. Goodpasture's syndrome usually is not diagnosed until serious lung and kidney problems are present. Tachycardia, decreased urine output, and weight gain are manifestations of Goodpasture's syndrome.

What eosinophil count indicates severe seasonal allergic rhinitis? 1 2-4% 2 11-12% 3 1-2% 4 5-6%

2 An eosinophil count as high as 12% or more may be indicative of severe seasonal allergic rhinitis. The eosinophil count increases in response to the allergen. The normal value of eosinophils ranges between 1-2%. Small deviations from this range do not indicate severe allergy, so the value 2-4% can represent either no infection or a very mild infection. A value of 5-6% may indicate moderate allergic rhinitis.

Epinephrine administration is essential during anaphylaxis. What is the mechanism of action of this drug? 1 Inhibits mast cells degranulation 2 Stimulates the alpha- and beta-adrenergic receptors 3 Blocks the effects of histamines on the gastrointestinal tract 4 Competes with histamine for H1 receptors on effector cells

2 Epinephrine stimulates the alpha- and beta-adrenergic receptors of the autonomic nervous system. This drug constricts the blood vessels and causes bronchodilation. Thus, it provides quick relief from the effects of anaphylaxis. The inhibition of mast cell degranulation is induced by corticosteroids and antihistamines. Antihistamines block the effects of histamines on the gastrointestinal tract or other systems. These drugs compete with histamine for H1 receptors and prevent type I reactions.

What should be the immediate nursing action for a patient having an allergic reaction to penicillin who has symptoms of swollen lips and tongue, soft palate, and widespread hives with pruritus? 1 Administering oral serratiopeptidase 2 Administering intravenous epinephrine 3 Administering inhalation of salbutamol 4 Administering intramuscular theophylline

2 The patient is experiencing a penicillin-induced anaphylactic reaction, which requires immediate medical treatment. The nurse should administer epinephrine, which helps in suppressing the anaphylactic reaction. Administering oral serratiopeptidase, inhaling salbutamol, or administering intramuscular theophylline does not help in the immediate treatment of anaphylaxis.

Which symptoms does the nurse expect to observe while examining a patient with allergic rhinitis? Select all that apply. 1 Achy joints 2 Itchy, watery eyes 3 Runny, stuffy nose 4 Poison ivy skin rash 5 Breathing through the mouth with a nasal sound

2, 3, 5 A runny, stuffy nose (rhinorrhea); itchy, watery eyes; and difficulty in breathing are usually the symptoms associated with allergic rhinitis. Achy joints and poison ivy skin rashes are associated with type III and type IV hypersensitivities, respectively. However, a person may suffer from one or more type of hypersensitivity. Further diagnosis is recommended for the confirmation of the disease.

What are the most common triggers for allergic rhinitis? Select all that apply. 1 Hay fever 2 Dust and molds 3 Latex gloves 4 Animal dander 5 Plant pollens

2, 4, 5 Allergic rhinitis, or hay fever, is triggered by immunity and inflammation reactions to airborne allergens, especially plant pollens, molds, dust, animal dander, wool, food, and air pollutants. Latex products are not associated with allergic rhinitis.

The nurse plans to assess a patient with type I hypersensitivity for which clinical manifestation? 1 Poison ivy 2 Autoimmune hemolytic anemia 3 Allergic asthma 4 Rheumatoid arthritis

3 Allergic asthma is a manifestation of type I hypersensitivity. Poison ivy is a type IV delayed mechanism of hypersensitivity. Autoimmune hemolytic anemia is a type II cytotoxic mechanism of hypersensitivity. Rheumatoid arthritis is a type III immune complex-mediated mechanism of hypersensitivity.

Which condition does the nurse suspect in a patient complaining of a runny and stuffy nose where the nasal mucosa of the patient is found to be swollen and there is a reduced glow observed at the sinus during a transillumination examination? 1 Vasculitis 2 Anaphylaxis 3 Allergic rhinitis 4 Allergic asthma

3 Allergic rhinitis is the inflammation of nasal airways. The swollen nasal mucosa is the symptom of inflammation of the nasal airway. Placing a penlight directly on the skin over the sinuses and transillumination often shows reduced glow in the presence of rhinitis. Vasculitis, anaphylaxis, and allergic asthma are not characterized by swollen nasal mucosa and reduced glow during transillumination.

A patient who is receiving an intravenous antibiotic begins to cough and states, "My throat feels like it is swelling." Which action does the nurse take next? 1 Infuse normal saline at 200 mL/hr. 2 Administer epinephrine 1:1000, 0.3 mL subcutaneously. 3 Discontinue infusing the antibiotic. 4 Give diphenhydramine 100 mg IV.

3 Because the antibiotic is the most likely cause of the patient's anaphylactic reaction, the nurse's first action should be to discontinue the antibiotic. The nurse must first assess the patient, and although infusing normal saline and administering epinephrine and diphenhydramine may be indicated, these are not the nurse's first action.

The laboratory report of a 38-year-old woman complaining of dry eyes, nose, mouth, and vaginal dryness shows elevated immunoglobulin M (IgM) levels, general antinuclear antibodies, and anti-SS-A antibodies. Which condition does the nurse suspect? 1 Myasthenia gravis 2 Reiter's syndrome 3 Sjogren's syndrome 4 Goodpasture's syndrome

3 Sjogren's syndrome is a group of problems that often appear with other autoimmune disorders. Most patients with Sjogren's syndrome are women aged 35 to 45 years old. Symptoms of Sjogren's syndrome are dry eyes, nose, mouth, and vaginal dryness. Laboratory assessments of the patient show elevated IgM levels, general antinuclear antibodies, and anti-SS-A antibodies. Myasthenia gravis, Reiter's syndrome, and Goodpasture's syndrome are not associated with these symptoms.

During the physical examination, the patient reports a history of latex allergy. Which item may cause this reaction? 1 Pollens 2 Milk products 3 Surgical gloves 4 Legumes and nuts

3 Surgical gloves may be made of natural latex proteins and can cause an allergy that has symptoms related to type I and type IV hypersensitivity reactions. Pollens, milk products, and legumes and nuts are not responsible for latex allergy because they do not contain latex.

The nurse is caring for a patient with a poison ivy skin rash. What type of hypersensitive reaction is the patient experiencing? 1 Immediate reaction 2 Immune complex-mediated reaction 3 Delayed reaction 4 Cytotoxic reaction

3 The patient is experiencing a delayed hypersensitivity reaction. This type IV reaction occurs hours to days after exposure. The reactive cell is the T-lymphocyte (T-cell). A type I reaction is an immediate hypersensitive reaction; hay fever, allergic asthma, and anaphylaxis are examples of type I reactions. A type III reaction is an immune complex-mediated hypersensitive reaction; serum sickness and vasculitis are examples of a type III reaction. In a type III reaction, excess antigens cause the formation of immune complexes in the blood. Cytotoxin reaction is a type II reaction in which the body makes special antibodies against self cells that have some form of foreign protein attached to them. Autoimmune hemolytic anemia and Goodpasture's syndrome are examples of type II reactions.

The nurse is reviewing the medical record of a patient who is prescribed a decongestant. The nurse plans to contact the patient's health care provider if the patient has which condition? 1 Cataracts 2 Crohn's disease 3 Diabetes mellitus 4 Hypertension

4 Decongestants have actions similar to adrenergic drugs, causing vasoconstriction, which can increase blood pressure. Decongestants are not contraindicated in patients with cataracts, Crohn's disease, or diabetes mellitus.

Which drug therapy is most useful for the patient suffering from Sjögren's syndrome? 1 Antihistamines 2 Anti-inflammatories 3 Immunostimulants 4 Immunosuppressants

4 Immunosuppressive drugs such as methotrexate are useful in treating Sjögren's syndrome. These drugs can suppress the highly active immune response. Antihistamines are not useful as immune reactions are not caused by the histamine mediator. Anti-inflammatory drugs can be used to treat inflammation. Immunostimulants must be avoided because they can worsen the condition.

The nurse is caring for a patient with Goodpasture's syndrome. Which statement about this disorder is correct? 1 Antibodies are made to kill microorganisms. 2 Antibodies are made to destroy inflamed cells. 3 Autoantibodies are produced against transplanted tissues. 4 Autoantibodies are produced against the glomerular basement membrane.

4 In Goodpasture's syndrome, autoantibodies are produced to destroy the glomerular basement membrane and neutrophils. The actual triggering agent for this syndrome is unknown. Antibodies against microorganisms do not cause Goodpasture's syndrome. Inflamed cells are not necessarily destroyed; inflammation can be reduced by some medications. Autoantibodies against transplant tissue do not cause Goodpasture's syndrome.

A middle-aged patient, who is alert, is admitted to the emergency department (ED) with wheezing, difficulty breathing, angioedema, blood pressure (BP) of 70/52 mm Hg, and apical pulse of 122 and irregular. The nurse makes an immediate assessment using the "ABCs" for any patient experiencing anaphylaxis. What nursing intervention is the immediate priority? 1 Raise the lower extremities. 2 Start intravenous (IV) administration of normal saline. 3 Reassure the patient that appropriate interventions are being instituted. 4 Apply oxygen using a high-flow non-rebreather mask at 90% to 100%.

4 Oxygen application helps provide adequate oxygenation for the patient who is in respiratory distress. Assessing respiratory status is an immediate priority; raising the lower extremities, starting an IV infusion, and reassuring the patient are not the first priority because the patient is in respiratory distress.

A patient in the allergy clinic develops all of these clinical manifestations after receiving an intradermal injection of an allergen. Which symptom requires the most immediate action by the nurse? 1 Anxiousness 2 Urticaria 3 Pruritus 4 Stridor

4 Stridor indicates airway involvement and warrants immediate intervention such as use of oxygen and administration of epinephrine. Maintaining the patient's airway is the highest priority. Anxiousness, urticaria, and pruritus may be symptoms of a reaction but are not the nurse's highest priority when the patient is in respiratory distress.

71. The nurse is caring for an African-American patient with a burn injury. The patient appears to be having severe pain and discomfort that are unrelated to the burned areas. The nurse advocates that the provider order which additional test? a. Sickle cell for trait b. Drug screen for opiate abuse c. X-rays to identify bone injuries d. ECG to identify cardiac dysrhythmia

a

A client's white blood cell count is 7500/mm3. Calculate the expected range for this client's neutrophils. (Record your answer using whole numbers separated with a hyphen; do not use commas.) ______/mm3

4125-5625/mm3 The normal range for neutrophils is 55% to 75% of the white blood cell count. 7500 ´ 0.55 = 4125 7500 ´ 0.75 = 5625 So the range would be expected to be 4125/mm3 to 5625/mm3.

The nurse hears in report that the patient has xerostomia. Which teaching point does the nurse plan to review with the patient? a. Regular dental visits are essential because of increased risk for dental carries b. Use mild soap and apply unscented moisturizers to reduce itching sensation c. Avoid rigorous sports because bones are more prone to pathologic fractures d. Avoid direct sun exposure for at least 1 year because skin will be sensitive

A Xerostomia is dry mouth

The nurse is teaching a group of women about prevention of toxic shock syndrome. What preventive measures does the nurse include? (select all that apply) a. "Avoid the use of superabsorbant tampons" b. "Use sanitary napkins at night" c. "Avoid using internal contraceptives" d. "Void immediately after intercourse" e. "Change your tampon every 8 hours"

A, B, C

For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (Select all that apply.) a. Antibody-mediated immunity b. Cell-mediated immunity c. Inflammation d. Red blood cells e. White blood cells

A, B, C The three processes that need to be functional and interact with each other for a person to be immunocompetent are antibody-mediated immunity, cell-mediated immunity, and inflammation. Red and white blood cells are not processes.

For a patient undergoing external radiation therapy, what do the nurse's instructions include? (SATA) a. Do not remove the markings b. Do not use lotions or ointments c. Avoid direct skin exposure to sunlight for up to a year d. Use mild soap and water on the affected skin e. Gently rub the treated areas to stimulate circulation

A, B, C, D

Which factors determine the type of therapy for cancer? (SATA) a. Type and location of the cancer b. Overall health of the patient c. Whether the cancer has metastasized d. Family history and genetics e. Previous lymph node biopsy

A, B, C, D

What types of examinations are done to reveal the presence of uterine enlargement related to fibroids? (select all that apply ) a. Abdominal examination b. Vaginal examination c. Rectal examination d. Excretory urography e. Transvaginal ultrasound with saline infusion

A, B, C, E

Which interventions does the nurse implement for patient receiving chemotherapy to prevent the serious side effects of sepsis and disseminated intravascular coagulation? (SATA) a. Strict handwashing b. Monitor WBCs and clotting factors c. Administer prophylactic IV heparin d. Frequently assess for signs of infection

A, B, C, E

A patient asks the nurse why untreated cancers cause gastrointestinal problems. Which responses are appropriate? (SATA) a. "A tumor in the bowel can decrease your ability to absorb necessary nutrients" b. "The spread or metastasis of the cancer to the stomach occurs very frequently" c. "Changes in taste can decrease appetite or cause food aversions" d. "Cancer is treated with radiation therapy that usually alters bowel function" e. "Tumors may increase metabolic needs which you are unable to meet"

A, C, E

Biologic response modifiers have which positive effects on patients receiving chemotherapy? (SATA) a. Less risk of life-threatening infections b. Reduces incidence of alopecia c. Reduced severity of nausea d. Able to tolerate higher doses of chemotherapy e. Euphoria and increased libido

A, D

The nurse reviews the initial postanesthesia care unit (PACU) flow record and notes that the client is alert and oriented 3 when stimulated, pulse is 88 per minute and regular, respirations are 12 per minute and unlabored, and oxygen saturation is 95% on 2 LPM of nasal oxygen. What is the nurse's priority action at this time? a. Examine the surgical site; obtain blood pressure and temperature. b. Suction the client and assess anterior and posterior lung sounds. c. Assess urinary output, the IV site, and the client's pain. d. Turn the client and perform chest physiotherapy.

A. examine the surgical site; obtain blood pressure and temperature

1. A client who had a hysterectomy has a 200-mg dose of ciprofloxacin (Cipro) ordered to infuse in 30 minutes. At what rate should the nurse infuse the medication if the pharmacy provides 200 mg in a 100-mL bag of normal saline? (Record your answer using a whole number.) ___ mL/hr

ANS: 200 mL/hr 100 mL 2 = 200 mL/hr.

The nurse teaches a client that intraperitoneal chemotherapy will be delivered to which part of the body? A.) Veins of the legs B.) Lung C.) Heart D.) Abdominal cavity

Abdominal cavity Intraperitoneal chemotherapy is placed in the peritoneal cavity or the abdominal cavity. Intravenous drugs are delivered through veins. Chemotherapy delivered into the lungs is typically placed in the pleural space (intrapleural). Chemotherapy is not typically delivered into the heart.

When caring for the client with hyperuricemia associated with tumor lysis syndrome (TLS), for which medication does the nurse anticipate an order? A.) Recombinant erythropoietin (Procrit) B.) Allopurinol (Zyloprim) C.) Potassium chloride D.) Radioactive iodine-131 (131I)

Allopurinol (Zyloprim) TLS results in hyperuricemia (elevation of uric acid in the blood), hyperkalemia, and other electrolyte imbalances; allopurinol decreases uric acid production and is indicated in TLS. Recombinant erythropoietin is used to increase red blood cell production and is not a treatment for hyperuricemia. Administering additional potassium is dangerous. Radioactive iodine-131 is indicated in the treatment of thyroid cancer, not TLS.

The nurse is caring for a client whose wound dehisces after vomiting. What is the nurse's first action? a. Prepare the client for emergency surgery. b. Cover the wound with sterile moist dressings. c. Give the client medication for nausea. d. Call the surgeon and the operating room.

B. cover the wound with sterile moist dressings

26. Which vaccine is routinely administered when a burn patient is admitted to the hospital? a. Hepatitis B b. Tetanus c. Influenza d. Pneumonia

b

A client with diabetes mellitus type 1 underwent surgery 24 hours ago. Which precaution does the nurse take to help prevent postoperative complications for this client? a. Order a high-protein diet. b. Observe the incision frequently. c. Have suction available at the bedside. d. Instruct the client to use an electric razor.

B. observe the incision frequently

A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess? a. Noticeable rubor b. Purulent drainage c. Swelling and pain d. Warmth at the site

B During the second phase of the inflammatory response, neutrophilia occurs, producing pus. Rubor (redness), swelling, pain, and warmth are cardinal signs of the general inflammatory process.

The nurse working in an organ transplantation program knows that which individual is typically the best donor of an organ? a. Child b. Identical twin c. Parent d. Same-sex sibling

B The recipient's immune system recognizes donated tissues as non-self except in the case of an identical twin, whose genetic makeup is identical to the recipient.

What does a course of chemotherapy normally include? (SATA) a. Rounds every week for a total of 6 weeks b. Variance with the patient's response to therapy c. Timed dosage of therapy to minimize normal cell damage d. A concurrent dose of radiation e. The administration of one specific anti-cancer drug

B, C

Iggy Ch.56 p. 1155 A nurse is assigned to care for a client who had an open partial colectomy and descending colostomy this morning. What assessment findings are expected for the client? Select all that apply. A. The colostomy stoma is purple and dry. B. The nasogastric tube is draining yellowish green fluid. C. The client has pain that is controlled by analgesics. D. The colostomy is not draining any stool. E. The perineal incision is covered with a surgical dressing.

B, C Rationale: A healthy stoma should be reddish pink and moist. A NG tube may be in place, draining yellowish green fluid. The client may experience pain postoperatively, which will be controlled with analgesics. The colostomy should start functioning in 2 to 3 days postoperatively; initially, gas will be passed, then liquid stool, followed by more solid stool. Perineal incisions are associated with an AP resection, not an open partial colectomy, which is an abdominal surgery.

A patient who has a total abdominal hysterectomy is anxious to resume her activities because she has young children at home. What postprocedure information does the nurse provide to the patient? (select all that apply) a. Climb stairs to build strength and endurance b. Avoid sitting for prolonged periods c. Do not lift anything heavier than 5 to 10 lbs d. Walk or jog at least 1-2 miles every day e. when sitting, do not cross the legs

B, C, E

The nurse is providing discharge teaching for a client who will be going home with a Jackson-Pratt (JP) drain. Which statement indicates that the client understands how to care for the drain correctly? a. "I will flush the tubing to make sure that it stays open." b. "I will measure the drainage before I discard it." c. "I will close the drain valve and then compress the bulb to create suction." d. "I will pull it out once the surgeon says I don't need it anymore."

B. "I will measure the drainage before I discard it."

The nurse is caring for a client who has had surgery the previous day. The client tells the nurse, "Breathing in using this thing (incentive spirometer) is a ridiculous waste of time." What is the nurse's best response? a. "The spirometer will help you cough effectively." b. "The spirometer will help your lungs expand." c. "The spirometer will help prevent blood clots." d. "The spirometer will improve blood flow in your lungs."

B. "The spirometer will help your lungs expand."

A client is being discharged after abdominal surgery. What information about the diet does the nurse teach the client? a. "Be sure to monitor your fluid intake." b. "Eat foods high in protein and vitamin C." c. "Call the physician if you develop gas." d. "You will need to limit your carbohydrates."

B. "eat foods high in protein and vitamin C"

A client is diagnosed with irritable bowel syndrome (IBS). What factors does the nurse suspect as possible causes of the client's problem? (Select all that apply.) A. Antihistamines B. Caffeinated drinks C. Stress D. Sleeping pills E. Anxiety

B. Caffeinated drinks C. Stress E. Anxiety Factors such as ingestion of coffee or other gastric stimulants, stress, anxiety, and milk allergy are being investigated as possible causes of IBS. Antihistamines and sleeping pills are not suspected as causing IBS.

A client is brought to the postanesthesia care unit (PACU) after surgery that took place with the client in the lithotomy position. Which action does the nurse take after assessing vital signs? a. Assess for sacral decubiti. b. Assess dorsalis pedis pulses. c. Turn the client on the left side. d. Put the client in the Trendelenburg position.

B. assess dorsalis pedis pulses

The nurse is assessing a client admitted to the postanesthesia care unit (PACU) after abdominal surgery. The client's respiratory rate is 8 breaths/min and breath sounds are decreased in the bases. What is the nurse's priority action? a. Prepare to administer naloxone (Narcan). b. Assess oxygen saturation and level of consciousness. c. Call a code or the Rapid Response Team. d. Turn the client and perform chest physiotherapy.

B. assess oxygen saturation and level of consciousness

The nurse is teaching a client who is receiving an antiestrogen drug about the side effects she may encounter. Which side effects does the nurse include in the discussion? (Select all that apply.) A.) Heavy menses B.) Smooth facial skin C.) Hyperkalemia D.) Breast tenderness Correct E.) Weight loss F.) Deep vein thrombosis Correct

Breast tenderness Deep vein thrombosis Breast tenderness and shrinking breast tissue may occur with antiestrogen therapy. Venous thromboembolism may also occur. Irregular menses or no menstrual period is the typical side effect of antiestrogen therapy. Acne may also develop. Hypercalcemia, not hyperkalemia, is typical. Fluid retention with weight gain may also occur.

When caring for the client receiving cancer chemotherapy, which signs or symptoms related to thrombocytopenia should the nurse report to the health care provider? (Select all that apply.) A.) Bruises B.) Fever C.) Petechiae D.) Epistaxis E.) Pallor

Bruises Petechiae Epistaxis Bruising, petechiae, and epistaxis (nosebleeds) are symptoms of a low platelet count. Fever is a sign of infection secondary to neutropenia. Pallor is a sign of anemia.

A patient has a diagnosis of cancer with gram-negative infection. The nurse assesses bleeding from many sites throughout the body. For which condition does the nurse expect to perform nursing interventions? a. Sepsis b. Anemia c. Disseminated intravascular coagulation d. Syndrome of inappropriate antidiuretic hormone

C

The nurse is caring for a patient who will receive stereotactic body radiotherapy. Which intervention is the nurse most likely to use in the care of this patient? a. Post a sign to remind pregnant visitors to avoid entering the patient's room b. Assess the UAP's understanding of how to handle radioactive urine and stool c. Teach the patient about the need for exact positioning during the treatment d. Assess the patient for history of allergies to iodine or contrast media

C

The nurse is supervising and nursing student who is giving care to a patient with a sealed implant. The nurse would intervene if the student performed which action? a. Places a "Caution: Radioactive Material" sign on the door of the patient's room b. Wears a dosimeter film badge at all times while caring for the patient c. Wears a lead apron while providing care, but turns away from the patient d. Saves all dressings and bed linens in the patient's room

C

What is the major side effect that limits dose dose of chemotherapy?

C

What technique is used in oral care for patients with stomatitis? a. Apply petroleum jelly to the lips after each math care b. Brush teeth and tongue with a hard bristled toothbrush every eight hours c. "Swish and spit" room temperature tap water at least four times a day d. Use commercial mouthwashes and glycerin swabs to refresh mouth

C

Which therapy is an example of the cornerstone for cancer treatment? a. Use of ionizing radiation to destroy cancer cells b. Physical rehabilitation exercises to restore function c. Surgical removal of the visible and microscopic tumor d. Chemotherapy to cure or increase survival time

C

Why does the nurse wear a dosimeter when providing care to a patient receiving brachytherapy? a. Indicates special expertise in radiation therapy b. Protects the nurse from absorbing radiation c. Measure's the nurse's exposure to radiation d. Ensures that the radiation dosage is accurate

C

28. A patient has sustained a burn which appears red and moist. The nurse gently applies pressure to the area to assess for what sign/symptom? a. Intensity of pain b. Blanching c. Pitting edema d. Fluid-filled blisters

b

The student nurse learns that the most important function of inflammation and immunity is which purpose? a. Destroying bacteria before damage occurs b. Preventing any entry of foreign material c. Providing protection against invading organisms d. Regulating the process of self-tolerance

C The purpose of inflammation and immunity is to provide protection to the body against invading organisms, whether they are bacterial, viral, protozoal, or fungal. These systems eliminate, destroy, or neutralize the offending agents. The cells of the immune system are the only cells that can distinguish self from non-self. This function is generalized and incorporates destroying bacteria, preventing entry of foreign invaders, and regulating self-tolerance.

The nurse understands that which type of immunity is the longest acting? a. Artificial active b. Inflammatory c. Natural active d. Natural passive

C Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural passive do not last as long. "Inflammatory" is not a type of immunity.

Which clients are at increased risk for postoperative nausea and vomiting? (Select all that apply.) a. Older adult with a history of hypertension b. Client who was in the lateral position during surgery c. Middle aged client with a body mass index (BMI) of 46 d. Woman who has undergone a cholecystectomy e. Young adult who received 3 L of IV fluid during surgery f. Man who has a history of seasickness g. Man who has a nasogastric tube to suction

C, D, F

Iggy Study Guide Ch.56 19. Which findings for a patient with a new colostomy will the nurse report to the surgeon? (Select all that apply.) a. A dark-red, dry stoma b. Stoma protruding about 2 cm from the abdominal wall c. Mucocutaneous separation d. A slight amount of edema in the initial postoperative period e. Large amount of bleeding

a,c,e

Which instruction does the nurse provide to a client to prevent postoperative venous thromboembolism? a. "Cough and deep-breathe six times every hour after surgery." b. "Use your incentive spirometer hourly." c. "Get up and walk as much as possible." d. "Keep the sterile dressing on your incision."

C. "Get up and walk as much as possible."

the nurse is giving discharge teaching to a woman who had a local cervical ablation. What information would be included? (select all that apply) a. Sexual activity may be resumed usually in 1 week b. Change tampons every 4 hours c. Report heavy vaginal bleeding or foul smelling drainage d. Showering is permitted, but no tub baths e. Avoid lifting heavy objects for 3 weeks

C. D, E

The nurse is caring for a client who had surgery 24 hours ago. He is alert and oriented when awakened and reports pain, but goes back to sleep when not being stimulated. He is on patient-controlled analgesia (PCA). What is the nurse's next action? a. Push the PCA control for the client. b. Discontinue the PCA immediately. c. Assess the client's respiratory status. d. Keep the client awake as much as possible.

C. assess the client's respiratory status

The nurse is performing a hand-off report in the PACU. What is the best action for the nurse to perform during the hand-off report? a. Write all information on a chart and hand it to the nurse who will assume care of the client. b. Follow the nurse assigned to the new client and give a verbal report that does not interrupt care. c. Focus on the report and sit with the nurse receiving the client to give a detailed report. d. Finish the report quickly so the nurse can assume care of the client.

C. focus on the report and sit with the nurse receiving the client to give a detailed report

The nurse is caring for a client who has just been brought to the postanesthesia care unit (PACU) after surgery. The client's oxygen saturation is 92% and his hemoglobin is 14 g/dL. What is the nurse's first action? a. Assess the client's pain response. b. Determine whether the client is alert and oriented. c. Increase oxygen and auscultate lung sounds. d. Assess vital signs and temperature.

C. increase oxygen and auscultate lung sounds

Which instruction is most appropriate for the nurse to convey to the client with chemotherapy-induced neuropathy? A.) Bathe in cold water. B.) Wear cotton gloves when cooking. C.) Consume a diet high in fiber. D.) Make sure shoes are snug.

Consume a diet high in fiber. A high-fiber diet will assist with constipation due to neuropathy. The client should bathe in warm water, not hotter than 96° F. Cotton gloves may prevent harm from scratching; protective gloves should be worn for washing dishes and gardening. Wearing cotton gloves while cooking can increase the risk for burns. Shoes should allow sufficient length and width to prevent blisters. Shoes that are snug can increase the risk for blisters in a client with peripheral neuropathy.

A patient diagnosed with bone cancer reports fatigue, loss of appetite, and constipation. Which laboratory results does the nurse report immediately? a. Potassium level of 4.2 mEq/L b. Magnesium level of 2.0 mg/dL c. Sodium level of 140 mEq/L d. Calcium level of 10.5 mEq/dL

D

A patient id being discharged with a prescription for an oral cancer agent. Based on recent research studies, which teaching point will the nurse emphasize? a. Oral anticancer medications are less toxic and can be handled like regular medications b. Oral forms are more convenient for home use and cost less than IV medications c. Crushing the medication and mixing it with pudding or juice will mask the unpleasant taste d. Adherence to therapy schedule is more of a problem, but do not skip or reduce doses

D

Based on the "inverse square law" for radiation exposure, which patient received the smallest radiation dose? a. Received radiation dose at a distance of 0.5 meter b. Received radiation dose at a distance of 1 meter c. Received radiation dose at a distance of 2.5 meters d. Received radiation dose at a distance of 3 meters

D

The nurse is caring for a 56-year old woman who had a modified mastectomy for breast cancer. The woman jokes, "That breast was too saggy anyway. Good riddance to it." Later, the nurse sees the woman crying. What should the nurse do first? a. Encourage the woman to accept the body changes by looking at the surgical site b. Suggest participation in a support group sponsored by the local chapter of the American Cancer Society c. Invite a breast cancer survivor who successfully coped with mastectomy d. Sit with the woman and encourage her to express her feelings and concerns

D

The nurse is talking to a young athlete who needs lung removal for treatment of lung cancer. Which statement best indicates that the patient is coping with the uncertainty of cancer and the long-term impact on his physical activities? a. "If I delay the surgery, I could still compete for a few months" b. "My coach says I might be able to compete even with one lung" c. "Competing in sports is important to me and I will eventually recover" d. "I love to compete in sports, but I like to do a lot of other things too"

D

Iggy Study Guide Ch.56 43. Which are potential complications of polyps? (Select all that apply.) a. Gross rectal bleeding b. Colorectal cancer c. Intestinal obstruction d. Septic shock e. intussusception

a,c,e

A client who is being admitted to the postanesthesia care unit (PACU) has weak hand grasps on assessment and is unable to lift his head off the bed. During hand-off report, the nurse notes that the client has received a neuromuscular-blocking agent. What is the nurse's best action? a. Document the finding. b. Check the client's pulses. c. Place the client in Fowler's position. d. Auscultate the lungs.

D. auscultate the lungs

An older adult has a mild temperature, night sweats, and productive cough. The client's tuberculin test comes back negative. What action by the nurse is best? a. Recommend a pneumonia vaccination. b. Teach the client about viral infections. c. Tell the client to rest and drink plenty of fluids. d. Treat the client as if he or she has tuberculosis (TB).

D Due to an age-related decrease in circulating T lymphocytes, the older adult may have a falsely negative TB test. With signs and symptoms of TB, the nurse treats the client as if he or she does have TB. A pneumonia vaccination is not warranted at this time. TB is not a viral infection. The client should rest and drink plenty of fluids, but this is not the best answer as it does not address the possibility that the client's TB test could be a false negative.

The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem? a. CD4+ cells b. Cytotoxic T cells c. Natural killer cells d. Suppressor T cells

D Suppressor T cells help prevent hypersensitivity to one's own cells, which is the basis for autoimmune disease. CD4+ cells are also known as helper/inducer cells, which secrete cytokines. Natural killer cells have direct cytotoxic effects on some non-self cells without first being sensitized. Suppressor T cells have an inhibitory action on the immune system. Cytotoxic T cells are effective against self cells infected by parasites such as viruses or protozoa.

The nurse is caring for a client who had abdominal surgery 3 days ago. He tells the nurse, "I felt something 'give way' when I coughed." What is the nurse's best response? a. "It is good that you are coughing and deep-breathing to prevent pneumonia." b. "That is a normal feeling in the incision whenever you are moving." c. "Be sure to splint the incision with a pillow or your hands when you cough." d. "Lie down flat on the bed with your knees up and let me examine your incision."

D. "Lie down flat on the bed with your knees up and let me examine your incision"

A client is scheduled for an operation. What does the nurse teach the client about postoperative pain control? a. "You should not ask for IV pain medication more than once every 4 or 5 hours." b. "You should not take the pain medication if you are nauseated." c. "You will not get pain medication until you are transferred to the floor." d. "You should ask for pain medication before the pain becomes severe."

D. "you should ask for pain medication before the pain becomes severe."

The nurse is caring for clients in the postanesthesia care unit (PACU). Which client is ready to be extubated? a. Client with an oxygen saturation of 90% b. Client with a respiratory rate of 14 breaths/min c. Client who is alert and oriented d. Client who is coughing and gagging

D. client who is coughing and gagging

The nurse assesses clients in the postanesthesia care unit (PACU). Which client does the nurse intervene for first? a. Client with a respiratory rate of 12 breaths/min b. Client with an oxygen saturation of 92% c. Client who is reporting pain (5 out of 10) d. Client with audible stridor

D. client with audible stridor

The nurse is caring for a client in the postanesthesia care unit (PACU) 2 hours after abdominal surgery. The nurse auscultates the client's abdomen and notes that there are no bowel sounds. What action does the nurse take? a. Position the client on the left side with the bed flat. b. Insert a nasogastric tube to low intermittent suction. c. Palpate the bladder and measure abdominal girth. d. Document the finding and continue to monitor.

D. document the finding and continue to monitor

After discharge from the postanesthesia care unit (PACU), the client returned to the surgical nursing unit at 10 AM. It is now 6 PM, and the client is not experiencing any complications. How often does the nurse assess the client's vital signs? a. Every 15 minutes b. Every 30 minutes c. Every hour d. Every 4 hours

D. every 4 hours

The nurse is reviewing postoperative medication orders. Which order can the nurse implement? a. Acetaminophen orally PRN pain b. Meperidine (Demerol) 75-100 mg every 3-4 hours PRN pain c. MS .5 mg subcutaneously every 1-3 hours PRN pain d. Hydromorphone hydrochloride (Dilaudid) 1 mg orally every 4 hours PRN pain

D. hydromorphone hydrochloride (Dilaudid) 1 mg orally every 4 hours PRN pain

A client has been transferred to the postanesthesia care unit (PACU). Which action does the receiving nurse perform first? a. Complete a nursing assessment sheet. b. Change the client's arm band. c. Enter client data into the computer. d. Participate in a hand-off report.

D. participate in a hand-off report

The nurse is changing the dressing on a postoperative client's abdominal incision. A Jackson-Pratt (JP) drain is present, along with a moderate amount of serosanguineous drainage. What is the best product for the nurse to use in performing wound care? a. Half hydrogen peroxide and half sterile saline b. Sterile water and antibacterial ointment c. Betadine swabs or alcohol wipes d. Sterile normal saline

D. sterile normal saline

Iggy Study Guide Ch.56 14. Which are the most common signs of colorectal cancer (CRC)? (Select all that apply.) a. Change in stool consistency b. Absent bowel soun ds c. Abdominal cramping d. Anemia e. Rectal bleeding

a,d,e

The nurse is instructing a client with breast cancer who will be undergoing chemotherapy about the side effects of doxorubicin (Adriamycin). Which side effect does the nurse instruct the client to report to the health care provider? A.) Diaphoresis B.) Dysphagia C.) Edema D.) Hearing loss

Edema Doxorubicin is an anthracycline, and clients must be instructed to be aware of and to report cardiotoxic effects, including edema, shortness of breath, chronic cough, and excessive fatigue. Diaphoresis (profuse sweating), dysphagia (difficulty swallowing), and hearing loss are not associated side effects of doxorubicin.

When monitoring a client with suspected syndrome of inappropriate antidiuretic hormone (SIADH), the nurse reviews the client's medical record, which contains the following information. The nurse notifies the health care provider for which signs and symptoms consistent with this syndrome? (Select all that apply.) Physical Assessment Findings Diagnostic Findings Medications Neuro: Episodes of confusion Cardiac: Pulse 88 and regular Musculoskeletal: Weakness, tremors Na: 115 K: 4.2 Creatinine: 0.8 ondansetron (Zofran) cyclophosphamide (Cytoxan) A.) Hyponatremia B.) Mental status changes C.) Azotemia D.) Bradycardia E.) Weakness

Hyponatremia Mental status changes Weakness Antidiuretic hormone (ADH) is secreted or produced ectopically, resulting in water retention and sodium dilution. Dilutional hyponatremia results from ADH secretion, causing confusion and changes in mental status. Weakness results from hyponatremia. Azotemia refers to buildup of nitrogenous waste products in the blood, typically from renal damage. Bradycardia is not part of the constellation of symptoms related to SIADH; tachycardia may result from fluid volume excess.

Which statement about breast reconstruction surgery is correct? A.) Many women want breast reconstruction using their own tissue immediately after mastectomy. B.) Placement of saline- or gel-filled prostheses is not recommended because of the nature of the surgery. C.) Reconstruction of the nipple-areola complex is the first stage in the reconstruction of the breast. D.) The surgeon should offer the option of breast reconstruction surgery once healing has occurred after a mastectomy.

Many women want breast reconstruction using their own tissue immediately after mastectomy. Many women want autogenous reconstruction after mastectomy. Saline- or gel-filled prostheses are recommended as breast expanders in breast augmentation surgery, not for reconstructive surgery. Reconstruction of the nipple-areola complex is the last stage in breast reconstruction surgery. Breast reconstruction surgery should be discussed before mastectomy takes place.

Which action can the same-day surgery charge nurse delegate to an experienced unlicensed assistive personnel (UAP) who is helping with the care of a client who is having a breast biopsy? A.) Assess anxiety level about the surgery. B.) Monitor vital signs after surgery. C.) Obtain data about breast cancer risk factors. D.) Teach about postoperative routine care.

Monitor vital signs after surgery. Vital sign assessment is included in UAP education and usually is part of the job description for UAP working in a hospital setting. Nursing assessment, obtaining data, and client teaching are not within the scope of practice for UAP and should be done by licensed nursing staff.

Which client problem does the nurse set as the priority for the client experiencing chemotherapy-induced peripheral neuropathy? A.) Potential for lack of understanding related to side effects of chemotherapy B.) Potential for injury related to sensory and motor deficits C.) Potential for ineffective coping strategies related to loss of motor control D.) Altered sexual function related to erectile dysfunction

Potential for injury related to sensory and motor deficits The highest priority is safety. Although knowing the side effects of chemotherapy may be helpful, the priority is the client's safety because of the lack of sensation or innervation to the extremities. The nurse should address the client's coping only after providing for safety. Erectile dysfunction may be a manifestation of peripheral neuropathy, but the priority is still the client's safety.

A 67-year-old male client reports pain in the inguinal area that occurs when he coughs. A bulge that can be pushed back into the abdomen is found in his inguinal area. What type of hernia does he have? A. Femoral B. Reducible C. Strangulated D. Ventral

Reducible The hernia is reducible because its contents can be pushed back into the abdominal cavity. Femoral hernias tend to occur more frequently in obese and pregnant women. A hernia is considered to be strangulated when the blood supply to the herniated segment of the bowel is cut off. It cannot be a ventral hernia because it would have to occur at the site of a previous surgical incision.

An outpatient client is receiving photodynamic therapy. Which environmental factor is a priority for the client to adjust for protection? A.) Storing drugs in dark locations at room temperature B.) Wearing soft clothing C.) Wearing a hat and sunglasses when going outside D.) Reducing all direct and indirect sources of light

Reducing all direct and indirect sources of light Lighting of all types must be kept to a minimum with clients receiving photodynamic therapy; it can lead to burns of the skin and damage to the eyes because these clients' eyes are sensitive to light. Any drug that the client is prescribed should be considered for its photosensitivity properties; drugs should be stored according to the recommendations, but this is not the primary concern for this client. Clothing must cover the skin to prevent burns from direct or indirect light; texture is not a concern for the client receiving this treatment. The client will be homebound for 1 to 3 months after the treatment and should not go outside.

A large-breasted client reports discomfort, backaches, and fungal infections because of her excessive breast size. The nurse provides information to the client about which breast treatment option? A.) Augmentation B.) Compression C.) Reconstruction D.) Reduction mammoplasty

Reduction mammoplasty Breast reduction mammoplasty surgery removes excess breast tissue and repositions the nipple and remaining skin flaps to produce the best cosmetic effect. Breast augmentation surgery enhances the size, shape, or symmetry of breasts. Breast compression is not a treatment. Breast reconstruction surgery is typically performed for women after a mastectomy.

The oncology nurse should use which intervention to prevent disseminated intravascular coagulation (DIC)? A.) Monitoring platelets B.) Administering packed red blood cells C.) Using strict aseptic technique to prevent infection D.) Administering low-dose heparin therapy for clients on bedrest

Using strict aseptic technique to prevent infection Sepsis is a major cause of DIC, especially in the oncology client. Monitoring platelets will help detect DIC, but will not prevent it. Red blood cells are used for anemia, not for bleeding/coagulation disorders. Heparin may be administered to clients with DIC who have developed clotting, but this has not been proven to prevent the disorder.

Iggy Study Guide Ch.56 20. The nurse is teaching a patient about what to expect after a descending colon clolostomy. The nurse tells the patient to expect the stool to have what kind of form? a. Similar to that of stool expelled from the rectum b. Thick and paste-like c. Thin and gelatin-like d. Watery

a

32. The nurse has just received report on a patient admitted for steam inhalation burns. The patient is alert and conversant, but reports that his throat feels raw. His wife says the he sounds hoarse compared to usual. Considering these findings, which order should the nurse question? a. Continuous pulse oximetry b. Vital signs and airway assessment every shift c. Intubation equipment at the bedside d. Oxygen 2 L via nasal cannula to maintain saturation of greater than 90%

b

The nurse is giving discharge teaching to a patient who had a transvaginal repair for pelvic organ prolapse using a surgical mesh. What does the nurse include? a. Avoid cigarette smoking for at least one month b. Abstain from sexual intercourse for 6 weeks c. Reduce calories to lose 2 months a month d. Avoid tub baths to prevent soaking the mesh

b. Abstain from sexual intercourse for 6 weeks

79. What is the most essential patient data needed for calculating the fluid rates, energy requirements, and drug doses for the burn patient? a. Age b. Health history c. Preburn weight d. Current weight

c

49. The nurse is caring for a burn patient about to undergo hydrotherapy. Which complementary therapies are appropriate for pain management in this patient? (Select all that apply.) a. Administration of IV opioid analgesics b. Allowing the patient to make decisions regarding pain control c. Playing music in the background d. Use of meditative breathing e. Use of guided imagery

c, d, e

4. The nurse is caring for several patients on the burn unit who have sustained extensive tissue damage. The nurse should monitor for which electrolyte imbalance that is typically associated with the initial third-spacing fluid shift? a. Hypercalcemia b. Hypernatremia c. Hypokalemia d. Hyperkalemia

d

A client with testicular cancer is worried about sterility and the ability to conceive children later. Which resource does the nurse refer the client to before surgery takes place? a) American Cancer Society b) American Fertility Society c) RESOLVE: The National Infertility Association d) Sperm bank (Chp 72, elsevier resources)

d) Sperm bank After radiation therapy or chemotherapy has been started, the client is at increased risk for producing mutagenic sperm, which may not be viable or may result in fetal abnormalities. If the client is interested in having children, he should be encouraged to arrange for semen storage as soon as possible after diagnosis. Sperm collection should be completed before radiation therapy or chemotherapy is started. The client is referred to the American Cancer Society for more generalized information on testicular cancer. The American Fertility Society and RESOLVE: The National Infertility Association are appropriate referrals if permanent sterility occurs and sperm storage has not been feasible. (Chp 72, elsevier resources)