AH Exam 3

The nurse caring for oncology clients knows that which form of metastasis is the most common? Bloodborne Direct invasion Lymphatic spread Via bone marrow

A Bloodborne metastasis is the most common way for cancer to metastasize. Direct invasion and lymphatic spread are other methods. Bone marrow is not a medium in which cancer spreads, although cancer can occur in the bone marrow

The nurse working with oncology clients understands that which age-related change increases the older client's susceptibility to infection during chemotherapy? Decreased immune function Diminished nutritional stores Existing cognitive deficits Poor physical reserves

A As people age, there is an age-related decrease in immune function, causing the older adult to be more susceptible to infection than other clients. Not all older adults have diminished nutritional stores, cognitive dysfunction, or poor physical reserves.

A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best? 0.45% normal saline 0.9% normal saline Dextrose 50% (D50) Lactated Ringer's solution

A Because clients in sickle cell crisis are often dehydrated, the fluid of choice is a hypotonic solution such as 0.45% normal saline. 0.9% normal saline and lactated Ringer's solution are isotonic. D50 is hypertonic and not used for hydration.

A client presents to the emergency department in sickle cell disease crisis. What intervention by the nurse takes priority? Administer oxygen. Initiate pulse oximetry. Give pain medication. Start an IV line.

A All actions are appropriate, but remembering the ABCs, oxygen would come first. The main problem in a sickle cell crisis is tissue and organ hypoxia, so providing oxygen helps halt the process.

A nurse working with clients who experience alopecia knows that which is the best method of helping clients manage the psychosocial impact of this problem? Assisting the client to pre-plan for this event Reassuring the client that alopecia is temporary Teaching the client ways to protect the scalp Telling the client that there are worse side effects

A Alopecia does not occur for all clients who have cancer, but when it does, it can be devastating. The best action by the nurse is to teach the client about the possibility and to give the client multiple choices for preparing for this event. Not all clients will have the same reaction, but some possible actions the client can take are buying a wig ahead of time, buying attractive hats and scarves, and having a hairdresser modify a wig to look like the client's own hair. Teaching about scalp protection is important but does not address the psychosocial impact. Reassuring the client that hair loss is temporary and telling him or her that there are worse side effects are both patronizing and do not give the client tools to manage this condition.

A nurse caring for a client with sickle cell disease (SCD) reviews the client's laboratory test results. Which finding would the nurse report to the primary health care provider? Creatinine: 2.9 mg/dL (256 mcmol/L) Hematocrit: 30% Sodium: 146 mEq/L (146 mmol/L) White blood cell count: 12,000/mm3 (12 109/L)

A An elevated creatinine indicates kidney damage, which occurs in SCD. A hematocrit level of 30% is an expected finding, as is a slightly elevated white blood cell count due to chronic inflammation. A sodium level of 146 mEq/L (146 mmol/L), although slightly high, is not concerning.

A nurse in the oncology clinic is providing preoperative education to a client just diagnosed with cancer. The client has been scheduled for surgery in 3 days. What action by the nurse is best? Call the client at home the next day to review teaching. Give the client information about a cancer support group. Provide all the preoperative instructions in writing. Reassure the client that surgery will be over soon.

A Clients are often overwhelmed at a sudden diagnosis of cancer and may be more overwhelmed at the idea of a major operation so soon. This stress significantly impacts the client's ability to understand, retain, and recall information. The nurse would call the client at home the next day to review the teaching and to answer questions. The client may or may not be ready to investigate a support group, but this does not help with teaching. Giving information in writing is important (if the client can read it), but in itself will not be enough. Telling the client that surgery will be over soon is giving false reassurance and does nothing for teaching.

The nurse is teaching a client who has pernicious anemia about necessary dietary changes. Which statement by the client indicates understanding about those changes? "I'll increase animal proteins like fish and meat." "I'll work on increasing my fats and carbohydrates." "I'll avoid eating green leafy vegetables. "I'll limit my intake of citrus fruits."

A Clients who have pernicious anemia have a Vitamin B12 deficiency and need to consume foods high in Vitamin B12, such as animal and plant proteins, citrus fruits, green leafy vegetables, and dairy products. While carbohydrates and fats can provide sources of energy, they do not supply the necessary nutrient to improve anemia.

A nurse teaches assistive personnel (AP) about how to care for a client with Parkinson disease. Which statement would the nurse include as part of this teaching? "Allow the client to be as independent as possible with activities." "Assist the client with frequent and meticulous oral care." "Assess the client's ability to eat and swallow before each meal." "Schedule appointments early in the morning to ensure rest in the afternoon."

A Clients with Parkinson disease do not move as quickly and can have functional problems. The client would be encouraged to be as independent as possible and provided time to perform activities without rushing. Although oral care is important for all clients, instructing the UAP to provide frequent and meticulous oral is not a priority for this client. This statement would be a priority if the client was immune-compromised or NPO. The nurse would assess the client's ability to eat and swallow; this would not be delegated. Appointments and activities would not be scheduled early in the morning because this may cause the client to be rushed and discourage the client from wanting to participate in activities of daily living.

A client hospitalized with sickle cell disease crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe that the client is drug seeking. When the client requests pain medication, what action by the nurse is best? Give the client pain medication if it is time for another dose. Instruct the client not to request pain medication too early. Request the primary health care provider leave a prescription for a placebo. Tell the client that it is too early to have more pain medication.

A Clients with sickle cell crisis often have severe pain that is managed with up to 48 hours of IV opioid analgesics. Even if the client is addicted and drug seeking, he or she is still in extreme pain. If the client can receive another dose of medication, the nurse would provide it. The other options are judgmental and do not address the client's pain. Giving a placebo is unethical.

The nurse is teaching a family caregiver about how best to communicate with the client who has been diagnosed with Alzheimer disease. Which statement by the caregiver indicates a need for further teaching? "I will avoid communicating with the client to prevent agitation." "I should use simple, short sentences and one-step instructions." "I can try to use gestures or pictures to communicate with the client." "I will limit the number of choices I provide for the client."

A Communication with the client is important to provide cognitive stimulation. Using short simple sentences, using gestures and pictures, and limiting choices provided for the client will help promote communication.

A client asks the nurse if eating only preservative- and dye-free foods will decrease cancer risk. What response by the nurse is best? "Maybe; preservatives, dyes, and preparation methods may be risk factors." "No; research studies have never shown those things to cause cancer." "There are other things you can do that will more effectively lower your risk." "Yes; preservatives and dyes are well known to be carcinogens."

A Dietary factors related to cancer development are poorly understood, although dietary practices are suspected to alter cancer risk. Suspected dietary risk factors include low-fiber intake and a high intake of red meat or animal fat. Preservatives, preparation methods, and additives (dyes, flavorings, sweeteners) may have cancer-promoting effects. It is correct to say that other things can lower risk more effectively, but this does not give the client concrete information about how to do so, and also does not answer the client's question.

A nurse works on an oncology unit and delegates personal hygiene to assistive personnel (AP). What action by the AP requires intervention from the nurse? Allowing a very tired client to skip oral hygiene and sleep Assisting clients with washing the perianal area every 12 hours Helping the client use a soft-bristled toothbrush for oral care Reminding the client to rinse the mouth with water or saline

A Even though clients may be tired, they still need to participate in hygiene to help prevent infection. The nurse would intervene and explain this to AP. The other options are all appropriate.

The nurse is caring for a patient with leukemia who has severe fatigue. What action by the client best indicates that an important outcome to manage this problem has been met? Doing activities of daily living (ADLs) using rest periods Helping plan a daily activity schedule Requesting a sleeping pill at night Telling visitors to leave when fatigued

A Fatigue is a common problem for clients with leukemia. This client is managing his or her own ADLs using rest periods, which indicates an understanding of fatigue and how to control it. Helping to plan an activity schedule is a lesser indicator. Requesting a sleeping pill does not help control fatigue during the day. Asking visitors to leave when tired is another lesser indicator. Managing ADLs using rest periods demonstrates the most comprehensive management strategy.

A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important? Assessing the IV site and blood return every hour Educating the client on side effects Monitoring the client for nausea d. Providing warm packs for comfort

A Intravenous chemotherapy can cause local tissue destruction if it extravasates into the surrounding tissues. Peripheral IV lines are more prone to this than centrally placed lines. The most important intervention is prevention, so the nurse would check hourly to ensure the IV site is patent, or frequently depending on facility policy. Education and monitoring for side effects such as nausea are important for all clients receiving chemotherapy. Warm packs may be helpful for some drugs, whereas for others ice is more comfortable. would monitor the site and check for blood return to prevent injury from infiltration or extravasation.

A client is receiving rituximab. What assessment by the nurse takes priority? Blood pressure Temperature Oral mucous membranes Pain

A Rituximab can cause infusion-related reactions, including hypotension, so monitoring blood pressure is the priority. Other complications of this drug include fever with chills/rigors, headache and abdominal pain, shortness of breath, bronchospasm, nausea and vomiting, and rash. Assessing the client's temperature and for pain are both pertinent assessments, but do not take priority over the blood pressure. Oral mucus membrane assessment is important for clients with cancer, but are not specific for this treatment.

A nurse is caring for four clients with leukemia. After hand-off report, which client would the nurse assess first? Client who had two bloody diarrhea stools this morning. Client who has been premedicated for nausea prior to chemotherapy. Client with a respiratory rate change from 18 to 22 breaths/min. Client with an unchanged lesion to the lower right lateral malleolus.

A The client who had two bloody diarrhea stools that morning may be hemorrhaging in the gastrointestinal (GI) tract and should be assessed first to monitor for or avoid the client from going into hypovolemic shock. The client with the slight change in respiratory rate may have an infection or worsening anemia and should be seen next. If the client's respiratory rate was greater than 28 to 30 breaths/min, the client may need the initial assessment. Marked tachypnea is an early sign of a deteriorating client condition. The other two clients are not a priority at this time.

A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL (61 mmol/L). The client is symptomatic but refuses blood transfusions. What medication does the nurse prepare to administer? Epoetin alfa Filgrastim Mesna Dexrazoxane

A The client's hemoglobin is very low, so the nurse prepares to administer epoetin alfa, a colony-stimulating factor that increases production of red blood cells. Filgrastim is for neutropenia. Mesna is used to decrease bladder toxicity from some chemotherapeutic agents. Dexrazoxane helps protect the heart from cardiotoxicity from other agents.

The nurse has educated a client on precautions to take with thrombocytopenia. What statement by the client indicates a need to review the information?a. "I will be careful if I need enemas for constipation." "I will use an electric shaver instead of a razor." "I should only eat soft food that is either cool or warm." "I won't be able to play sports with my grandkids."

A The thrombocytopenic client is at high risk for bleeding even from minor trauma. Due to the risk of injuring rectal and anal tissue, the client should not use enemas or rectal thermometers. This statement would indicate the client needs more information. The other statements are appropriate for the thrombocytopenic client.

A client has been admitted after sustaining a humerus fracture that occurred when picking up the family cat. What test result would the nurse correlate to this condition? Bence-Jones protein in urine Epstein-Barr virus: positive Hemoglobin: 18 mg/dL (180 mmol/L) Red blood cell count: 8.2 million/mcL (8.2 1012/L)

A This client has possible multiple myeloma. A positive Bence-Jones protein finding would correlate with this condition. The Epstein-Barr virus is a herpesvirus that causes infectious mononucleosis and some cancers. A hemoglobin of 18 mg/dL (180 mmol/L) is slightly high for a male and somewhat high for a female; this can be caused by several conditions, and further information would be needed to correlate this value with a specific medical condition. A red blood cell count of 8.2 million/mcL (8.2 1012/L) is also high, but again, more information would be needed to correlate this finding with a specific medical condition.

A client in the emergency department reports difficulty breathing. The nurse assesses the client's appearance as depicted below: What action by the nurse is most important? Assess blood pressure and pulse. Attach the client to a pulse oximeter. Have the client rate his or her pain. Facilitate urgent radiation therapy.

A This client has superior vena cava syndrome, in which venous return from the head, neck, and trunk is blocked. Decreased cardiac output can occur. The nurse would assess indicators of cardiac output, including blood pressure and pulse, as the priority. The other actions are also appropriate but are not as important. The ED nurse may or may not be able to facilitate radiation therapy.

A client with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important? Assess the client's gait and balance. Ask the client about the ease of urine flow. Document the report completely. Inquire about the client's job risks.

A This client has symptoms of spinal cord compression, which can be seen with prostate cancer. This may affect both gait and balance and urinary function. For client safety, assessing gait and balance is most important. Documentation would be complete. The client may or may not have occupational risks for low back pain, but with his history of prostate cancer, this would not be where the nurse starts investigating.

A nurse is caring for a client admitted for Non-Hodgkin's lymphoma and chemotherapy. The client reports nausea, flank pain, and muscle cramps. What action by the nurse is most important? Request an order for serum electrolytes and uric acid. Increase the client's IV infusion rate. Instruct assistive personnel to strain all urine. Administer an IV antiemetic.

A This client's reports are consistent with tumor lysis syndrome, for which he or she is at risk due to the diagnosis. Early symptoms of TLS stem from electrolyte imbalances and can include lethargy, nausea, vomiting, anorexia, flank pain, muscle weakness, cramps, seizures, and altered mental status. The nurse would notify the primary health care provider and request an order for serum electrolytes. Hydration is important in both preventing and managing this syndrome, but the nurse would not just increase the IV rate. Assistive personnel may need to strain the client's urine and the client may need an antiemetic, but first the nurse would assess the situation further by obtaining pertinent lab tests.

The nurse observes a client with late-stage Alzheimer disease eat breakfast. Afterward the client states, "I am hungry and want breakfast." What is the nurse's best response? "I see you are still hungry. I will get you some toast." "You ate your breakfast 30 minutes ago." "It appears you are confused this morning." "Your family will be here soon. Let's get you dressed."

A Use of validation therapy with clients who have late-stage Alzheimer disease involves acknowledgment of the client's feelings and concerns. This technique has proved more effective in later stages of the disease because reality orientation only increases agitation. The other statements do not validate the client's concerns.

A client has a platelet count of 9000/mm3 (9 109/L). The nurse finds the client confused and mumbling. What nursing action takes priority at this time? Call the Rapid Response Team. Take a set of vital signs. Institute bleeding precautions. Place the client on bedrest

A With a platelet count this low, the client is at high risk of spontaneous bleeding. The most disastrous complication would be intracranial bleeding. The nurse needs to call the Rapid Response Team as this client has manifestations of a sudden neurologic change. Bleeding precautions will not address the immediate situation. Placing the client on bedrest is important, but the critical action is to call for immediate medical attention.

A client's family members are concerned that telling the client about a new finding of cancer will cause extreme emotional distress. They approach the nurse and ask if this can be kept from the client. What actions by the nurse are most appropriate? (Select all that apply.) Ask the family to describe their concerns more fully. Consult with a social worker, chaplain, or ethics committee. Explain the client's right to know and ask for their assistance. Have the unit manager take over the care of this client and family. Tell the family that this secret will not be kept from the client.

A, B, C The client's right of autonomy means that the client must be fully informed as to his or her diagnosis and treatment options. The nurse cannot ethically keep this information from the client. The nurse can ask the family to explain their concerns more fully so everyone understands them. A social worker, chaplain, or ethics committee can become involved to assist the nurse, client, and family. The nurse would explain the client's right to know and ask the family how best to proceed. Enlisting their help might reduce their reluctance for the client to be informed. The nurse would not abdicate responsibility for this difficult situation by transferring care to another nurse. Simply telling the family that he or she will not keep this secret sets up an adversarial relationship. Explaining this fact along with the concept of autonomy would be acceptable, but this by itself is not.

The nurse working with oncology clients understands that interacting factors affect cancer development. Which factors does this include? (Select all that apply.) Exposure to carcinogens Genetic predisposition Immune function Normal doubling time State of euploidy

A, B, C The three interacting factors needed for cancer development are exposure to carcinogens, genetic predisposition, and immune function.

The nurse is assessing a client with chronic leukemia. Which laboratory test result(s) is (are) expected for this client? (Select all that apply.) Decreased hematocrit Abnormal white blood cell count Low platelet count Decreased hemoglobin Increased albumin

A, B, C, D Chronic leukemia affects all types of blood cells causing a decrease is red blood cells (RBCs) and platelets. When the number of RBCs decreases, the client's hemoglobin and hematocrit also decrease. White blood cell counts are also abnormal depending on disease progression and management.

The nurse is caring for a client being treated for Hodgkin lymphoma. For which side effect(s) of treatment will the nurse assess? (Select all that apply.) Severe nausea and vomiting Low platelet count Skin irritation at radiation site Low red blood cell count High white blood cell count

A, B, C, D Drug and radiation therapy for Hodgkin lymphoma cause many side and adverse effects, including all of the choices except for a high white blood cell (WBC) count. Instead, most clients experience a low WBC count making them very susceptible to infections.

The nurse caring for clients who have cancer understands that the general consequences of cancer include which client problems? (Select all that apply.) Clotting abnormalities from thrombocythemia Increased risk of infection from white blood cell deficits Nutritional deficits such as early satiety and cachexia Potential for reduced gas exchange Various motor and sensory deficits Increased risk of bone fractures

A, B, C, D, E, F The general consequences of cancer include reduced immunity and blood-producing functions, altered GI structure and function, decreased respiratory function, and motor and sensory deficits. Clotting problems often occur due to thrombocytopenia (not enough platelets), not thrombocythemia (too many platelets).

A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (Select all that apply.) "Chemo" gloves Face mask Impervious gown N95 respirator Shoe covers Eye protection

A, B, C, F The Occupational Safety and Health Administration (OSHA) and the Oncology Nurses Society have developed safety guidelines for those preparing or administering IV chemotherapy. These include double gloves (or "chemo" gloves), eye protection, a face mask, and a gown. An N95 respirator and shoe covers are not required.

A client has thrombocytopenia. What actions does the nurse delegate to assistive personnel (AP)? (Select all that apply.) Apply the client's shoes before getting the client out of bed. Assist the client with ambulation. Shave the client with a safety razor only. Use a lift sheet to move the client up in bed. Use a water pressure device be set on low for oral care.

A, B, D Clients with thrombocytopenia are at risk of significant bleeding even with minor injuries. The nurse instructs the AP to put the client's shoes on before getting the client out of bed, assist with ambulation, shave the client with an electric razor, use a lift sheet when needed to reposition the client, and use a soft-bristled toothbrush for oral care. All of these measures help prevent client injury.

The nurse is preparing to administer a blood transfusion. Which action(s) by the nurse is (are) most appropriate? (Select all that apply.) Hang the blood product using normal saline and a filtered tubing set. Take a full set of vital signs prior to starting the blood transfusion. Tell the client that someone will remain at the bedside for the first 5 minutes. Use gloves to start the client's IV if needed and to handle the blood product. Verify the client's identity, and checking blood compatibility and expiration time.

A, B, D Correct actions prior to beginning a blood transfusion include hanging the product with saline and the correct filtered blood tubing, taking a full set of vital signs prior to starting, and using gloves. Someone stays with the client for the first 15 to 20 minutes of the transfusion. Two registered nurses must verify the client's identity and blood compatibility.

The nurse is caring for a client receiving a unit of whole blood. Which nursing action(s) is (are) appropriate regarding infusion administration. (Select all that apply.) Use a dedicated filtered blood administration set. Stay with the client for the first 15 to 20 minutes of the infusion. Infuse the blood over a 30-minute period of time. Monitor and document vital signs per agency policy. Use a 21-gauge or smaller catheter to administer the blood. Infuse the transfusion with intravenous normal saline.

A, B, D, F Blood administration requires a dedicated and filtered intravenous set and a larger catheter or needle due to the viscosity of the infusion. Normal saline is the only IV fluid that is compatible with blood. Vital signs are frequently monitored and documented while the client is carefully assesses for signs and symptoms of a blood transfusion reaction, usually within the first 15 to 20 minutes. One unit of blood is administered in no less than 60 minutes.

A nurse is caring for an older adult receiving multiple packed red blood cell transfusions. Which assessment finding(s) indicate(s) possible transfusion circulatory overload? (Select all that apply.) Acute confusion Dyspnea Depression Hypertension Bradycardia Bounding pulse

A, B, D, F Circulatory overload is the result of excessive body fluid which can cause signs and symptoms of heart failure including dyspnea, increased blood pressure, tachycardia (not bradycardia), and a bounding pulse. Dyspnea is caused by hypoxia which in older adults can cause acute confusion. Depression is not a common finding resulting from fluid overload.

A client has mucositis. What actions by the nurse will improve the client's nutrition? (Select all that apply.) Assist with rinsing the mouth with saline frequently. Encourage the client to eat room-temperature foods. Give the client hot liquids to hold in the mouth. Provide local anesthetic medications to swish and spit. Remind the client to brush teeth gently after each meal. Offer the client fluids to drink each hour.

A, B, D, F Mucositis can interfere with nutrition. The nurse can help with rinsing the mouth frequently with water or saline; encouraging the client to eat cool, slightly warm, or room-temperature foods; providing swish-and-spit anesthetics; and reminding the client to keep the mouth clean by brushing gently after each meal. Drinking plenty of fluids (unless contraindicated for another condition) is another beneficial measure. Hot liquids would be painful for the client.

A nurse is preparing to administer a packed red blood cell transfusion to an older adult. Understanding age-related changes, what alteration(s) in the usual protocol is (are) necessary for the nurse to implement? (Select all that apply.) Assess vital signs at least every 15 minutes. Avoid giving other IV fluids. Premedicate to prevent transfusion reaction. Transfuse smaller bags of blood. Transfuse each unit over 8 hours. Assess the client for fluid overload.

A, B, F The older adult needs vital signs monitored as often as every 15 minutes for the duration of the transfusion because vital sign changes may be the only indication of a transfusion-related problem. To prevent fluid overload, the nurse obtains a prescription to hold other running IV fluids during the transfusion and assesses the client frequently for signs and symptoms of overload. The other options are not correct.

A client receiving chemotherapy has a white blood cell count of 1000/mm3 (1 109/L). What actions by the nurse are most appropriate? (Select all that apply.) Assess all mucous membranes every 4 to 8 hours. Do not allow the client to eat meat or poultry. Listen to lung sounds and monitor for cough. Monitor the venous access device appearance hourly. Take and record vital signs every 4 to 8 hours. Encourage activity the client can tolerate.

A, C, D, E Depending on facility protocol, the nurse would assess this client for infection every 4 to 8 hours by assessing all mucous membranes, listening to lung sounds, monitoring for cough, monitoring the appearance of the venous access device, and recording vital signs. Assisting the client with mobilization will also help prevent infection. Eating meat and poultry is allowed.

A nurse working with clients diagnosed with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crises. What factor(s) should clients be taught to avoid? (Select all that apply.) Dehydration Exercise Extreme stress High altitudes Pregnancy

A, C, D, E Several factors cause red blood cells to sickle in SCD, including dehydration, extreme stress, high altitudes, and pregnancy. Strenuous exercise can also cause sickling, but not unless it is very vigorous.

A client receiving radiation therapy reports severe skin itching and irritation. What actions does the nurse delegate to assistive personnel (AP)? (Select all that apply.) Apply approved moisturizers to dry skin. Apply steroid creams to the skin. Bathe the client using mild soap. Help the client pat skin dry after a bath. Teach the client to avoid sunlight. Make sure no clothing is rubbing the site.

A, C, D, F The nurse can delegate applying moisturizer approved by the radiation oncologist using mild soap for bathing, and helping the client pat wet skin dry after bathing. Any clothing worn over the site should be soft and not create friction. Steroid creams are not used for this condition. Hot water will worsen the irritation. Client teaching is a nursing function.

Which risk factor(s) places a client at risk for leukemia? (Select all that apply.) a. Chemical exposure Genetically modified foods Ionizing radiation exposure Vaccinations Viral infections

A, C, E Chemical and ionizing radiation exposure and viral infections are known risk factors for developing leukemia. Eating genetically modified food and receiving vaccinations are not known risk factors.

Which statement(s) about blood transfusion compatibilities is (are) correct? (Select all that apply.) Donor blood type A can donate to recipient blood type AB. Donor blood type B can donate to recipient blood type O. Donor blood type AB can donate to anyone. Donor blood type O can donate to anyone. Donor blood type A can donate to recipient blood type B.

A, D Blood type A can be donated to people who have blood types A or AB. Blood type O can be given to anyone. Blood type B can be donated to people who have blood types B or AB. Blood type AB can only go to recipients with blood type AB.

The nurse learning about cancer development remembers characteristics of normal cells. Which characteristics does this include? (Select all that apply.) Differentiated function Large nucleus-to-cytoplasm ratio Loose adherence Nonmigratory Specific morphology Orderly and specific growth

A, D, E, F Normal cells have the characteristics of differentiated function, nonmigratory, specific morphology, a smaller nucleus-to-cytoplasm ratio, tight adherence, and orderly and well-regulated growth.

Which assessment finding(s) may indicate that a client may be experiencing a blood transfusion reaction? (Select all that apply.) a. Tachycardia b. Fever c. Bronchospasm d. Tachypnea e. Urticaria f. Hypotension

A,B,C,D,E,F Several types of blood transfusion reactions can occur and cause all of the findings listed.

A nurse is providing community education on the seven warning signs of cancer. Which signs are included? (Select all that apply.) A sore that does not heal Changes in menstrual patterns Indigestion or trouble swallowing Near-daily abdominal pain Obvious change in a mole Frequent indigestion

A,B,C,E,F The seven warning signs for cancer can be remembered with the acronym CAUTION: changes in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in a wart or mole, and nagging cough or hoarseness. Abdominal pain is not a warning sign.

A client with long-standing heart failure being treated for cancer has received a dose of ondansetron for nausea. What action by the nurse is most important? Assess the client for a headache or dizziness. Request a prescription for cardiac monitoring Instruct the client to change positions slowly. Weigh the client daily before eating.

B 5-HT3 antagonists, such as ondansetron, can prolong the QT interval within the cardiac conduction cycle. ECG monitoring is recommended in patients with electrolyte abnormalities (e.g., hypokalemia or hypomagnesemia), heart failure, bradyarrhythmias or patients taking other medications that can cause QT prolongation. The nurse would contact the primary health care provider and request cardiac monitoring. The nurse would assess the client for any other reported changes, but this is not a critical safety factor. Weight is not related directly to this drug.

A client has a platelet count of 9800/mm3 (9800 109/L). What action by the nurse is most appropriate? Assess the client for calf pain, warmth, and redness. Instruct the client to call for help to get out of bed. Obtain cultures as per the facility's standing policy. Place the client on protective Isolation Precautions.

B A client with a platelet count this low is at high risk for serious bleeding episodes. To prevent injury, the client would be instructed to call for help prior to getting out of bed. Calf pain, warmth, and redness might indicate a deep vein thrombosis, not associated with low platelets. Cultures and isolation relate to low white cell counts.

A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client would the nurse assess first? Client with a blood pressure of 180/98 mm Hg Client who reports shortness of breath Client who reports calf tenderness and swelling Client with a swollen and painful left great toe

B Clients with polycythemia vera often have clotting abnormalities due to the hyperviscous blood with sluggish flow. The client reporting shortness of breath may have a pulmonary embolism and should be seen first. The client with a swollen calf may have a deep vein thrombosis and should be seen next. High blood pressure and gout symptoms are common findings with this disorder.

The nurse learning about cellular regulation understands that which process occurs during the S phase of the cell cycle? Actual division (mitosis) Doubling of DNA Growing extra membrane No reproductive activity

B During the S phase, the cell must double its DNA content through DNA synthesis. Actual division, or mitosis, occurs during the M phase. Growing extra membrane occurs in the G1 phase. During the G0 phase, the cell is working but is not involved in any reproductive activity.

A client with cancer has anorexia and mucositis, and is losing weight. The client's family members continually bring favorite foods to the client and are distressed when the client won't eat them. What action by the nurse is best? Explain the pathophysiologic reasons behind the client not eating. Help the family show other ways to demonstrate love and caring. Suggest foods and liquids the client might be willing to try to eat. Tell the family the client isn't able to eat now no matter what they bring.

B Families often become distressed when their loved ones won't eat. Providing food is a universal sign of caring, and to some people the refusal to eat signifies worsening of the condition. The best option for the nurse is to help the family find other ways to demonstrate caring and love, because with treatment-related anorexia and mucositis, the client is not likely to eat anything right now. Explaining the rationale for the problem is a good idea but does not suggest to the family anything that they can do for the client. Simply telling the family the client is not able to eat does not give them useful information and is dismissive of their concerns.

A nurse is preparing to administer a blood transfusion. What action is most important? Correctly identify client using two identifiers. Ensure that informed consent is obtained. Hang the blood product with Ringer's lactate. Stay with the client for the entire transfusion.

B If the facility requires informed consent for transfusions, this action is most important because it precedes the other actions taken during the transfusion. Correctly identifying the client and blood product is a National Patient Safety Goal, and is the most important action after obtaining informed consent. Ringer's lactate is not used to transfuse blood. The nurse does not need to stay with the client for the duration of the transfusion.

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication would the nurse anticipate to prepare for administration? Atenolol Lorazepam Phenytoin Lisinopril

B Initially, intravenous lorazepam or diazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These drugs are typically administered for hypertension and heart failure.

The family of a neutropenic client reports that the client "is not acting right." What action by the nurse is the priority? Ask the client about pain. Assess the client for infection. Take a set of vital signs. Review today's laboratory results.

B Neutropenic clients often do not have classic manifestations of infection, but infection is the most common cause of death in neutropenic clients. The nurse would definitely assess for infection. The nurse would assess for pain but this is not the priority.

A nurse is teaching a client who experiences migraine headaches and is prescribed propranolol. Which statement would the nurse include in this client's teaching? "Take this drug only when you have symptoms indicating the onset of a migraine headache." "Take this drug as prescribed, even when feeling well, to prevent vascular changes associated with migraine headaches." "This drug will relieve the pain during the aura phase soon after a headache has started." "This drug will have no effect on your heart rate or blood pressure because you are taking it for migraines."

B Propranolol is a beta-adrenergic blocker which is prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client would monitor these side effects. The other responses do not discuss appropriate uses of this drug.

A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate? "Are you getting adequate rest and sleep each day?" "It is normal to be fatigued even for months afterward." "This is not normal and I'll let the primary health care provider know." "Try adding more vitamins B and C to your diet."

B Radiation-induced fatigue can be debilitating and may last for months after treatment has ended. Rest and adequate nutrition can affect fatigue, but it is most important that the client (and family) understands this is normal.

The nurse cares for a client with middle-stage (moderate) Alzheimer disease. The client's caregiver states, "She is always wandering off. What can I do to manage this restless behavior?" What is the nurse's best response? "This is a sign of fatigue. The client would benefit from a daily nap." "Engage the client in scheduled activities throughout the day." "It sounds like this is difficult for you. I will consult the social worker." "The provider can prescribe a mild sedative for restlessness."

B Several strategies may be used to cope with restlessness and wandering. One strategy is to engage the client in structured activities. Another is to take the client for frequent walks. Daily naps and a mild sedative will not be as effective in the management of restless behavior. Consulting the social worker does not address the caregiver's concern.

The nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate for migraine headaches. Which condition would alert the nurse to withhold the medication and contact the primary health care provider? Bronchial asthma Heart disease Diabetes mellitus Rheumatoid arthritis

B Sumatriptan succinate effectively reduces pain and other associated symptoms of migraine headache by binding to serotonin receptors and triggering cranial vasoconstriction. Vasoconstrictive effects are not confined to the cranium and can cause coronary vasospasm in clients with heart disease, hypertension, or Prinzmetal angina. The other conditions would not affect the client's treatment.

A client with early-stage Alzheimer disease is admitted to the hospital with chest pain. Which nursing action is most appropriate to manage this client's dementia? Provide animal-assisted therapy as needed. Ensure a structured and consistent environment. Assist the client with activities of daily living (ADLs). Use validation therapy when communicating with the client.

B The client who has early Alzheimer disease (AD) does not require assistance with ADLs or validation therapy. While animal-assisted therapy may be helpful, some health care agencies do not allow this intervention. Therefore, the most appropriate action is to provide a structured and consistent environment while the client is hospitalized to prevent worsening of the client's symptoms.

The nurse is assessing a client who has probable lymphoma. What is the most common early assessment finding for clients with this disorder? Weight gain Enlarged painless lymph node(s) Fever at night Nausea and vomiting

B The first change that is noted for clients with probable lymphoma is one or more enlarged lymph nodes. The other findings are either not common in clients with lymphoma or later findings.

A nurse learns that which of the following is the single biggest risk factor for developing cancer? Exposure to tobacco Advancing age Occupational chemicals Oncovirus infection

B The single biggest risk factor for developing cancer is advancing age. As one ages, immunity decreases and exposures increase. Tobacco use is the single most preventable cause of cancer. Exposure to chemicals and oncoviruses cause fewer cancers.

A client tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate? "Avoid getting salt water on the radiation site." "Do not expose the radiation area to direct sunlight." "Have a wonderful time and enjoy your vacation!" "Remember you should not drink alcohol for a year."

B The skin overlying the radiation site is extremely sensitive to sunlight after radiation therapy has been completed. The nurse would inform the client to avoid sun exposure to this area. This advice continues for 1 year after treatment has been completed. The other statements are not appropriate.

A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important? Document the events in the client's medical record. Double-check the client and blood product identification. Place the client on strict bedrest until the pain subsides. Review the client's medical record for known allergies.

B This client most likely had a hemolytic transfusion reaction, most commonly caused by blood type or Rh incompatibility. The nurse should double-check all identifying information for both the client and blood type. Documentation occurs after the client is stable. Bedrest may or may not be needed. Allergies to medications or environmental items are not related.

A client is having a catheter placed to deliver chemotherapy beads into a liver tumor via the femoral artery. What action by the nurse is most important? Assessing the client's abdomen beforehand Ensuring that informed consent is on the chart Marking the client's bilateral pedal pulses Reviewing client teaching done previously

B This is an invasive procedure requiring informed consent. The nurse would ensure that consent is on the chart. The other actions are also appropriate but not as important as ensuring the client has given consent.

A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse most likely to engage? (Select all that apply.) Demonstrating breast self-examination methods to women Instructing people on the use of chemoprevention Providing vaccinations against certain cancers Screening teenage girls for cervical cancer Teaching teens the dangers of tanning booths Educating adults about healthy eating habits

B, C, E, F Primary prevention aims to prevent the occurrence of a disease or disorder, in this case cancer. Secondary prevention includes screening and early diagnosis. Primary prevention activities include teaching people about chemoprevention, providing approved vaccinations to prevent cancer, teaching teens the dangers of tanning beds, and educating adults on eating habits to reduce the risk of getting cancer. Breast examinations and screening for cervical cancer are secondary prevention methods.

A nurse is caring for a young male client with lymphoma who is to begin treatment. What teaching topic is a priority? Genetic testing Infection prevention Sperm banking Treatment options

C All teaching topics are important to the client with lymphoma, but for a young male, sperm banking is of particular concern if the client is going to have radiation to the lower abdomen or pelvis.

A nurse is learning the difference between normal cells and benign tumor cells. What information does this include? Benign tumors grow through invasion of other tissue. Benign tumors have lost their cellular regulation from contact inhibition. Growing in the wrong place or time is typical of benign tumors. The loss of characteristics of the parent cells is called anaplasia.

C Benign tumors are basically normal cells growing in the wrong place or at the wrong time. Benign cells grow through hyperplasia, not invasion. Benign tumor cells retain contact inhibition. Anaplasia is a characteristic of cancer cells.

The nurse teaches assistive personnel (AP) about how to care for a client with early-stage Alzheimer disease. Which statement would the nurse include? "If she is confused, play along and pretend that everything is okay." "Remove the clock from her room so that she doesn't get confused." "Reorient the client to the day, time, and environment with each contact." "Use validation therapy to recognize and acknowledge the client's concerns."

C Clients who have early-stage Alzheimer disease would be reoriented frequently to person, place, and time. The AP would reorient the client and not encourage the client's delusions. The room would have a clock and white board with the current date written on it. Validation therapy is used with late-stage Alzheimer disease.

The nurse is teaching the daughter of a client who has middle-stage Alzheimer disease. The daughter asks, "Will the sertraline my mother is taking improve her dementia?" How would the nurse respond about the purpose of the drug? "It will allow your mother to live independently for several more years." "It is used to halt the advancement of Alzheimer disease but will not cure it." "It will not improve her dementia but can help control emotional responses." "It is used to improve short-term memory but will not improve problem solving."

C Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer disease. However, certain psychoactive drugs may help suppress emotional disturbances and manage depression, psychoses, or anxiety. Drug therapy will not allow the client with middle-stage dementia to safely live independently.

The nurse assesses a client who has a history of migraines. Which symptom would the nurse identify as an early sign of a migraine with aura? Vertigo Lethargy Visual disturbances Numbness of the tongue

C Early warning of impending migraine with aura usually consists of visual changes, flashing lights, or diplopia. The other symptoms are not associated with an impending migraine with aura.

A nurse is caring for a client who is about to receive a bone marrow transplant. To best help the client cope with the long recovery period, what action by the nurse is best? Arrange a visitation schedule among friends and family. Explain that this process is difficult but must be endured. Help the client find things to hope for each day of recovery. Provide plenty of diversionary activities for this time.

C Providing hope is an essential nursing function during treatment for any disease process, but especially during the recovery period after bone marrow transplantation, which can take up to 3 weeks. The nurse can help the client look ahead to the recovery period and identify things to hope for during this time. Visitors are important to clients, but may pose an infection risk. Telling the client that the recovery period must be endured does not acknowledge his or her feelings. Diversionary activities are important, but not as important as instilling hope.

A client is receiving rituximab and asks how it works. What response by the nurse is best? "It causes rapid lysis of the cancer cell membranes." "It destroys the enzymes needed to create cancer cells." "It prevents the start of cell division in the cancer cells." "It sensitizes certain cancer cells to chemotherapy."

C Rituximab prevents the initiation of cancer cell division. The other statements are not accurate.

A client is admitted with superior vena cava syndrome. What action by the nurse is most appropriate? Administer a dose of allopurinol. Assess the client's serum potassium level. Gently inquire about advance directives. Prepare the client for emergency surgery.

C Superior vena cava syndrome is often a late-stage manifestation. After the client is stabilized and comfortable, the nurse would initiate a conversation about advance directives. Allopurinol is used for tumor lysis syndrome. Potassium levels are important in tumor lysis syndrome, in which cell destruction leads to large quantities of potassium being released into the bloodstream. Surgery is rarely done for superior vena cava syndrome.

The nurse assesses a client's oral cavity as seen in the photo below: What action by the nurse is most appropriate? Encourage the client to have genetic testing. Instruct the client on high-fiber foods. Place the client in protective precautions. Teach the client about cobalamin therapy.

D This condition is known as glossitis, and is characteristic of B12 anemia. If the anemia is a pernicious anemia, it is treated with cobalamin. Genetic testing is not a priority for this condition. The client does not need high-fiber foods or protective precautions.

Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients would the nurse assess first? Dry, itchy, peeling skin Serum calcium of 9.2 mg/dL (2.3 mmol/L) Serum potassium of 2.8 mEq/L (2.8 mmol/L) Weight gain of 0.5 lb (1.1 kg) in 1 day

C TKIs can cause electrolyte imbalances. This potassium level is very low, so the nurse would assess this client first. Dry, itchy, peeling skin can be a problem in clients receiving cancer treatments, and the nurse would assess that client next because of the potential for discomfort and infection. This calcium level is normal. TKIs can also cause weight gain, but the client with the low potassium level is more critical.

A client has thrombocytopenia. What statement indicates that the client understands self-management of this condition? "I brush and use dental floss every day." "I chew hard candy for my dry mouth." "I usually put ice on bumps or bruises." "Nonslip socks are best when I walk."

C The client should be taught to apply ice to areas of minor trauma. Flossing is not recommended. Hard foods should be avoided. The client should wear well-fitting shoes when ambulating.

The nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. What action would the nurse take first? Start fluids via a large-bore catheter. Administer IV push diazepam. Turn the client's head to the side. Prepare to intubate the client.

C The nurse would turn the client's head to the side to prevent aspiration and allow drainage of secretions. Anticonvulsants are administered on a routine basis if a seizure is sustained. If the seizure is sustained (status epilepticus), the client must be intubated and would be administered oxygen, 0.9% sodium chloride, and IV push lorazepam or diazepam.

The nurse is assessing a client in sickle cell disease (SCD) crisis. What priority client problem will the nurse expect? a. Infection b. Pallor c. Pain d. Fatigue

C The priority expected client problem for clients experiencing sickle cell disease crisis is pain, often concentrated in the legs, arms, and joints. Clients may also be fatigued and pale but these symptoms are not a priority for care. Infection is not expected but can occur in clients who have SCD crisis.

A nurse has taught a client about dietary changes that can reduce the chances of developing cancer. What statement by the client indicates the nurse needs to provide additional teaching? "Foods high in vitamin A and vitamin C are important." "I'll have to cut down on the amount of bacon I eat." "I'm so glad I don't have to give up my juicy steaks." "Vegetables, fruit, and high-fiber grains are important."

C To decrease the risk of developing cancer, one should cut down on the consumption of red meats and animal fat. The other statements are correct.

A client has received a bone marrow transplant and is waiting for engraftment. What action(s) by the nurse are most appropriate? (Select all that apply.) Not allowing any visitors until engraftment Limiting the protein in the client's diet Placing the client in protective precautions Teaching visitors appropriate hand hygiene Telling visitors not to bring live flowers or plants

C, D, E The client waiting for engraftment after bone marrow transplant has no white cells to protect him or her against infection. The client is on protective precautions and visitors are taught hand hygiene. No fresh flowers or plants are allowed due to the standing water in the vase or container that may harbor organisms; clients are also told not to work with houseplants in the home. Limiting protein is not a healthy option and will not promote engraftment.

A nurse is assessing a female client who is taking hormone therapy for breast cancer. What assessment finding requires the nurse to notify the primary health care provider immediately? Irregular menses Edema in the lower extremities Ongoing breast tenderness Red, warm, swollen calf

D Clients receiving hormone therapy are at risk for thromboembolism. A red, warm, swollen calf is indicative of deep vein thrombosis and would be reported to the provider. Irregular menses, edema in the lower extremities, and breast tenderness are not as urgent as the possible thromboembolism.

The nurse has taught a client with cancer ways to prevent infection. What statement by the client indicates that more teaching is needed? "I should take my temperature daily and when I don't feel well." "I will discard perishable liquids after sitting out for over an hour." "I won't let anyone share any of my personal toiletries." "It's alright for me to keep my pets and change the litter box."

D Clients should wash their hands after touching their pets and would not empty or scoop the cat litter box. The other statements are appropriate for self-management.

A nurse is assessing a client with glioblastoma. What assessment is most important? Abdominal palpation Abdominal percussion Lung auscultation Neurologic examination

D A glioblastoma arises in the brain. The most important assessment for this client is the neurologic examination.

A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority? Helping clients adjust to their appearance Reassuring clients that this change is temporary Referring clients to a reputable wig shop Teaching measures to prevent scalp injury

D All of the actions are appropriate for clients with alopecia. However, the priority is client safety, so the nurse would first teach ways to prevent scalp injury.

A client with multiple myeloma demonstrates worsening bone density on diagnostic scans. About what drug does the nurse plan to teach this client? Bortezomib Dexamethasone Thalidomide Zoledronic acid

D All the options are drugs used to treat multiple myeloma, but the drug used specifically for bone manifestations is zoledronic acid, which is a bisphosphonate. This drug class inhibits bone resorption and is used to treat osteoporosis as well.

A client diagnosed with Parkinson disease will be starting ropinirole for symptom control. Which statement by the client indicates a need for further teaching? "This drug should help decrease my tremors and help me move better." "I need to change positions slowly to prevent dizziness or falls." "I should take the drug at the same time each day for the best effect." "I know the drug will probably make help me prevent constipation."

D Although ropinirole is a dopamine agonist and mimics dopamine to promote movement, it does not work to prevent constipation. This class of drugs can cause orthostatic hypotension and should be taken at the same time every day.

A nurse asks the staff development nurse what "apoptosis" means. What response best? Growth by cells enlarging Having the normal number of chromosomes Inhibition of cell growth Programmed cell death

D Apoptosis is programmed cell death. With this characteristic, organs and tissues function with cells that are at their peak of performance. Growth by cells enlarging is hyperplasia. Having the normal number of chromosomes is euploidy. Inhibition of cell growth is contact inhibition.

After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife's understanding. Which statement by the client's wife indicates that she correctly understands changes associated with this disease? "His masklike face makes it difficult to communicate, so I will use a white board." "He should not socialize outside of the house due to uncontrollable drooling." "This disease is associated with anxiety causing increased perspiration." "He may have trouble chewing, so I will offer bite-sized portions."

D Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the client's nutritional needs. A masklike face and drooling are common in clients with Parkinson disease. The client would be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the client's masklike face can be misinterpreted and additional time may be needed for the client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson disease and is associated with the autonomic nervous system's response.

The nurse prepares to discharge a client with early to moderate Alzheimer disease. Which statement to maintain client safety would the nurse include in the discharge teaching for the caregiver? "Provide periods of exercise and rest for the client." "Place a padded throw rug at the bedside." "Provide a highly stimulating environment." "Install safety locks on all outside doors."

D Clients with early to moderate Alzheimer disease have a tendency to wander, especially at night. If possible, alarms would be installed on all outside doors to alert family members if the client leaves. At a minimum, all outside doors should have safety locks installed to prevent the client from going outdoors unsupervised. The client would be allowed to exercise within his or her limits, but this action does not ensure his or her safety. Throw rugs are a slip and fall hazard and would be removed. A highly stimulating environment would likely increase the client's confusion.

The primary health care provider prescribes donepezil for a client diagnosed with early-stage Alzheimer disease. What teaching about this drug will the nurse provide for the client's family caregiver? "Monitor the client's temperature because the drug can cause a low grade fever." "Observe the client for nausea and vomiting to determine drug tolerance." "Donepezil will prevent the client's dementia from progressing as usual." "Report any client dizziness or falls because the drug can cause bradycardia."

D Donepezil is a cholinesterase inhibitor that may temporarily slow cognitive decline for some clients but does not alter the course of the disease. The family caregiver would want to monitor the client's heart rate and report any incidence of dizziness or falls because the drug can cause bradycardia. It does not typically cause fever or nausea/vomiting.

A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the client's oral chemotherapy medications. What action by the nurse is most appropriate? Crush the medications if the client cannot swallow them. Give one medication at a time with a full glass of water. No special precautions are needed for these medications. Wear personal protective equipment when handling the medications.

D During the administration of oral chemotherapy agents, nurses must take the same precautions that are used when administering IV chemotherapy. This includes using personal protective equipment. These medications cannot be crushed, split, or chewed. Giving one at a time is not needed.

The nurse plans care for a client with Parkinson disease. Which intervention would the nurse include in this client's plan of care? Restrain the client to prevent falling. Ensure that the client uses incentive spirometry. Teach the client pursed-lip breathing techniques. Keep the head of the bed at 30 degrees or greater.

D Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson disease. Pursed-lip breathing increases exhalation of carbon dioxide; incentive spirometry expands the lungs. The client should not be restrained to prevent falls. Other less restrictive interventions should be used to maintain client safety.

The nurse is caring for a client experiencing sickle cell disease crisis. Which priority action would help prevent infection? Administering prophylactic antibiotics Monitoring the client's temperature Checking the client's white blood cell count Performing frequent handwashing

D Frequent and thorough handwashing is the most important intervention that helps prevent infection. Antibiotics are not usually used to prevent infection. Monitoring the client's temperature or white blood cell count helps to detect the presence of infection, but prevent it.

A client asks about the process of graft-versus-host disease. What explanation by the nurse is correct? "Because of immunosuppression, the donor cells take over." "It's like a transfusion reaction because no perfect matches exist." "The patient's cells are fighting donor cells for dominance." "The donor's cells are actually attacking the patient's cells."

D Graft-versus-host disease is an autoimmune-type process in which the donor cells recognize the client's cells as foreign and begin attacking them. The other answers are not accurate.

An assistive personnel is caring for a client with leukemia and asks why the client is still at risk for infection when the white blood cell count (WBC) is high. What response by the nurse is correct? "If the WBCs are high, there already is an infection present." "The client is in a blast crisis and has too many WBCs." "There must be a mistake; the WBCs should be very low." "Those WBCs are abnormal and don't provide protection."

D In leukemia, the WBCs are abnormal and do not provide protection to the client against infection. The other statements are not accurate.

The nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How would the nurse document this type of seizure? Atonic Myoclonic Absenced Tonic-clonic

D Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. An atonic seizure presents as a sudden loss of muscle tone followed by postictal confusion. A myoclonic seizure presents with a brief jerking or stiffening of extremities that may occur singly or in groups. Absence seizures present with automatisms, and the client is unaware of his or her environment.

A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads in the client's chart that the cancer classification is TISN0M0. What does the nurse conclude about this client's cancer? The primary site of the cancer cannot be determined. Regional lymph nodes could not be assessed. There are multiple lymph nodes involved already. There are no distant metastases noted in the report.

D TIS stands for carcinoma in situ; N0 stands for no regional lymph node metastasis; and M0 stands for no distant metastasis.

Which statement by a client with leukemia indicates a need for further teaching by the nurse? "I will use a soft-bristled toothbrush and avoid flossing." "I will not take aspirin or any aspirin product." "I will use an electric shaver instead of my manual one." "I will take a daily laxative to prevent constipation."

D The client experiencing leukemia needs to prevent injury to prevent bleeding, including avoiding hard-bristled toothbrushes, floss, aspirin, and straight or manual safety razors. However, although constipation can cause hemorrhoids or rectal bleeding, laxatives can cause fluid and electrolyte imbalances and abdominal cramping. Stool softeners would be a better option to allow the passage of soft stool.

A new nurse has been assigned a client who is in the hospital to receive iodine-131 treatment. Which action by the nurse is best? Ensure the client is placed in protective isolation. Have pregnant visitors stay 6 feet from the client No special action is necessary to care for this client. Read the policy on handling radioactive excreta.

D This type of radioisotope is excreted in body fluids and excreta (urine and feces) and would not be handled directly. The nurse would read the facility's policy for handling and disposing of this type of waste. The other actions are not warranted.

A nurse is preparing to administer a blood transfusion. Which action is most important? Document the transfusion. Place the client on NPO status. Place the client in isolation. Put on a pair of gloves.

D To prevent bloodborne illness, the nurse should don a pair of gloves prior to hanging the blood. Documentation is important but not the priority at this point. NPO status and isolation are not needed.

Which statement about carcinogenesis is accurate? An initiated cell will always become clinical cancer. Cancer becomes a health problem once it is 1 cm in size. Normal hormones and proteins do not promote cancer growth. Tumor cells need to develop their own blood supply.

D Tumors need to develop their own blood supply through a process called angiogenesis. An initiated cell needs a promoter to continue its malignant path. Normal hormones and proteins in the body can act as promoters. A 1-cm tumor is a detectable size, but other events have to occur for it to become a health problem.