Cellular Regulation

11. A 4-year-old child is admitted to the pediatric unit with the diagnosis of acute lymphocytic leukemia (ALL). A blood transfusion is ordered and an intravenous line is started. What should the nurse do in regard to administering the transfusion? A. Infuse the blood over no more than 4 hours. B. Take the vital signs 3 hours after the transfusion. C. Check the vital signs 15 minutes after starting the transfusion. D. Have the blood warm at room temperature for 1 hour before administration

Correct Answer: A Blood should be administered within 4 hours; the risk for bacterial proliferation increases over time and exposure to room temperature.

8. A client who is to receive radiation therapy for cancer says to the nurse, "My family said I will get a radiation burn." What is the nurse's best response? A. "Your skin will look like a blistering sunburn." B. "A localized skin reaction usually occurs." C. "A daily application of an emollient will prevent a burn." D. "Your family must have had experience with radiation therapy."

Correct Answer: B Radiodermatitis occurs three to six weeks after the start of treatment.

1. A client with follicular non-Hodgkin lymphoma is to be treated with rituximab (Rituxan), a targeted monoclonal antibody. The nurse should monitor the client for what common side effect of rituximab? A. Polyphagia B. Leukopenia C. Constipation D. Hypertension

Correct Answer: B Rituximab targets the CD 20 antigen, which regulates cell cycle differentiation and is found on malignant B lymphocytes; as a result, rituximab therapy can cause leukopenia and neutropenia. Anorexia, not polyphagia, may occur with rituximab therapy. Frequent stools and diarrhea, not constipation, may occur with rituximab therapy. Hypotension, not hypertension, may occur as a fatal infusion reaction to rituximab therapy.

3. A client is receiving whole-body radiation for Hodgkin disease. Which side effect should the nurse expect as a result of this therapy? A. Increased tendency to bleed B. Increased tendency for fractures C. Decreased number of erythrocytes D. Decreased susceptibility to infection

Correct Answer: C Depression of the bone marrow interferes with hemopoiesis, resulting in anemia.

4. The nurse is reviewing the breast self-examination procedure with a client. What comment by the client should the nurse should consider significant? A. "My breasts feel larger when I'm having a period." B. "My breasts feel lumpy right before my period starts." C. "My left breast has always been a little bigger than my right one." D. "My right breast feels thicker and seems bigger than the left one."

Correct Answer: D Together, lack of symmetry and palpation of a thickening are abnormal findings.5.

2. A nurse is caring for a client after a left pneumonectomy for cancer. The nurse palpates the client's trachea routinely. What is the rationale for this nursing intervention? A. A mediastinal shift may have occurred. B. Nodular lesions may demonstrate metastasis. C. Tracheal edema may lead to an obstructed airway. D. The cuff of the endotracheal tube may be overinflated.

Correct Answer:A After a pneumonectomy, the mediastinum may shift toward the remaining lung, or the remaining lung may shift toward the empty space, depending on the pressure within the empty space. Either of these shifts will cause the trachea to move from its usual midline position.

7. Late in the postoperative period after resection of an aldosterone-secreting adenoma, the nurse expects the client's blood pressure to: A. Gradually return to near normal levels B. Rise quickly above the preoperative level C. Fluctuate greatly during this entire period D. Drop very low, then increase rapidly to normal levels

Correct Answer: A Once the excessive secretion of aldosterone is stopped, the blood pressure gradually drops to a near normal level.

6. A 28-year-old male client is undergoing tests to confirm the diagnosis of Hodgkin lymphoma. The client and his wife are worried that he may have cancer. The wife states, "Don't you think it is unlikely for someone like my husband to have cancer?" The nurse's response is based on the information that Hodgkin lymphoma is: A. More likely to affect women than men. B. Diagnosed during adolescence and young adulthood. C. Typically a disease of older rather than younger adults. D. Usually occurs frequently among populations of Asian heritage

Correct Answer: B Hodgkin lymphoma occurs most often during the ages of 15 to 35 years of age and between 50 to 60 years of age.

10. What change in blood pressure (BP) should the nurse anticipate after a client has an aldosteronoma surgically removed? A. Rise quickly above preoperative levels. B. Fluctuate greatly during this entire period. C. Gradually return to expected levels for an adult. D. Drop very low before increasing rapidly to expected levels.

Correct Answer: C Once excessive secretion of aldosterone has stopped, BP gradually drops to a near-normal level. The blood pressure drops gradually; it does not rise.

9. On admission, the laboratory results of a client with leukemia indicate elevated blood urea nitrogen (BUN) and uric acid levels. The nurse determines that these laboratory results may be related to: A. Lymphadenopathy B. Thrombocytopenia C. Hypermetabolic status D. Hepatic encephalopathy

Correct Answer: C The hypermetabolic state associated with leukemia causes more urea and uric acid (end products of metabolism) to be produced and to accumulate in the blood.

5. The chemotherapy protocol prescribed for a client with tuberculosis includes vitamin B6 and isoniazid (INH). The nurse determines that vitamin B6 is used to: A. Improve the nutritional status of the client B. Enhance the tuberculostatic effect of isoniazid C. Accelerate the destruction of dormant tubercular bacilli D. Counteract the peripheral neuritis that isoniazid may cause

Correct Answer: D One of the most common side effects of INH is peripheral neuritis, and vitamin B6 will counteract this problem.