Chapter 52 Practice Questions

Nurse is caring for a client who is postoperative following a pelvic exenteration, the HCP changes the clients diet from NPO to clear liquids. The nurse should check which priority item before admin the diet? 1. bowel sounds 2. ambulate 3. incision appearance 4. urine specific gravity

Answer:1 NPO till peristalsis occurs 4-6 days signs bowel function return: BS excretion no distention of bowel diet is advanced as tolerated most imp to assess BS before feeding client

Nurse is teaching the client about risk factors associated with colorectal cancer. Further teaching is necessary when the client ID which item as an associated risk factor? 1. age less than 50 2. Hx of colorectal polyps 3. familial Hx of colorectal cancer 4. chronic IBD

Answer: 1 ages 50 and old is most common all other are risk factors

The nurse is reviewing the lab results of a client dx with multiple myeloma. which would the nurse expect to note specifically in this disorder? 1. increased calcium levels 2. increased WBC's 3. decreased BUN 4. decreased # of plasma cells in the bone marrow

Answer: 1 Increased # of plasma cells in bone marrow, anemia, hypercalcemia caused by release of Ca from degrading bones and elevated BUN .

The nurse is developing a plan of care for the client with multiple myeloma and includes which priority intervention in the plan? 1. Encourage fluids 2. Frequent oral care 3. Cough & deep breathing 4. Monitor RBC count

Answer: 1 Fluids 1.5-2L daily to maintain kidney function due to hypercalcemia. Dilute the calcium.

The home health care nurse is caring for a client with cancer, who is complaining of acute pain. The most appropriate determination of the clients pain should include which assessment? 1. client pain rating 2. nonverbal cues from client 3. nurses impression of their pain 4. pain relief after appropriate nursing intervention

Answer: 1 self is critical describe by client nonverbal are imp but not appropriate pain assessment measure no use judgment reassessment after pain med given is not related to subject of question

the nurse is caring for client with bladder cancer and bone metastasize. what s/s nurse recogn as indications of a possible oncological emergency: SATA 1. facial edema in am 2. serum calcium level of 12mg/dL 3. weight loss 20 lbs in one month 4. serum sodium level of 136 mg/dL 5. serum potassium level of 3.4mg/dL 6. numbness and tingling of the lower extremities

Answer: 1 2 6 sepsis , DIC, SIADH spinal cord compression:numbness and tingling of LE sign of spinal cord compression hypercalcemia 12mg/dL superior vena cava syndrome-causes facial edema weight loss is not oncological emergency

Nurse is instructing a client to perform a TSE (testicular self exam) and should provide the client with which information about the procedure: 1. examine while laying down 2. best to examine after a shower 3. gently feel the testicle with one finger for a growth 4. down at least every 6 months

Answer: 2 TSE recommended monthly after a warm shower or bathe when scrotal skin is relaxed use both hands and fingers roll checking for lumps or growths

The nurse is assessing the perineal wound in a client who has returned from the operating room following an abd perineal resection and notes serosanguious drainage. which is appropriate nursing intervention? 1. clamp the penrose drain 2. change drs as prescribed 3. notify HCP 4. remove and replace the perineal packing

Answer: 2 serosang is expected change the drs as indicated never clamp a penrose drain packing is removed slowly over 5-7 days -nurse should not remove the perineal packing

Client who has been getting radiation therapy for bladder cancer tells the nurse it feels as if she is voiding thru the vaginal. Nurse may interpret that the client is experiencing which condition? 1. rupture of the bladder 2. vesicovaginal fistula development 3. extreme stress by DX of cancer 4. altered perineal sensation as a side effect of radiation therapy

Answer: 2 vesicovaginal fistula development occurs between bladder and vaginal abnormal open of two body parts and if this happens they experience urine thru the vagina

When caring for client with internal radiation implant, nurse observes which principles? SATA 1. limit the time with client to 1 hr per shift 2. keep pregnant women out of clients room 3. client needs private room with a private bath 4. wear lead shield with direct client care 5. Remove dosimeter film badge when enter clients room 6. allow individuals younger than 16 yo in room as long as they are 6 feet away from client

Answer: 2, 3, 4 30 mins per nurse per shift in room wear lead private room & bath dosimeter badge must be worn children 16 and younger are not allowed in there

A gastrectomy is performed on a client with gastric cancer. in the immediate postOP period the nurse notes bloody drainage from the NGTube. Nurse should take which most appropriate action? 1. measure abd girth 2. irrigate the NGTube 3. continue to monitor for drainage 4. notify HCP

Answer: 3 Bloody drainage here is normal for 24 hrs postOP then changes to brown-tinged and then is yellow or clear. Continue to monitor for drainage. Abd girth can be measured to see distention.

The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy: 1. restrict all visitors 2. restrict fluid intake 3. teach client about need for hand hygiene 4. insert foley to prevent skin break down

Answer: 3 meticulous hand hygiene implemented for client and all visitors and family. not all visitors are restricted fluids encouraged no foley, encourages infection

A client is DX with multiple myeloma and the client ask the nurse about the DX. the nurses bases the response on which description of this disorder? 1. altered RBC production 2. altered production of lymph nodes 3. malignant exacerbation in the # of leukocytes 4. malignant proliferation of plasma cells within the bone

Answer: 4 B-cell neoplastic condition with malignant proliferation of plasma cells and accumulation of mature plasma cells in the bone marrow.

While giving care to a client with a internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action? 1. call HCP 2. reinster the implant into the vagina 3. pick up implant with gloved hands and flush down toilet 4. pick up the implant with long-handled forceps and place into a lead container

Answer: 4 Encourage the client to remain still while nurse places it into a safe lead container using long-handled forceps. call radiation oncology and then document the event and actions taken. not in scope of practice to reinsert the implant

During the admission assessment of a client with advanced ovarian cancer, the nurse recognize which symptoms as typical of the disease 1. diarrhea 2. hypermenorrhea 3. abnormal bleeding 4. abdominal distention

Answer: 4 abdominal distention urinary frequency and urgency pleural effusion malnutrition pain from pressure by growth of tumor urinary and bowel obstruction constipation ascites with dyspnea then general severe pain abnormal bleeding from hypermenorrhea is assoc. with uterine cancer

Client is admitted with suspected DX of Hodgkins disease. which assessment finding is the nurse to note specifically in the client: 1. fatigue 2. weakness 3. weight gain 4. enlarge lymph nodes

Answer: 4 chronic progressive neoplastic disorder of the lymphoid tissue painless enlarge of lymph nodes with progression to extra lymphatic sites like spleen and liver weight loss is likely fatigue and weakness may occur but not related specifically to disease