Exam 4

A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is most appropriate? A -The cancer involves only the cervix B -The cancer cells look almost like normal cells C-Further testing is needed to determine the spread of the cancer D-It is difficult to determine the original site of the cervical cancer

A- Cancer in situ indicates that the cancer is localized to the cervix and is not invasive at this time. Cell differentiation is not indicated by clinical staging. Because the cancer is in situ, the origin is the cervix. Further testing is not indicated given that the cancer has not spread.

A patient asks what dietary changes can be made to help protect against cancer. The nurse should base his or her response to the patient's question on which of the following? A- Reduced dietary fat intake can lower cancer risk. B- Reduced dietary salt intake reduces malignancy development. C- Increased intake of beef and poultry decrease the risk of malignancy. D- Increased intake of milk products will lower risk of cancer development.

A- Diet is a large factor in both cause and prevention of malignancies. People who eat high-fat, low-fiber diets are more prone to develop colon cancers. High-fat diets are linked to breast cancer in women and prostate cancer in men. Reduced salt intake reduces blood pressure and fluid retention, not cancer. Increased intake of milk, beef, and poultry will not lower cancer risk.

The perioperative nurse is reviewing the chart of a patient who is being admitted into the operating room for a laminectomy. What information obtained from the chart review should the nurse discuss with the anesthesiologist? A- pt's father developed an elevated temp during a recent surgery B- pt's brother developed nausea after surgery with general anesthesia C- pt's mother developed contact dermatitis related to a latex allergy D- pt's grandmother developed hypothermia during a craniotomy

A- Malignant hyperthermia is an autosomal dominant disorder characterized by hyperthermia with rigidity of skeletal muscles that can result in death. May occur if exposed to certain anesthetics. Obtain careful family hx

A client receiving intravenous chemotherapy asks the nurse the reason for wearing a mask, gloves, and gown while administering drugs to the client. What is the nurse's best response? A- The clothing protects me from accidentally absorbing these drugs B- These coverings protect you from getting an infection from me C- I am preventing the spread of infection from you to me or any other client here D- The policy is for any nurse giving these drugs to wear a gown, gloves, and mask.

A- Most chemotherapy drugs are absorbed through the skin and mucous membranes. As a result, health care workers who prepare or give these drugs, especially nurses and pharmacists, are at risk for absorbing them. Even at low doses, chronic exposure to chemotherapy drugs can affect health. The Oncology Nursing Society and the Occupational Safety and Health Administration (OSHA) have specific guidelines for using caution and wearing protective clothing

The nurse is assessing a client recovering from anesthesia. Which of the following is an early indicator of hypoxemia? A- somnolence B- restlessness C- chills D- urgency

B- One of the earliest signs of hypoxia is restlessness and agitation. Decreased LOC and somnolence are later signs of hypoxia. Chills can be related to the anesthetic agent used and urgency is not related.

While performing preoperative teaching, the patient asks when he is no longer able to eat or drink. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, what is the best response by the nurse? A- "you may drink clear liquids up until she is moved into the OR" B- "you may drink clear liquids up to 2 hours before surgery" C- "maintain NPO status until after breakfast" D- "stay NPO after midnight"

B- Practice guidelines for preop fasting state the minimum fasting period for clear liquids is 2 hours. EBP no longer supports the long-standing practice of requiring patients to be NPO after midnight.

The nurse is planning care for a patient with a radioactive implant. Which intervention should the nurse select to help prevent social isolation in this patient? A- Visit the patient frequently, but do not touch the patient B- Help provide diversional activities that the patient enjoys C- Have only one nurse provide care to increase consistency D- Encourage family to stay with the patient, but have them wear masks and gloves at all times

B- Providing diversional activities for the patient may help reduce feelings of isolation. Limited contact and distance are used to protect the nurse, visitors, and other personnel from radiation exposure when a patient is being treated with radiation therapy. Assigning only one nurse increases that nurse's exposure, which is not safe. Mask and gloves will not protect family from radiation.

The young nursing student who wants a tan before spring break asks the nurse what the safest method would be. The nurse's best response is: A- Take advantage of morning sun while using sunscreen with an SPF of 30 B- Use a spray-on tanning solution C- Use a sun lamp for only 20 minutes a day D- Use a tanning salon for no more than 10 minutes per visit

B- Spray-on tanning solution is the safest. All other options increase ultraviolet exposure, even with the use of sunscreen.

A patient asks a student nurse if his family member may accompany him to the surgical area. What is the best response by the nurse? A- "your family member may not enter the surgical area" B- "your family member can be with you in the preop holding area" C- "your family can't be with you until the postanesthesia care unit" D- "your family is only allowed in the conference room for preop teaching"

B- The perioperative RN should explain to the student nurse that the family can be in the preop holding area before the patient goes to surgery, but this includes talking to the RN at the nurses station. They are also taken to the conference room for preop and postop meetings with the staff, including teaching

Following a visit from his family, the 55-year-old male patient with terminal cancer tearfully says, "I am so afraid" and begins to cry. The nurse's most supportive response is to: A- Ask, "Would you like to have your pain medication now?" B- Sit down and say, "Let's talk about what you are afraid of. C- Offer to call the hospital chaplain D- Darken the room and leave to give the patient privacy

B- Verbalizing fears to a caring nurse is comforting. Offering medications, chaplains, and privacy is not helpful or supportive as a first nursing response in this situation.

A patient requests that the nurse give his hearing aid to a family member so it will not be lost in surgery. What is the appropriate action by the nurse? A- give the hearing aid to the wife as he wishes B- tape the hearing aid to his ear to prevent loss C- encourage the patient to wear it for the surgery D- tell the surgery nurse that he has his hearing aid out

C- Although jewelry is removed before surgery, hearing aids should be left in place to allow the patient to better follow instructions given in the surgical suite and the PACU as well the dismissal instructions that will be given

The nurse is performing a preoperative assessment for a patient scheduled for a surgical procedure. What is the rationale for the nurse's careful documentation of the patient's current medication list? A- some medications may alter the patient's perceptions about surgery B- many anesthetics alter renal and hepatic function, causing toxicity of other drugs C- some meds may interact with anesthetics, altering the potency and effect of the drug D- routine meds are withheld the day of surgery, requiring dosage and schedule adjustments after surgery

C- Drug interactions may occur between prescribed meds and anesthetic agents during surgery. Take a careful med hx and check that it's recommended to the anesthesia care provider.

The nurse in the outpatient clinic is caring for a 50-year-old who smokes heavily. To reduce the patient's risk of dying from lung cancer, which action will be best for the nurse to take? A- Educate the patient about the seven warning signs of cancer B- Plan to monitor the patient's carcinoembryonic antigen (CEA) level C- Discuss the risks associated with cigarettes during every patient encounter D- Teach the patient about the use of annual chest x-rays for lung cancer screening

C- Education about the risks associated with cigarette smoking is recommended at every patient encounter, since cigarette smoking is associated with multiple health problems.

A patient who has severe pain associated with terminal breast cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective? A -The patient uses the ordered opioid pain medication whenever the pain is greater than 5 (0 to 10 scale) B -The patient agrees to take the medications by the IV route in order to improve analgesic effectiveness. C -The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs. D- The patient states that nonopioid analgesics may be used when the maximal dose of the opioid is reached without adequate pain relief.

C- For chronic cancer pain, analgesics should be taken on a scheduled basis, with additional doses as needed for breakthrough pain. Taking the medications only when pain reaches a certain level does not provide effective pain control. Although nonopioid analgesics also may be used, there is no maximum dose of opioid. Opioids are given until pain control is achieved. The IV route is not more effective than the oral route, and usually the oral route is preferred.

The nurse is assessing a 58-year-old patient. What yearly screening test for colorectal cancer should the nurse educate the patient about getting done? A- Colonoscopy B- Barium Enema C- Fecal occult blood test D- Sigmoidoscopy

C- The American Cancer Society recommends one of the following five options to screen for colorectal cancer, beginning at age 50: (1) an annual stool test for blood, (2) a flexible sigmoidoscopy every 5 years, (3) a yearly stool test for blood and flexible sigmoidoscopy every 5 years, (4) a double-contrast barium enema every 5 years, and (5) a colonoscopy every 10 years. Screening should begin earlier and take place more frequently in high-risk people.

The nurse is preparing to start an IV infusion and has raised the HOB. After the nurse applies gloves to insert an IV catheter, the client begins to rub her eyes wipe away nasal drainage. Which of the following should the nurse do first? A- Distract the client's attention B- Assess the client for pain C- Remove the IV catheter and assess the client's VS D- Lower the HOB

C- The RN should assess the VS of the client who exhibits urticaria, rhinitis, and conjunctivitis a few seconds after coming in contact with rubber gloves, a plastic catheter, plastic IV tubing, and a plastic IV solution bag. Can proceed into anaphylactic shock

The patient donated a kidney, and early ambulation is included in the plan of care, but the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation? A- "early walking keeps your legs limber and strong" B- "early ambulation will help you be ready to go home" C- "early ambulation will help you get rid of your syncope and pain" D- "early walking is the best way to prevent postop complications"

D- Early ambulation will prevent postop complications. Ambulating increases muscle tone, stimulates circulation that prevents DVT, and increases vital capacity and maintains normal respiratory function.

A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient? A -Remove food debris from the teeth and oral mucosa with a stiff toothbrush. B -Use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth. C- Gargle and rinse the mouth several times a day with an antiseptic mouthwash. D -Rinse the mouth before and after each meal and at bedtime with a saline solution.

D-The patient should rinse the mouth with a saline solution frequently. A soft toothbrush is used for oral care. Hydrogen peroxide may damage tissues. Antiseptic mouthwashes may irritate the oral mucosa and are not recommended.

When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. What is the priority action by the nurse? A- recheck in 1 hour for increased drainage B- notify the surgeon of a potential hemorrhage C- assess the patient's BP and HR D- remove the dressing and assess the surgical incision

C- First action of the RN is to gather additional assessment data to form more complete picture. Continued assessment will be done

The nurse recognizes the staging T3, N3, M2 of the patient's cancer to mean that there is a: A- Small tumor with fewer than two lymph nodes involved B- Large tumor that is localized C- Small tumor with adjacent nodes involved D- Large tumor with extensive lymph node involvement

D

The surgical team in the operating room performs a surgical time-out just before starting hip replacement surgery. Which action would be part of the surgical time-out? A- assess the patient's VS and oxygen saturation level B- check the chart for a signed consent form for the procedure C- determine if the patient has any questions about the procedure D- have the patient verify the procedure and the location of the surgery

D- During a time out, the surgical team will stop all activities right before the procedure to verify patient, procedure, and surgical site. Pt will state name, birth date, and procedure and location.

A patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge (select all that apply.)? A- comfortable after IV opioid 15 min ago B- VS baseline or stable C- wants to go to the bathroom at home D- responsible adult taking patient home E- minimal nausea and vomiting

B,D,E- Ambulatory discharge criteria includes meeting phase I PACU discharge criteria that includes VS baseline or stable and minimal N&V. Phase II includes responsible adult driving patient and no IV opioids for past 30 min

The nurse at the clinic is interviewing a 64-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk (select all that apply)? A- Pap testing B- Sunscreen Use C- Tobacco use D- Mammography E- Colorectal screening

A,B,D,E-The patient's age, gender, and history indicate a need for screening and/or teaching about colorectal cancer, mammography, Pap smears, and sunscreen.

Which intraoperative nursing responsibilities should be performed by the scrub nurse (select all that apply)? A- documenting intraoperative care B- keeping track of irrigation solutions for monitoring of blood loss C- passing instruments and supplies to the surgeon by anticipating his or her needs D- coordinating the flow and activities of members of the surgical team in the surgical site E- performing the count of sponges, needles, and instruments used during procedure

B,C,E- Both the scrub and circulating RN participate in the counting of supplies. Passing instruments to the surgeon and other sterile activities are for the scrub RN.

A patient is 6 hours postop from having a chest tube placed and is refusing to take deep breaths because of the pain . Which intervention should the nurse implement? A- Medicate the patient and have them take deep breaths B- Encourage the patient to take shallow breaths to help with the pain C- Explain deep breaths do not have to be taken at this time D- Tell the patient if he doesn't take deep breaths, he could die

A- After having a chest tube placed it is important to take deep breaths to help push the air out of the pleural space and into the water seal chamber. Deep breaths help prevent the client from developing complications such as pneumonia or atelectasis.

A patient smokes 2.5 packs of cigarettes every day for the last 20 years. How will the nurse document the patient's pack year in the chart?

50 pack years To calculate the pack year you take the number of packs of cigarettes smoked per day X by the number of years. 2.5 X 20= 50

The client has a latex allergy. What should the nurse teach the client to do before having surgery? Select all that apply: A- determine that there will be a latex-safe environment for surgery B- Report symptoms experienced with the latex allergy C- Notify the HCP at the surgery center D- Wear a stainless steel medical alert bracelet into the surgical site E- Ask to have the surgery at a hospital

A,B,C

When reviewing the preoperative forms, the nurse notices that the informed consent form is not present or signed. What is the best action for the nurse to take? A- have the patient sign the consent form B- have the family sign the form for the patient C- call the surgeon to obtain consent for surgery D- teach the patient about the surgery and get verbal permission

C- The informed consent must be obtained by the physician. RN can witness the signature on the consent form and verify the patient understands the informed consent. Verbal consents are not enough.

A patient who is scheduled for a right breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct? A -"Benign tumors do not cause damage to other tissues." B- "Benign tumors are likely to recur in the same location." C-"Malignant tumors may spread to other tissues or organs." D-"Malignant cells reproduce more rapidly than normal cells."

C- The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors never metastasize.

On the day of surgery, a client with DM who takes insulin on a sliding scale is to be NPO and all medications withheld. The client's 0600 glucose level is 300 mg/dL. The nurse should: A- Withhold all medications B- Administer the insulin dose dictated by the sliding scale C- Call the physician for specific prescriptions based on the glucose level D- Notify the surgery department

C- The nurse should notify the PCP directly for specific prescriptions based on the client's glucose level. The surgical experience is stressful, and the client needs specific insulin coverage during the peri-op period.

A nurse is providing education to a group of people about preventing colon cancer. What information should be included in the presentation? A- Wear a high filtration mask when around chemicals B- Do not engage in high risk sexual behaviors C- Take a multivitamin daily D- Eat several servings of vegetables daily

D- Risk factors for colon cancer are diets high in red and processed meats, high fat and low fruits and vegetables. Therefore, education about increased fruits and vegetables in the diet is important.

The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider? A- Hematocrit of 30% B- Platelets of 95,000/µL C- Hemoglobin of 10 g/L D- White blood cell (WBC) count of 2700/µL

D- The low WBC count places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that WBC growth factors such as filgrastim (Neupogen) are needed

A client has been unable to void since having abd surgery 7 hours ago. The nurse should first: A- encourage the client to increase oral fluid intake B- insert an intermittent urinary catheter C- notify the HCP D- assist the client up to the toilet to attempt to void

D- Urinary retention is common following surgery with anesthesia, following childbirth, or as a result of specific medication use, for example narcotics for pain. Clients should be assisted to an anatomically comfortable position to void prior to resorting to invasive methods such as catheterization

Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks to get up to go to the bathroom to urinate. What is the most appropriate action for the nurse to take? A- offer the pt to use a urinal or bedpan after explaining need to maintain safety B- assist the pt to the bathroom and stay next to the door to assist pt back to bed C- allow the pt to go to the bathroom since the onset of the medication will be more than 5 min D- ask the pt to hold the urine for a short period of time since a catheter will be placed in OR

A- Prime issue after administration of either sedative or opioid analgesic is safety. Effects the CNS, patient is at risk for falls and should not be allowed out of bed, even with assistance.

The nurse is doing a preoperative assessment on a male patient who has type 2 diabetes mellitus; weighs 146 kg; and is 5 feet 8, inches tall. Which patient assessment is a priority related to anesthesia? A- has a body mass index of 48.8kg/m2 B- has a hx of postop vomiting C- has several seasonal allergies D- has hemoglobin A1C of 8.5%

A- The patient's body mass index is the priority because it indicated the patient is severely obese. The patient's size may impair the anesthesiologist's ability to ventilate and medicate the patient properly, as well as the surgery room staff's ability to position the patient safely.

A patient is admitted to the postanesthesia care unit (PACU) after abdominal surgery. Which assessment, if made by the nurse, is the best indicator of respiratory depression? A- increased CO2 pressure B- decreased oxygen saturation C- increased RR D- frequent premature ventricular contractions (PVCs)

A- Transcutaneous carbon dioxide pressure (PtcCO2) monitoring is a sensitive indicator of respiratory depression. Increased CO2 pressures would indicate respiratory depression. (Inadequate oxygenation, PVCs)

A lung cancer patient just had a right sided chest tube inserted 2 hours ago. Which action should the nurse implement if there is no fluctuation (tidaling) in the water seal chamber? A- Obtain an order for a STAT x-ray B- Check the tubing for kinks or clots C- Increase the amount of wall suction D- Monitor the client's pulse oximeter reading

B- The air from the pleural space is not able to get to the water seal chamber and the nurse needs to figure out why. If no tidaling appears then the patient may be lying on the tubing causing it to become kinked or there is a big clot blocking the flow.

A patient is experiencing mucositis as a result of radiation therapy. Which interventions should the nurse include in the plan of care? (Select all that apply.) A- Provide oral care once daily. B- Discourage use of alcohol and tobacco. C- Encourage citrus juice for vitamin C supplementation. D- Advise the patient to avoid very cold foods and drinks.

B,D- Mucositis is inflammation of the mucous membranes, especially of the mouth and throat. Smoking, alcohol, acidic foods or drinks, extremely hot or cold foods and drinks, and commercial mouthwash can irritate inflamed mucous membranes. The use of a neutral mouthwash is appropriate. Frequent mouth care is important to reduce the risk of infection.

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? A- assess patient's pain B- assess patient's VS C- check the rate of the IV infusion D- check the physician's postop orders

B- Highest priority by the RN is to assess physiologic stability of the patient. Taking VS

A patient with cancer is scheduled for palliative surgery. Which explanation should the nurse use to describe the purpose of this surgery? A- Palliative surgery is done to reconstruct tissues damaged by the cancer. B- Palliative surgery is done to increase the patient's comfort when cure is not possible. C- Palliative surgery is done to remove a cancer completely and increase the chances for cure. D- Palliative surgery is done to remove surrounding lymph nodes, reducing the risk for spread of the primary tumor.

B- The goals of palliative surgery are to increase comfort and quality of life. A. Reconstructive surgery can be done for cosmetic enhancement or for return of function of a body part. It is not done to treat or cure the cancer

A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to maintain the patient's self-esteem? A -Tell the patient to limit social contacts until regrowth of the hair occurs. B -Encourage the patient to purchase a wig or hat and wear it once hair loss begins. C -Teach the patient to gently wash hair with a mild shampoo to minimize hair loss. D -Inform the patient that hair usually grows back once the chemotherapy is complete

B- The patient is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats.

The nurse is positioning a patient after a surgical procedure. What is the best position unless contraindicated, for this patient to be placed in to prevent respiratory complications? A- supine B- lateral C- semi-foweler's D- high-fowler's

B- Unless contraindicated, an unconscious pt is positioned lateral to keep airway open and reduces risk of aspiration. Once conscious, pt can return to supine or semi fowlers

A patient is being prepared for a surgical procedure. What is the priority intervention by the nurse prior to the start of the procedure according to the National Patient Safety Goal (NPSG)? A- identify patients at risk for suicide B- improved staff communication C- patient, surgical procedure, and site are checked D- prevention of infection

C- Time-outs verify the patient's identity, surgical procedure, and site to prevent mistakes in surgery.

Eight hours following bowel surgery, the nurse observes that the client's urine output has decreased from 50 to 20 ml/hr. The nurse should assess the client further for which of the following? A- bowel obstruction B- adverse effect of opioid analgesics C- hemorrhage D- HTN

C- When the urine output is less than 30 mL/hr, the RN should assess for the potential causes such as hypovolemia or hemorrhage. Assess and evaluate VS, I&Os, dressing, and available labs and notify HCP

When the nurse asks the client who is to have abdominal surgery today if the client understands the procedure, the client replies, "No, not really; I talked about several different things with my surgeon, and I am just not sure." The nurse should: A- Teach the client all the details of the planned procedure B- Utilize a second witness when the client signs for consent C- Notify the surgeon of the client's expressed lack of understanding D- Administer the prescribed preop narcotics and/or sedatives

C- it's the surgeon's responsibility to discuss the planned procedure and review the risks, benefits, and alternatives to the planned procedure. Nurse should notify surgeon of patient's lack of understanding

When attempting to check the pupils of a client scheduled to receive general anesthesia, the nurse notices that the client has trouble tilting the head back. Which of the following is the primary concern related to this finding? A- the client has limited movement of his neck B- the client is at risk for postop neck pain C- the client is at risk for difficult intubation D- the ability to assess the client's pupils is limited

C- the client is a risk for difficult intubation because the neck must be hyperextended to pass the endotracheal tube.

The student nurse demonstrates an understanding of cancer risk factors by identifying which patient as being at the highest risk for developing colorectal cancer? A- 50-year-old male who has been exposed to arsenic in the workplace B- 45-year-old female with a doctorate degree in psychology who smokes occasionally C- 38-year-old female who had her first child one year ago D- 29-year-old male who has had Crohn's disease since the age of 13

D- Inflammatory diseases of the colon increase the risk of colorectal cancer. Arsenic exposure places the patient at risk for lung cancer.

An older adult patient is undergoing coronary artery bypass graft (CABG) surgery and has just experienced intraoperative vomiting. The nurse should consequently anticipate the use of which drug? A- fentanyl B- midazolam C- meperidine D- ondanestron

D- Ondansetron (Zofran) is an antiemetic; midazolam is a benzo, and fentanyl and meperidine are opioid analgesics

While the perioperative nurse is transporting a patient to the operating room for general surgery, the patient states, "I am a Jehovah's Witness, and I am worried about blood transfusions." What would be the best response by the nurse to this patient's statement? A- "I will make sure that you do not receive a blood transfusion during surgery" B- "Would you like to sign the consent form just in case you need blood?" C- "Do you have someone I can contact in an emergency if you need a blood transfusion?" D- "Tell me what you would like done if it is determined that you need blood replacement during surgery"

D- RN should identify what the patient's concern is related to a blood transfusion. Clarify whether the patient wants a blood transfusion.

Before surgery, a client states that she is afraid of surgery because her cousin died in surgery when having her tonsils removed. What is the nurse's best response? A- Reassure the client that technology has changed over the last 10 years B- Have the client perform deep breathing exercises to decrease her anxiety before surgery C- Explain to the client that it is normal to be afraid D- Ask the client if anyone else in her family has had trouble when they had surgery

D- RN should immediately think of the congenital metabolic tendency for malignant hyperthermia, which occurs in the presence of certain kinds of anesthetics.