FINAL EXAM - Passpoint

Use gloves and disposable long-sleeved gowns when handling agents.

When preparing to administer a chemotherapeutic agent to a client, what should the nurse do?

Evaluate the tube for patency.

At 0800, the nurse reviews the amount of T-tube drainage for a client who underwent an open cholecystectomy yesterday. After reviewing the output record (see chart), what should the nurse do next?

redness of the surface tissue

A client is to have radiation therapy following a mastectomy. What should the nurse tell the client to expect as a normal local tissue response to radiation?

developing a tolerance for the medication

A client with pancreatic cancer has been receiving morphine via a subcutaneous pump for 2 weeks. The client is requiring an increased dose of the morphine to manage the pain. How should the nurse document this finding?

Place the client in a side-lying position. Administer morphine sulfate for pain as needed. Monitor the client's respiratory status. Obtain daily weights.

When the nurse is providing care for a client hospitalized with acute pancreatitis who has severe abdominal pain, which nursing interventions would be most appropriate for this client? Select all that apply.

potassium: 2.2 mEq/L (2.2 mmol/L)

The nurse is reviewing laboratory data for a client with pancreatic cancer. Which finding does the nurse prioritize as requiring notification of the health care provider?

reassessing the client after administering pain medication

Which action is most important when the nurse is planning pain management for a client after a lobectomy for lung cancer?

prostate-specific antigen, which is used to screen for prostate cancer.

A client asks the nurse what PSA is. The nurse should reply that it stands for

Cullen's sign

A client has been hospitalized with pancreatitis for 3 days. The nurse assesses the client and documents the accompanying results. The nurse realizes these findings are a manifestation of what sign?

Using incentive spirometry every 2 hours while awake.

A client has had an incisional cholecystectomy. Which of the following nursing interventions has the highest priority in postoperative care for this client?

increase in red blood cells

A client is receiving epoetin alfa. Which findings indicate the effectiveness of the drug?

ensure that health education is begun as early as possible.

A client is scheduled for a laparoscopic cholecystectomy and is surprised to learn that they will be discharged later the same day, provided there are no complications. When caring for a client who will be discharged shortly after a procedure, the nurse must

Assess the leg for swelling and redness.

A client who had an open cholecystectomy 2 days ago reports pain in the right calf. What is the nurse's priority intervention?

bleeding disorder

A client with suspected lung cancer is scheduled for thoracentesis as part of the diagnostic workup. The nurse reviews the client's history for conditions that might contraindicate this procedure. Which condition is a contraindication for thoracentesis?

Foley catheter draining urine at 10 mL/hour

A nurse is assessing a client in the recovery room who has had a vaginal hysterectomy. Which assessment finding should the nurse bring to the healthcare provider's immediate attention?

a white blood cell count of 2200/mm3

A nurse is caring for a client who is receiving chemotherapy for lung cancer. During the hand-off report, the nurse from the previous shift states that the client has been placed on neutropenic precautions. Which laboratory value supports this nursing action?

thrombocytopenia

After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/µl. What term should the nurse use to describe this low platelet count?

Give the adolescent more pain medication to control pain and suffering.

An adolescent in the terminal stage of leukemia cries out for more pain medicine. What is the bestaction for a nurse to take in caring for this dying adolescent?

"I remove white patches from my tongue and cheeks with my toothbrush."

An adolescent is receiving chemotherapy for lymphoma. Which statement by the adolescent supports a nursing diagnosis of Deficient knowledge related to mouth care?

dyspnea

An adult with a history of chronic obstructive pulmonary disease (COPD) and metastatic carcinoma of the lung has not responded to radiation therapy and is being admitted to the hospice program. The nurse should conduct a focused assessment for which symptom?

"It's okay to be scared. What is it about cancer that you are afraid of?"

On the night before a 58-year-old wife and mother is to have a lobectomy for lung cancer, she remarks to the nurse, "I'm so scared of this cancer. I should've quit smoking years ago. Now I've brought all this fear and sadness on myself and now my family." How should the nurse respond to the client?

increased blood glucose

Teaching children and parents about the potential adverse effects of treatment for leukemia is important. What is an adverse effect of taking prednisone?

"I will rinse my mouth every 2-4 hours with baking soda and water."

The nurse developed a plan of care for an adolescent who is receiving chemotherapy for lymphoma and has developed stomatitis. What statement made by the adolescent demonstrates understanding of the education provided from the plan of care?

Instruct the client not to use a razor for shaving. Assess the client for pain in joints.

The nurse is caring for a 15-year-old client with myelogenous leukemia whose platelet count is 26,000/mcL. Which nursing interventions would be included in the plan of care? Select all that apply.

Prevent infection.

The nurse is developing a care plan for a client who has had radiation therapy for Hodgkin's lymphoma. What is the primary goal of care for this client?

"CRRT is faster than hemodialysis."

The nurse is explaining to a client the difference between hemodialysis and continuous renal replacement therapy (CRRT). What statement by the client leads the nurse to determine that additional education is needed?

a hard prostate, localized or diffuse

The nurse is performing a digital rectal examination. Which finding is a key sign for prostate cancer?

Access the port using a Huber needle.

The nurse is preparing to administer a chemotherapy infusion to a client with esophageal cancer. The client has an implanted port that was last accessed 7 days ago. The insertion site is clean and dry and without erythema. Which is the appropriate action by the nurse?

bleeding

The nurse reviews the laboratory report of a child with leukemia (see exhibit). What does the nurse determine is the priority problem for this client?

IM injections

The nurse reviews the plan of care for the child with leukemia who is at risk for bleeding. Which intervention would the nurse question?

Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly.

What education should the nurse give to a male client older than age 50 to help ensure early identification of prostate cancer?

She blames herself for her husband's cancer.

Which characteristic displayed by the wife of a 36-year-old man with pancreatic cancer suggests that she may be at risk for negative bereavement outcomes?

a client with lung cancer and a 3- to 4-month life expectancy

Which client is the most appropriate candidate for whom the nurse would assist in coordinating hospice services?

female nurse with 3 years' experience working in oncology

Which nurse should be assigned to a client receiving brachytherapy for the treatment of cervical cancer?

Teach the client to use a folded blanket or pillow to splint the incision.

Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy?

"I'm worried I'll expose my family members to radiation."

Which statement by a client undergoing external radiation therapy indicates the need for further teaching?

nausea after ingestion of high-fat foods

Which symptom would the nurse most likely observe in a client with cholecystitis from cholelithiasis?

encourage coughing, deep breathing, and early ambulation

A client is diagnosed with esophageal cancer has undergone an open esophagectomy. Which intervention would receive the highest priority?

Expand the alveoli and increase lung surface available for ventilation.

After a lobectomy for lung cancer, the nurse instructs the client to perform deep breathing exercises. What is the expected outcome of these exercises?

Kegel exercises

After a radical prostatectomy for prostate cancer, a client has an indwelling catheter removed. The client then begins to have periods of incontinence. During the postoperative period, which intervention should be implemented first?

pneumonia

The nurse should monitor the client with acute pancreatitis for which complication?

"I will take acetaminophen for pain." "I will not be able to play basketball for the next 2 days." "I can apply an ice pack or a cold compress to the puncture site."

A 21-year-old client undergoes bone marrow aspiration at the clinic to establish a diagnosis of possible lymphoma. Which statement made by the client demonstrates proper understanding of discharge teaching? Select all that apply.

support systems and coping strategies

A 45-year-old single mother of three teenaged boys has metastatic breast cancer. Her parents live 750 miles (1,200 km) away and have only been able to visit twice since her initial diagnosis 14 months ago. The progression of her disease has forced the client to consider high-dose chemotherapy. She is concerned about her children's welfare during the treatment. When assessing the client's present support systems, the nurse will be most concerned about which potential problem?

autonomy

A client with esophageal cancer decides against placement of a jejunostomy tube. Which ethical principle is a nurse upholding by supporting the client's decision?

poor gag reflex

A client with pancreatitis returns from an endoscopic retrograde cholangiopancreatography (ERCP). Which assessment would be of most concern to the nurse?

shallow breathing and increasing lethargy

A client with stage II ovarian cancer undergoes a total abdominal hysterectomy and bilateral salpingo-oophorectomy with tumor resection, omentectomy, appendectomy, and lymphadenectomy. During the second postoperative day, which assessment finding requires immediate intervention?

activity intolerance related to lack of normal blood cell production

A healthcare provider diagnoses leukemia in a 4-year-old child who complains of being tired and sleeps most of the day. Which nursing diagnosis should the nurse use to best reflect this physiologic effect of leukemia?

The client reports a feeling of a lump in the throat.

A nurse is assessing a client with a family history of cancer. Which finding requires immediate follow-up?

Have the dietician meet with the child and family to provide foods the child will eat.

The nurse is caring for a 3-year-old with acute lymphocytic leukemia and notes that the child has a decreased appetite. What is the priority nursing intervention?

Ovarian cancer signs and symptoms are often vague until late in development.

The nurse is planning a presentation about ovarian cancer to a group of women. Which topic should receive priority attention in the lesson plan?

Ask the client if they would like to see a priest.

The nurse is preparing a client who has pancreatic cancer for surgery, during which the client will have a Whipple procedure. The client says they are Catholic but never really goes to church or prays much. The client is crying and very frightened. What is the most appropriate action the nurse can do for the client before the surgery?

annual mammogram

The nurse is speaking to a group of women about early detection of breast cancer. Which screening does the nurse recommend to women age 50 and older?

"Keep the area covered when you go outdoors."

The nurse plans to teach a client who is receiving radiation therapy how to care for the skin at the radiation site. What should the nurse tell the client?

withholding all oral intake, as ordered, to decrease pancreatic secretions

Which nursing action is most appropriate for a client hospitalized with acute pancreatitis?

helping the client walk

Which nursing measure would most likely relieve postoperative gas pains after abdominal hysterectomy?

excessive alcohol use gallstones abdominal trauma hyperlipidemia with excessive triglycerides

A nurse is assessing a client who has a potential diagnosis of pancreatitis. Which risk factors predispose the client to pancreatitis? Select all that apply.

a meal delivery service

A widowed client who is receiving chemotherapy tells the nurse that he does not like to cook for himself. Which community resource is appropriate for this client?

a client who underwent cholecystectomy today a client with pain related to pancreatitis

The charge nurse is working on a medical-surgical unit and must rearrange room assignments for several clients. Which clients should the nurse put in the same room? Select all that apply.

water-soluble vaginal lubricants

A 36-year-old female has increased vaginal dryness during sexual intercourse. She has received chemotherapy in the past and has menopausal symptoms due to ovarian suppression. The nurse should instruct the client on the use of which solution for vaginal dryness?

before treatment is started

A client diagnosed with testicular cancer expresses concerns about fertility. The client and his spouse desire to eventually have a family, and the nurse discusses the option of sperm banking. What should the nurse tell the couple about the best time to donate the sperm?

"Each person responds differently to chemotherapy treatments. We'll monitor your responses closely."

A client fears chemotherapy because of the side effects. What is the nurse's best response to the client's concerns?

pancreatitis

A client has been admitted to the emergency department with severe mid-epigastric, upper quadrant abdominal pain. Based on the signs and symptoms and laboratory data documented in the chart, the nurse would anticipate preparing for which diagnosis?

increased serum amylase and lipase levels

A client is admitted with acute pancreatitis. The nurse should monitor which laboratory values?

ways to prevent infection

A client is receiving chemotherapy for treatment of acute lymphocytic leukemia. During discharge preparation, which topic is most important for the nurse to discuss with the client and caregivers?

lymphedema

A client is undergoing a left modified radical mastectomy for breast cancer. Postoperatively, blood pressure should be obtained from the right arm, and the client's left arm and hand should be elevated as much as possible to prevent:

Acknowledge the client's right to make the choices regarding treatment.

A client on the palliative unit discusses treatment with the nurse. The client wants to refuse further chemotherapy and request pain management strategies only. What is the appropriate action by the nurse in relation to the client's requests?

potassium level of 6.5 mEq/L (6.5 mmol/L)

The nurse is caring for a 3-year-old child with acute kidney injury. Which laboratory finding should the nurse immediately report to the healthcare provider?

to administer an antifungal agent

A client receiving radiation therapy for thyroid cancer reports mouth and throat pain. While inspecting the mouth and throat, the nurse notices white patches and ulcerations in the oral mucosa. The nurse notifies the radiation oncologist, and expects which intervention?

conserve energy by prioritizing activities

A client receiving radiation therapy has fatigue. What should the nurse include in the teaching plan?

"Start with liquids and see how you feel."

A client undergoes a laparoscopic cholecystectomy. Which instructions should the nurse give the client about a diet immediately after surgery?

Diphenhydramine decreases incidence of a reaction to the vincristine.

A client with acute lymphocytic leukemia is receiving vincristine. Prior to infusing the drug, the nurse administers diphenhydramine. What should the nurse tell the client about the purpose of taking diphenhydramine?

handling of the dislodged radiation source

A client with cervical cancer is undergoing internal radium implant therapy. A lead-lined container and a pair of long forceps have been placed in the client's hospital room. What should the nurse tell the client about how these will be used? The forceps and container will be used for:

Obtain the client's vital signs and assess breath sounds.

A home care nurse is making the initial home visit to a client with lung cancer who had a peripherally inserted central catheter placed during hospitalization for an upper respiratory infection. During the visit, the nurse must administer an antibiotic, teach the client how to care for the catheter, and provide information about when to notify the home care agency and physician. When the nurse arrives at the client's home, the client's face is flushed and he complains of feeling tired. Which actions should the nurse take first?

acute pain.

A nurse is caring for a client diagnosed with ovarian cancer. Diagnostic testing reveals that the cancer has spread outside the pelvis. The client has previously undergone a right oophorectomy and received chemotherapy. The client now wants palliative care instead of aggressive therapy. The nurse determines that the care plan's priority nursing diagnosis should be:

petechiae epistaxis

Which signs and symptoms of leukemia would lead the nurse to suspect the client has thrombocytopenia? Select all that apply.