IMMUNOLOGICAL STUDIES:
A widowed mother of 4 school-age children is hospitalized with metastatic ovarian cancer. The patient is crying and tells the nurse that she does not know what will happen to her children when she dies. Which response would the nurse provide?
Would you like to talk about options for the care of your children?"
A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for brachytherapy. Which of the following instructions should the nurse include?
You will need to stay still in the bed during each treatment session."
a nurse has received change-of-shift report for a group of clients. which of the following clients should the nurse assess first?
a client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN sublingual nitroglycerin tablet
A nurse is assessing a group of clients for indications of role changes. the nurse should identify that which of the following clients is at risk for experiencing a role change?
a client who has multiple sclerosis and is experiencing progressive difficulty ambulating
Which statement by a patient with systemic lupus erythematosus (SLE) indicates the patient understands the nurse's teaching about the condition?
"I will use sunscreen when I am outside."
A nurse is planning a health promotional presentation for a group of African American clients at a community center. Which of the following disorders presents the greatest risk to this group of clients?
-Hypertension
A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority?
-Report of sore throat
a nurse is planning care to decreased psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. which of the following interventions should the nurse include in the plan?
-tell the client that it is possible to return to similar previous levels of activity
a nurse is providing dietary teaching to a client who is postoperative following a thyroidectomy with removal of the parathyroid glands. the nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in her diet?
12 almonds
A nurse is teaching a client who has a family history of colorectal cancer to help mitigate this risk, which of the following dietary alterations should the nurse recommend?
Add cabbage to the diet
patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan?
Cook food thoroughly before eating. Avoid public transportation such as buses. Talk to the oncologist before having any dental work.
A nurse is preparing to present a program about prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include?
Follow a smoking cessation program Maintain an appropriate weight Eat a low-fat diet
The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse would monitor for which adverse effect?
Hematuria
A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide?
Hemodialys is something required following surgery
A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. the client is experiencing excessive stools. which of the following findings is an adverse effect of the medication?
Hypokalemia
a nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. which of the following statements by the client indicates and understanding of the teaching?
I am taking this medication to increase my energy level.
a nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. which of the following client statements indicates an understanding of the teaching?
I will monitor my blood pressure while taking this medication
A 25-yr-old female patient with systemic lupus erythematosus (SLE) has a facial rash and alopecia. She tells the nurse, "I never leave my house because I hate the way I look." Which patient problem would the nurse plan to address?
Impaired socialization
A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
Initiate IV therapy Insert an NG tube Administer ranitidine
A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take?
Irrigate the indwelling urinary catheter.
A patient has scleroderma manifested by CREST (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome. Which action would the nurse include in the plan of care?
Keep the environment warm and draft free.
A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is accurate?
Malignant tumors may spread to other tissues or organs."
During a routine health examination, a 40-yr-old patient tells the nurse about a family history of colon cancer. Which action would the nurse take first?
Obtain more information about the patient's relatives.
An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hr in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider?
Patient has crackles up to the midline posterior chest.
After change-of-shift report on the oncology unit, which patient would the nurse assess first?
Patient who is neutropenic and has a temperature of 100.5F (38.1C).
A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority?
Place tach tray at the bedside
A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions would the nurse give to this patient?
Rinse the mouth before and after each meal and at bedtime with a saline solution.
a nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication?
calcium
A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect?
constipation
A nurse is assessing heart sounds of a client who reports substernal precordial pain. Identify which of the following sounds the nurse should document in the client's medical record by listening to the audio clip. (Click on the audio button to listen to the clip.) ANSW-Pericardial friction rub
iv==document in the client's medical r
a nurse is performing a cardiac assessment for a client who had a myocardial infraction 2 days ago. which of the following actions should the nurse take first after hearing the following sound?
listen with the client on their left side
a nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan?
monitor the client's temperature every 4 hrs.
A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care?
nstruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period.
a nurse is caring for a client who has portal hypertension. the client is vomiting blood mixed with food after a meal. which of the following actions should the nurse take first?
obtain vital signs
A patient who has severe pain with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching about pain management has been effective?
the patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs.
a nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. which of the following actions should the nurse include in the client's plan of care?
wear a lead apron while providing care to the client
a nurse is assessing a client who has graves disease. which of the following images should indicate to the nurse that the client has exophthalmos?
wide eyes
A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. which of the following statements should the nurse include in the teaching
you should cut the opening of the skin barrier one-eighth inch wider than the stoma
a nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analgesic for pain management. which of the following information should the nurse include in the teaching?
you should void every 4 hours to decrease the risk of urinary retention
A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
AdminiSTER o2 Initiate IV therapy Insert an NG tube Administer ranitidine
A patient with metastatic colon cancer has severe vomiting after each administration of chemotherapy. Which action would the nurse take?
Administer prescribed antiemetics 1 hour before the treatments.
The health care provider has prescribed the following interventions for a patient who is taking azathioprine (Imuran) for systemic lupus erythematosus. Which order would the nurse question?
Administer varicella vaccine.
A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about the management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective?
"I can apply aloe vera gel after I bathe."
A nurse is caring for a client who has breast cancer and tells the nurse that they would like to have acupuncture because it provides greater relief than pain medication. Which of the following statements should the nurse make?
"I can speak to the provider about incorporating acupuncture into your treatment plan.
The nurse would determine additional instruction is needed when a patient diagnosed with scleroderma makes which statement?
"I should lie down for an hour after each meal."
The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective?
"I will need follow-up examinations for many years after treatment before I can be considered cured."
The nurse assesses a patient with non-Hodgkin's lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse?
Shortness of breath
An IV vesicant chemotherapeutic agent is prescribed for a patient. Which action is would the nurse plan to take?
Stop the infusion if swelling is observed at the site.
A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation?
Stress ulcers
Which action would the nurse take when caring for a patient who is receiving chemotherapy and reports problems with concentration?
Suggest use of a daily planner and encourage adequate sleep.
The nurse receives change-of-shift handoff report on the oncology unit. Which patient would the nurse assess first?
A 24-yr-old patient who received neck radiation and has blood oozing from the neck
A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients?
A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughedA
he nurse at the clinic is interviewing a 64-yr-old woman who is 5 feet, 3 inches tall and weighs 125 lb (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.Tobacco use c. Sunscreen use d.Mammography e.Colorectal screening
A, C, D, E
A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care?
ANSW Keep a lead-lined container in the client's room.
A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I wish I could stop these treatments. I am ready to die." Which of the following statements should the nurse make?
ANSW-"Discontinuing with the treatments is your choice if it is your wish to do so."
A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching?
ANSW-"I will eat more high-fiber foods."
A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer?
ANSW-Dyspnea
A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan?
ANSW-Encourage the client to take deep breaths after the procedure
A nurse is providing discharge teaching to a client who is postoperative following a modified radical mastectomy. Which of the following instructions should the nurse include?
ANSW-Numbness can occur along the inside of the affected arm
A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's priority?
ANSW-Temperature 38.9° C (102° F)
A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia?
ANSW-The client's heart rate increases.
a nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney disease (ESKD). the client reports muscle cramps and a tingling sensation in their hands. which of the following medications should the nurse plan to administer?
ANSW-calcium carbonate
a nurse is reviewing the laboratory results of a client who has cirrhosis. which of the following laboratory values should the nurse expect?
ANSW-elevated bilirubin level
A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contract. which of the following information should the nurse provide?
ANSW-increase fluid intake
a nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. which of the following assessment findings in the nurse's priority?
ANSW-increased respiratory secretions
a nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analgesic for pain management. which of the following information should the nurse include in the teaching?
ANSW-you should void every 4 hours to decrease the risk of urinary retention
A new clinic patient with joint swelling and pain is having diagnostic tests. Which testwould the nurse identify as specific to systemic lupus erythematosus?
Anti-Smith antibody (Anti-Sm)
During the teaching session for a patient who has a new diagnosis of acute leukemia, the patient is restless and looks away without making eye contact. The patient asks the nurse to repeat the information about the complications associated with chemotherapy. Based on this assessment, which patient problem would the nurse identify?
Anxiety
A patient has inadequate nutrition due to painful oral ulcers. Which nursing action will be most effective in improving oral intake?
Apply prescribed anesthetic gel to oral lesions before meals.
A patient with cancer is eating very little due to altered taste sensation. Which nursing action would address the cause of the patient problem?
Avoid giving the patient foods that are strongly disliked.
Which food choice would the nurse suggest for a patient scheduled to receive external-beam radiation for abdominal cancer?
Baked chicken
The nurse teaches a patient who has liver cancer about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective?
Blueberry yogurt
Which finding for a patient who is taking hydroxychloroquine (Plaquenil) to treat rheumatoid arthritis would the nurse identify as a likely adverse effect of the medication?
Blurred vision
A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion?
Bubbling in the water seal chamber has ceased.
A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, "Last week I crashed my car because my vision suddenly became blurry." Which of the following actions is the nurse's priority?
Check the client's neurologic status.
External-beam radiation is planned for a patient with cervical cancer. What instructions would the nurse give the patient to prevent complications from the effects of the radiation?
Clean the perianal area carefully after each bowel movement.
A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the following findings should the nurse report to the provider?
Client reports back pain
A patient with a large stomach tumor attached to the liver is scheduled for a debulking procedure. Which information would the nurse teach the patient about the expectedoutcome of this procedure?
Decreasing the tumor size will improve the effects of other therapy.
A patient who has ovarian cancer is crying and tells the nurse, "My husband rarely visits. He just doesn't care." The husband tells the nurse that he does not know what to say to his wife. Which problem would the nurse address in the plan of care?
Difficulty coping
A patient smokes 2 packs of cigarettes/day. Which action by the nurse could help the patient reduce the risk of lung cancer?
Discuss dangers associated with cigarettes during each patient encounter.
Which result for a patient with systemic lupus erythematosus (SLE) would the nurse identify as most important to communicate to the health care provider?
Elevated blood urea nitrogen (BUN)
A chemotherapy drug that causes alopecia is prescribed for a patient. Which action would the nurse take to support the patient's self-esteem?
Encourage the patient to purchase a wig or hat to wear when hair loss begins.
A patient with Hodgkin's lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." Which intervention would the nurse add to the plan of care?
Establish time to take a short walk almost every day.
A nurse is reviewing the medical record of a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?
Facial butterfly rash
Which action by assistive personnel (AP) caring for a patient who is pancytopenic indicates a need for the nurse to intervene?
The AP assists the patient to use dental floss after eating.
The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by assistive personnel (AP), if observed by the nurse, would require an intervention?
The AP stands by the patient's bed for 30 minutes talking with the patient.
The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement by the patient indicates that teaching was effective?
The biopsy will help guide the treatment choices for my enlarged prostate."
A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse indicates a need for further teaching?
The patient ambulates around the hospital.
The nurse is assessing a patient with osteoarthritis who uses naproxen (Naprosyn) for pain management. Which assessment finding would the nurse recognize as likely to require a change in medication?
The patient has dark-colored stools.
A patient with dermatomyositis is receiving long-term prednisone therapy. Which assessment finding would the nurse report immediately to the health care provider?
The patient reports burning with urination.
A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)?
Troponin I 8 ng/mL
An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration?
Urine specific gravity of 1.045
A nurse is caring for a client 1 hr following a cardiac catheterization. the nurse notes the formation of a hematoma at the insertion side and a decreased pulse rate in the affected extremity. which of the following interventions is the nurse's priority?
apply firm pressure to the insertion site
a nurse is caring for a client who has a new diagnosis of hyperthyroidism. which of the following is the priority assessment finding that the nurse should report to the provider?
blood pressure 170/80 mm Hg
The nurse is caring for a patient with colon cancer. Which information indicates a need for specific patient teaching before the patient begins external radiation therapy to the abdomen?
he patient swims several days each week.
a nurse is caring for a client who has chronic glomerulonephritis with oliguria. which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis?
hyperkalemia
a nurse is caring for a client who has a potassium level of 3 mEq/L. which of the following assessment findings should the nurse expect?
hypoactive bowel sounds
a nurse is providing teaching to a client who has irritable bowel syndrome (IBS). which of the following instructions should the nurse include in teaching?
increase fiber intake to at least 30 mg per day
