NCLEX #4

The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care?

" I empty the urinary collection bag when it is two thirds full."

As part of chemotherapy education, nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed when the client makes which statement ?

" Im going to take aspirin for my headache as soon as I get home"

The nurse is assessing the perineal wound in a client who has retuned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate ?

Change the dressing as prescribed

A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action?

Continue to monitor the drainage

The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency?

Facial edema in the morning, serum calcium level of 12mg/dL (3.0 mmol/L), numbness and tingling of the lower extremities

The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common sign or symptom of this type of cancer?

Hematuria

The nurse is conducting a history and monitoring lab values on a client with multiple myeloma. What assessment finding should the nurse expect to note?

Pathological fracture, urinalysis positive for Bence Jones protein, serum creatine level of 2.0 mg/dL

The nurse is mentoring a a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency?

Periorbital edema

While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action?

Pick up the implant with long-handled forceps and place it in a lead container

A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which condition?

The development of a vesicovaginal fistula

The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?

The passage of flatus

The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment?

The client's pain rating

A client is diagnosed as having a intestinal tumor. The nurse should monitor the client for which complications of this type of tumor? Select all that apply

2. Peritonitis 3. Hemorrhage 4. Fistula formation 5. Bowel perforation

. The nurse is instructing a client with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction should the nurse tell the client?

. Administer the iron through a straw.

The nurse is caring for a client who is postoperative following a pelvic exenteration, and the surgeon changes the clients diet from NPO (nothing by mouth) status to clear liquids. The nurse should check which priority item before administering the diet?

Bowel sounds

During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which manifestation as typical of the disease?

Abdominal distention

The nurse is teaching the client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor?

Age younger than 50 years

The nurse manager is teaching the nursing staff and signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which is a late sign or symptom of this oncological emergency ?

Electrocardiographic changes

The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm?

Elevating the affected arm on a pillow above heart level

The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan?

Encouraging fluids

A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to not specifically in the client?

Enlarged lymph nodes

The nurse is reviewing the lab results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder?

Increased calcium level

When caring for a client with an internal radiation implant, the nurse should observe which principles?

Keeping pregnant women out of the child's room, Placing the client in a private room with a private bath, Wearing a lead shield when providing direct client care.

The nurse is providing dietary teaching for a client who underwent a partial gastrectomy to treat gastric cancer about foods high in vitamin B12. The nurse would instruct the client to include which food items in the diet that are high in this vitamin? Select all that apply

Milk, fish, beef, turkey

The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time?

One week after menstruation begins

A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the primary health care provider will request which prescriptions?

Radiation, Chemotherapy, serum sodium level determination, medication that is antagonistic to antidiuretic hormone

Laboratory studies are performed for a client suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia?

Red blood cells that are microcytic and hypochromic

The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy?

Teach the client and family about the need for hand hygiene

The nurse is instructing the client to preform a testicular self examination (TSE). The nurse should provide the client with which information about the procedure?

That the best time for the examination is after a shower