NCLEX Prep U Med Surg 1

Which statement indicates that the client needs further teaching about taking medication to control cancer pain? a) "I should skip doses periodically so I do not get hooked on my drugs." b) "It is okay to take my pain medication even if I am not having any pain." c) "I should take my medication around-the-clock to control my pain." d) "I should contact the oncology nurse if my pain is not effectively controlled."

a) "I should skip doses periodically so I do not get hooked on my drugs." The client should not skip his dosages of pain medication to prevent addiction. Clients with cancer pain do not become psychologically dependent on the medication and should not fear becoming addicted. The nurse should allow the client and family members to verbalize their concerns about drug addiction.

Two days after a right total knee replacement, a client rates his right-knee pain as 9 on a 10-point pain scale. A physician orders hydrocodone/APAP 1 tablet by mouth every 4 to 6 hours as needed for pain. When a nurse notifies the physician of the client's pain, the physician states that one hydrocodone/APAP tablet should be sufficient and refuses to order anything stronger for pain. Which measure should the nurse select to act as an advocate for the client? a) Document that the physician was notified of the client's pain and continue to administer hydrocodone/APAP as ordered. b) Follow the chain of command to obtain adequate pain relief for the client. c) Give the client 2 hydrocodone/APAP tablets every 4 hours. d) Give the client 1 hydrocodone/APAP tablet every 3 hours.

b) Follow the chain of command to obtain adequate pain relief for the client. Clients must receive adequate pain relief. Allowing a client to experience a pain score of 9 out of 10 is unacceptable nursing practice. Acting as a client advocate requires a nurse to be assertive, even if this means confronting a physician. If the physician doesn't give an order for adequate pain relief, the nurse should follow the chain of command to report the physician's inaction and obtain adequate pain relief for the client. A nurse may not adjust medication frequency or dosage without a physician's order.

A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal? a) Inadequate massaging of the affected area b) Inadequate vitamin D intake c) Low calcium level d) Inadequate protein intake

d) Inadequate protein intake Clients on bed rest suffer from lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels aren't factors in poor healing for this client. A pressure ulcer should never be massaged.

A client with multiple sclerosis is taking baclofen. Which sign indicates the drug is having the intended outcome? The client: a) does not have a urinary tract infection. b) has relief from muscle spasms. c) no longer has double vision. d) has increased energy.

has relief from muscle spasms. Correct Explanation: Baclofen is a central-acting skeletal muscle relaxant that is used to decrease the spasticity experienced by individuals with multiple sclerosis. Baclofen is not an antibiotic. Baclofen does not decrease fatigue. Common side effects are fatigue and weakness. Baclofen does not improve vision.

A client with granulocytopenia has many visitors. The most important measure to prevent infection is for the visitors to: a) leave the children at home. b) wash their hands. c) not kiss the client. d) visit only if they do not have a cold.

wash their hands. Correct Explanation: Washing hands before, during, and after care has a significant effect in reducing infections. It is advisable to avoid introducing a cold or children's germs and to avoid kissing the client, but the primary prevention technique is hand washing.

Which action must a nurse perform when cleaning the area around a Jackson-Pratt wound drain? a) Clean from the center outward in a circular motion. b) Wear sterile gloves and a mask. c) Remove the drain before cleaning the skin. d) Clean briskly around the site with alcohol.

a) Clean from the center outward in a circular motion. The nurse should move from the center outward in ever-larger circles when cleaning around a wound drain because the skin near the drain site is more contaminated than the site itself. The nurse should never remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may irritate the skin and, because it evaporates, has no lasting effect on bacteria. The nurse should wear sterile gloves to prevent contamination, but need not wear a mask.

Allopurinol is prescribed for a client who has chronic gout. Which comment indicates that the client understands how to take the allopurinol? a) "I should not take aspirin when taking allopurinol." b) "I should drink plenty of fluids when taking allopurinol." c) "I will take the medication whenever my joints hurt." d) "I must take this drug on an empty stomach."

"I should drink plenty of fluids when taking allopurinol." Correct Explanation: It is important that the client force fluids to 3,000 mL/day to avoid the development of renal calculi when taking allopurinol. Allopurinol must be taken consistently to be effective in the treatment of gout. The drug should be taken after meals to avoid gastrointestinal distress. Although the client can take aspirin when taking allopurinol, both drugs can cause gastrointestinal irritation, and the practice is not recommended if the client is sensitive to the medications.

A client with rheumatoid arthritis is being discharged with a prescription for aspirin, 600 mg P.O. every 6 hours. Which statement by the client indicates understanding of the adverse effects of the medication? a) "I'll call my physician if I have ringing in the ears." b) "I know this mediation may cause bleeding so I will take it on an empty stomach." c) "I'll call my physician if I have difficulty voiding." d) "I know this medication may cause constipation so I will take a daily stool softener."

"I'll call my physician if I have ringing in the ears." Correct Explanation: The client with rheumatoid arthritis typically takes a relatively high dosage of aspirin for its anti-inflammatory effect. The nurse should instruct the client to report signs and symptoms of aspirin toxicity, such as tinnitus (ringing in the ears). Dysuria and constipation are not associated with aspirin use or toxicity. Bleeding is so the client is instructed to take with food.

The nurse is teaching the parents of a child with sickle cell disease. To instruct them on how to prevent sickle cell crisis, she should include which instruction? a) Avoid exercising in cool temperatures. b) Drink at least 2 quarts (2.3 liters) of fluids per day. c) Avoid physical activity. d) Stay away from other teenagers.

Drink at least 2 quarts (2.3 liters) of fluids per day. Correct Explanation: Increasing fluid intake and being well hydrated will help prevent cell stasis in the small vessels. Restricting fluids causes stasis of red blood cells and promotes obstruction and increases the chance of sickling with hypoxia and pain to the part that is involved. Clients with sickle cell should avoid exercising in cool temperatures or swimming in cold water. Clients with sickle cell disease should stay away from others who have infections. When the spleen of a client who has sickle cell disease has become fibrotic and nonfunctional, the client is more susceptible to infections. Clients with sickle cell disease should not avoid physical activity as long as the client stays well hydrated.

A client with rheumatoid arthritis has been on aspirin therapy for an extended time. Which assessment is the most important for the nurse to obtain? a) Muscle mass b) Gait c) Weight d) Hearing

Hearing Correct Explanation: Prolonged use of aspirin and other salicylates sometimes causes bilateral hearing loss of 30 to 40 decibels. Usually, this adverse effect resolves within 2 weeks after the therapy is discontinued. Aspirin doesn't lead to weight gain, gait problems, or changes in muscle mass.

The client tells the nurse that he is allergic to shellfish. The nurse should ask the client if he is also allergic to:

You selected: Iodine skin preparations. Correct Explanation: Clients who are allergic to shellfish are allergic to iodine skin preparations (Iodophor and Betadine) or any other products containing iodine, such as dyes. Clients who are allergic to shellfish do not necessarily have an allergy to any other substances or seafood. (less)

Which finding requires immediate intervention when planning care for an adolescent with cystic fibrosis (CF)? a) large, foul-smelling, and bulky stools b) chest pain with dyspnea c) poor weight gain d) delayed puberty

b) chest pain with dyspnea Chest pain and dyspnea are signs of a pneumothorax and should be treated immediately. Delayed puberty is common in adolescents with CF and is caused by poor nutrition. Poor weight gain is common in children with CF because so little is absorbed in the small intestine. Large, foul-smelling stools indicate noncompliance with taking enzymes and should be addressed, but respiratory complications are the greatest concern.

The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved in the client? a) an increase in body weight b) fluid intake less than urinary output c) urine output greater than 35 mL/hour d) blood pressure of 90/60 mm Hg

c) urine output greater than 35 mL/hour A urine output of 30 to 50 mL/h indicates adequate fluid replacement in the client with burns. An increase in body weight may indicate fluid retention. A urine output greater than fluid intake does not represent a fluid balance. Depending on the client, blood pressure of 90/60 mm Hg could indicate the presence of a hypovolemic state; by itself, it does not indicate adequate fluid replacement.

A client undergoing antineoplastic therapy is prescribed subcutaneous epoetin. The nurse evaluates that the drug is effective when: a) biopsies no longer show malignancy. b) nausea and vomiting stop. c) hemoglobin levels rise. d) a scan shows tumor shrinkage.

hemoglobin levels rise. Correct Explanation: Epoetin stimulates erythropoiesis and the production of RBCs. This is important for clients taking antineoplastics because they often suffer bone marrow depression as a side effect of antineoplastic therapy. Epoetin does not affect tissue malignancy or tumor size. Nausea and vomiting are commonly associated with antineoplastics, but these are treated with antiemetics.

The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first: a) administer the PRBCs through a percutaneously inserted central catheter line with a 20-gauge needle. b) flush PRBCs with 5% dextrose and 0.45% normal saline solution. c) stay with the client during the first 15 minutes of infusion. d) discontinue the IV catheter if a blood transfusion reaction occurs.

stay with the client during the first 15 minutes of infusion. Explanation: The most likely time for a blood transfusion reaction to occur is during the first 15 minutes or first 50 ml of the infusion. If a blood transfusion reaction does occur, it is imperative to keep an established I.V. line so that medication can be administered to prevent or treat cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a 19-gauge or larger needle; a peripherally inserted central catheter line is not recommended, in order to avoid a slow flow. RBCs will hemolyze in dextrose or lactated Ringer's solution and should be infused with only normal saline solution.

The nurse is teaching a client with rheumatoid arthritis about how to manage the fatigue associated with this disease. Which statement by the client indicates she understands how to manage the fatigue? a) "I sleep for 8 to 10 hours every night so that I will have the energy to care for my children during the day." b) "I schedule afternoon rest periods for myself in addition to sleeping 10 hours every night." c) "I spend one weekend day a week resting in bed while my husband cares for the children." d) "I get up early in the morning and get all my household chores completed before my children wake up."

"I schedule afternoon rest periods for myself in addition to sleeping 10 hours every night." Explanation: Regularly scheduled rest periods during the day along with 8 to 10 hours of sleep at night helps relieve the fatigue, pain, and stiffness associated with rheumatoid arthritis. Even with mild rheumatoid arthritis, the client may find it difficult to perform activities of daily living without some rest periods. Spending 1 day a week in bed to relieve fatigue does not adequately manage the disease. The client must recognize the need for rest before feeling exhausted because overexertion can cause exacerbations. In addition, prolonged periods of inactivity can increase joint stiffness and pain. Getting up early to do household chores before the children are awake does not allow for adequate rest.

A client is admitted to the facility with an exacerbation of her chronic systemic lupus erythematosus (SLE). The client gets angry when the call bell isn't answered immediately. What is the nurse's most appropriate response? a) "I know this is difficult for you but you should calm down. You know that stress will make your symptoms worse." b) "You seem angry. Would you like to talk about it?" c) "I can see you're angry but there is a lot going on right now. Please be patient and I will be back when I can." d) "I am sensing that you would like to talk about the problem, I will get the nursing supervisor to speak with you."

"You seem angry. Would you like to talk about it?" Correct Explanation: Verbalizing the observed behavior is a therapeutic communication technique in which the nurse acknowledges what the client is feeling. Offering to listen to the client express her anger can help both the nurse and the client understand its cause and begin to deal with it. Although stress can exacerbate the symptoms of SLE, telling the client to calm down doesn't acknowledge her feelings. Offering to get the nursing supervisor also ignores the client's feelings. Ignoring the client's feelings by leaving suggests that the nurse has no interest in what the client has said.

A client is about to undergo bone marrow aspiration of the sternum. What should the nurse tell the client? a) "You may feel a solution being wiped over your entire front from your neck down to your navel and out to your shoulders." b) "After the needle is removed, you will feel a bandage being applied around your chest." c) "You will not feel the local anesthetic being applied because it will be sprayed on." d) "You will feel a pulling type of discomfort for a few seconds."

"You will feel a pulling type of discomfort for a few seconds." Correct Explanation: As the bone marrow is being aspirated, the client will feel a suction or pulling type of sensation or discomfort that lasts a few seconds. A systemic premedication may be given to decrease this discomfort. A small area over the sternum is cleaned with an antiseptic. It is unnecessary to paint the entire anterior chest. The local anesthetic is injected through the subcutaneous tissue to numb the tissue for the larger-bore needle that is used for aspiration and biopsy. After the needle is removed, pressure is held over the aspiration site for 5 to 10 minutes to achieve hemostasis. A small dressing is applied; a large pressure dressing, such as an Ace bandage, would restrict the expansion of the lungs and is not used.

A client must receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product? a) Current guidelines suggest that no priming is needed since blood products must be infused alone b) Dextrose 5% in water as this is considered an isotonic solution c) Normal saline solution as this is considered an isotonic solution d) Lactated Ringer's solution as this is considered an isotonic solution

Normal saline solution as this is considered an isotonic solution Correct Explanation: Normal saline solution is used for administering blood transfusions. Lactated Ringer's solution or dextrose solutions may cause blood clotting or RBC hemolysis. Current guidelines do not indicate a "no priming" method without NSS

A nurse preparing to discharge a child with leukemia observes a family member who has a cold sharing a meal with the child. How should the nurse approach the situation? a) Instruct family members not share food because it isn't healthful. b) Tell family members to be careful to avoid the child if they're sick. c) Offer a face mask to the person with the cold and use this as an opportunity for further teaching. d) Post isolation signs on the child's door and carefully assess the health status of all visitors.

Offer a face mask to the person with the cold and use this as an opportunity for further teaching. Correct Explanation: Offering a face mask is the best approach; it protects the child while supporting the family and using the situation as an opportunity for learning. Instructing family members that it isn't healthful to share food and to avoid the child if they're sick are technically correct, but these responses don't include a rationale that enables the family to understand why these actions are important. The nurse should have posted an isolation sign on the child's door long before the time of his discharge.

A nurse is developing a care plan for a client with disseminated intravascular coagulation (DIC). Which nursing intervention should the nurse include? a) Place a pressure-reducing mattress on the client's bed. b) Administer aspirin daily as ordered. c) Administer meperidine (Demerol) I.M. as needed for pain. d) Provide mouth care every 4 hours with lemon-glycerin swabs.

Place a pressure-reducing mattress on the client's bed. Correct Explanation: A client with DIC is at risk for Impaired skin integrity related to bleeding or ischemia. The nurse should place the client on a pressure-reducing mattress and perform skin care every 2 hours. The nurse should avoid administering any medication that decreases platelet function, such as aspirin. The nurse should perform mouth care using sponge swabs and baking soda solution, not lemon-glycerin swabs, because lemon-glycerin swabs can dry the oral mucosa, which may lead to bleeding. I.M. injections should be avoided in clients with DIC because of the potential for bleeding.

A client seeks care for hoarseness that has lasted for 1 month. To elicit the most appropriate information about this problem, the nurse should ask which question? a) "Do you smoke cigarettes, cigars, or a pipe?" b) "Do you eat spicy foods?" c) "Do you eat a lot of red meat?" d) "Have you strained your voice recently?"

a) "Do you smoke cigarettes, cigars, or a pipe?" Persistent hoarseness may signal throat cancer, which commonly is associated with tobacco use. To assess the client's risk for throat cancer, the nurse should ask about smoking habits. Although straining the voice may cause hoarseness, it wouldn't cause hoarseness lasting for 1 month. Consuming red meat or spicy foods isn't associated with persistent hoarseness.

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 am so scared of this cancer. I should have quit smoking years ago. Now I have brought all this fear and sadness on myself and now my family." The nurse should tell the client: a) "It is okay to be scared. What is it about cancer that you are afraid of?" b) "Do not be so hard on yourself. You do not know if your smoking caused the cancer." c) "It is normal to be scared. I would be, too. We will help you through it." d) "Do you feel guilty because you smoked?"

a) "It is okay to be scared. What is it about cancer that you are afraid of?" Acknowledging the basic feeling that the client expressed and asking an open-ended question allows the client to explain her fears. Saying, "It is normal to be scared. We will help you through it," does not focus on the client's feelings; rather, it gives reassurance. Asking if the client feels guilty for having smoked assumes guilt, which might be present, but additional information is needed to confirm. Telling the client not to be so hard on herself does not acknowledge the client's feelings at all.

The client is to receive antibiotic intravenous (IV) therapy in the home. The nurse should develop a teaching plan to ensure that the client and family can manage the IV fluid and infusion correctly and avoid complications. What should the nurse instruct the client to do? Select all that apply. a) Cleanse the port with alcohol wipes. b) Place the IV bag on a table level with the client's arm. c) Call the health care provider (HCP) for a temperature above 100° F (37.8° C). d) Wear sterile gloves to change the fluids. e) Report signs of redness or inflammation at the site.

a) Cleanse the port with alcohol wipes. d) Wear sterile gloves to change the fluids. e) Report signs of redness or inflammation at the site. When intravenous (IV) therapy must be administered in the home setting, teaching is essential. Written instructions, as well as demonstration and return demonstration help reinforce key points. The client and/or caregiver is responsible for adhering to the established plan of care that includes the treatment plan, monitoring plan, potential for complications, expected outcome/s, potential adverse effects, and plan for communicating with the HCP. Periodic laboratory testing may be necessary to assess the effects of IV therapy and the client's progress. The client should report signs of redness or inflammation that could indicate infection, and also report an elevated temperature. Prior to changing the fluids, the caregiver should cleanse the port with alcohol wipes. It is not necessary to use sterile gloves; the IV bag should be elevated to promote gravity flow.

A client has been receiving chemotherapy for cancer treatment. The client is competent and has been actively involved in decisions regarding care; however, the client has now decided to refuse treatment. What should the nurse do when the client refuses the next dose of chemotherapy? a) Document the client's choice and offer to discuss feelings about the chemotherapy. b) Persuade the client to take the medication as ordered. c) Ensure that the client understands the rationale for taking the medication. d) Ask the client's spouse to encourage the client to take the chemotherapy.

a) Document the client's choice and offer to discuss feelings about the chemotherapy. The client has the right to choose whether to take the medication. The nurse should try to determine the reason for the client not wanting the medication other than choice (e.g., side effects, fear of falling asleep and not waking). The other options do not allow for client choice or consent.

The selection of a nursing care delivery system (NCDS) is critical to the success of client care in a nursing area. Which factor is essential to the evaluation of an NCDS? a) Identifying who will be responsible for making client care decisions b) Determining how planned absences, such as vacation time, will be scheduled so that all staff are treated fairly c) Deciding what type of dress code will be implemented d) Identifying salary ranges for various types of staff

a) Identifying who will be responsible for making client care decisions Determining who has responsibility for making decisions regarding client care is an essential element of all client care delivery systems. Dress code, salary, and scheduling planned staff absences are important to any organizations, but they are not actually determined by the NCDS.

A client with a subdural hematoma needs a feeding tube inserted due to inadequate swallowing ability. How would the nurse best explain this to the family? a) Nutrients are needed; however, eating and drinking without control of the swallowing reflex can result in aspirational pneumonia. b) Because of limited mobility, the client is susceptible to developing pneumonia. Extra nutrients are necessary to strengthen the immune system and promote recovery. c) Demonstrate to the family that pureed foods or liquids result in coughing. This signifies the importance of the need for a feeding tube. d) Tube feedings are less invasive than total parenteral nutrition; either one can meet hydration and nutritional needs.

a) Nutrients are needed; however, eating and drinking without control of the swallowing reflex can result in aspirational pneumonia. A swallowing assessment will test whether there is complete closure of the epiglottis during swallowing. Incomplete closure indicates that there is not protection of the trachea during oral ingestion of food or fluids. This will necessitate insertion of a nasogastric tube and initiating tube feedings. Tube feedings are less invasive, but this does not answer the underlying basis for insertion of the feeding tube. Demonstrating to the family that the client will choke presents a hazard and is inappropriate when swallowing impairment has been diagnosed. Limited mobility and being susceptible to pneumonia does not answer the underlying reason for the feeding tube.

A nurse is working with an unlicensed assistive personnel (UAP). Which clients should the nurse assign to the UAP? Select all that apply. a) Older adult client who had hip replacement surgery and needs to walk in the hall with a walker. b) Adult client who had abdominal surgery yesterday and requires a dressing change. c) Adult client who had a hysterectomy 3 days ago and requires vital sign checks every 4 hours. d) Adult client newly diagnosed with diabetes who is learning to administer insulin. e) Young adult client who requires tube feedings.

a) Older adult client who had hip replacement surgery and needs to walk in the hall with a walker. c) Adult client who had a hysterectomy 3 days ago and requires vital sign checks every 4 hours. The UAP can assist clients ambulate and take vital signs. It is within the RN scope of practice to teach the client to administer insulin, change dressings, and administer tube feedings.

A nurse is performing a sterile dressing change. Which action contaminates the sterile field? a) Pouring solution onto a sterile field cloth b) Holding sterile objects above the waist c) Opening the outermost flap of a sterile package away from the body d) Leaving a 1″ (2.5-cm) edge around the sterile field

a) Pouring solution onto a sterile field cloth Pouring solution onto a sterile field cloth contaminates the sterile field because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. Holding sterile objects above the waist, leaving a 1″ edge around the sterile field, and opening the outermost flap of a sterile package away from the body maintain the sterile field.

A client who is in the end-stages of cancer is increasingly upset about receiving chemotherapy. Which approach by the nurse would likely be most helpful in gaining the client's cooperation? a) Tell the client how the treatment can be expected to help. b) Suggest having a massage during the treatment. c) Describe the probable effect that missing a treatment would have. d) Explain that being upset makes the treatment more difficult.

a) Tell the client how the treatment can be expected to help. The best course of action when the client has outbursts concerning treatments is to explain how the treatment is expected to help. Describing the effect if the client misses a treatment is a negative approach and may be threatening to the client. Explaining the effects of being upset does not deal with the client's feelings. Offering to arrange for a massage during the chemotherapy may be helpful, but does not deal with the client's immediate feelings.

A nurse observes an LPN measuring a client's urine output from an indwelling catheter drainage bag. Which observation by the nurse ensures that the client's urine has been measured accurately? a) The LPN pours the urine into a graduated measuring container. b) The LPN pours the urine into a paper cup that holds approximately 250 mL. c) The LPN holds the Foley drainage bag up to eye level. d) The LPN uses the measuring markings on the Foley drainage bag.

a) The LPN pours the urine into a graduated measuring container. The only means to measure urine output accurately is to use a container that has specific markings for measuring liquid. The other options would not provide an accurate measure of urine output.

A 32-year-old woman recently diagnosed with Hodgkin's disease is admitted for staging by undergoing a bone marrow aspiration and biopsy. To obtain more information about the client's nutrition status, the nurse should review the results of which test? a) albumin level b) reticulocyte count c) red blood cell count d) direct and indirect bilirubin levels

a) albumin level Serum albumin levels help determine whether protein intake is sufficient. Proteins are broken down into amino acids during digestion. Amino acids are absorbed in the small intestine, and albumin is built from amino acids. The red blood cell count, bilirubin levels, and reticulocyte count do not indicate protein intake.

After a lobectomy for lung cancer, the nurse instructs the client to perform deep-breathing exercises to: a) expand the alveoli and increase lung surface available for ventilation. b) elevate the diaphragm to enlarge the thorax so that the lung surface area available for gas exchange is increased. c) decrease blood flow to the lungs for rest and increased surface alveoli ventilation. d) control the rate of air flow to the remaining lobe to decrease the risk of hyperinflation.

a) expand the alveoli and increase lung surface available for ventilation. Deep breathing helps prevent microatelectasis and pneumonitis and also helps force air and fluid out of the pleural space into the chest tubes. It does not decrease blood flow to the lungs or control the rate of air flow. The diaphragm is the major muscle of respiration; deep breathing causes it to descend, thereby increasing the ventilating surface.

Which action is most important when the nurse is planning pain management for a client after a lobectomy for lung cancer? a) reassessing the client after administering pain medication b) readjusting the pain medication dosage as needed c) repositioning the client immediately after administering pain medication d) reassuring the client after administering pain medication

a) reassessing the client after administering pain medication It is essential for the nurse to evaluate the effects of pain medication after it has had time to act. Although other interventions may be appropriate, continual reassessment is most important to determine the effectiveness and need for additional intervention, if any. Repositioning could provide some comfort, but assessment of the client's pain level is essential. Reassuring the client is important, but it will be of no value unless the nurse evaluates the client's pain level. To readjust the pain dosage is appropriate only if titration is prescribed by the health care provider (HCP).

Which precautions should the health care team observe when caring for clients with hepatitis A? a) wearing gloves when giving direct care b) wearing a mask when providing care c) gowning when entering a client's room d) assigning the client to a private room

a) wearing gloves when giving direct care Contact precautions are recommended for clients with hepatitis A. This includes wearing gloves for direct care. A gown is not required unless substantial contact with the client is anticipated. It is not necessary to wear a mask. The client does not need a private room unless incontinent of stool.

The nurse is documenting the assessment of a wound on a client's foot. Which of the following assessments would be included as subjective data? a) Temperature is 100.4 degrees F (38 degrees C). b) Area around the wound is tender to touch. c) Drainage from the wound is yellow. d) Area around the wound is pink and swollen.

b) Area around the wound is tender to touch. Subjective data is that which is reported by the client. The other options represent objective data that is observed by the nurse.

Which nursing action best addresses the outcome: The client will be free from falls? a) Install a monitoring system to help the client in an emergency situation. b) Encourage use of grab bars and railings in the bathroom and halls c) Use large muscle group when transfer client from bed to chair. d) Place emergency contact's telephone number in a prominent place.

b) Encourage use of grab bars and railings in the bathroom and halls To address the client outcome of being free from falls, it is best to place assistive devices of grab bars especially in the bathroom and railing in the halls to promote balance. It is a nursing focused action to use large muscle groups when transferring a client. It is important to place an emergency contact number close by and have an emergency monitoring system; however, they will not prevent falls.

Prior to surgery for a modified radical mastectomy, the client is extremely anxious and asks many questions. Which approach offers the best guide for the nurse to answer these questions? a) Delay discussing the client's questions with her until she is convalescing. b) Tell the client as much as she wants to know and is able to understand. c) Explain to the client that she should discuss her questions first with the health care provider (HCP). d) Delay discussing the client's questions with her until her apprehension subsides.

b) Tell the client as much as she wants to know and is able to understand. An important nursing responsibility is preoperative teaching, and the most frequently recommended guide for teaching is to tell the client as much as she wants to know and is able to understand. Delaying discussion of issues about which the client has concerns is likely to aggravate the situation and cause the client to feel distrust. As a general guide, the client would not ask the question if she were not ready to discuss her situation. The nurse is available to answer the client's questions and concerns and should not delay discussing these with the client.

When explaining the long-term toxic effects of cancer treatments on the immune system, what should the nurse tell the client? a) The helper T cells recover more rapidly than the suppressor T cells, which results in positive helper cell balance that can last 5 years. b) The use of radiation and combination chemotherapy can result in more frequent and more severe immune system impairment. c) Clients with persistent immunologic abnormalities after treatment are at a much greater risk for infection than clients with a history of splenectomy. d) Long-term immunologic effects have been studied only in clients with breast and lung cancer.

b) The use of radiation and combination chemotherapy can result in more frequent and more severe immune system impairment. Studies of long-term immunologic effects in clients treated for leukemia, Hodgkin's disease, and breast cancer reveal that combination treatments of chemotherapy and radiation can cause overall bone marrow suppression, decreased leukocyte counts, and profound immunosuppression. Persistent and severe immunologic impairment may follow radiation and chemotherapy (especially multiagent therapy). There is no evidence of greater risk of infection in clients with persistent immunologic abnormalities. Suppressor T cells recover more rapidly than the helper T cells.

The client is advised by the health care provider to have mammography screening annually. Measures to improve adherence with mammography screening include: a) emphasizing that mammography screening is a low-cost approach to cancer prevention. b) making sure that the individual barriers to screening are minimized. c) informing the client that she is at high risk for breast cancer and needs to follow the health care provider's recommendation. d) emphasizing that mammography screening can prevent breast cancer.

b) making sure that the individual barriers to screening are minimized. Reducing barriers to mammography is the best way to improve adherence with screening. Mammography can detect breast cancer in the early stages but cannot prevent it. Mammography is not a low-cost approach for all clients. In fact, it may cost the client a significant amount of money. The client is not at high risk for developing breast cancer at this point.

When reporting to the outpatient cancer center for his first chemotherapy treatment, a client appears anxious and apprehensive. Which statement by the nurse may help allay the client's anxiety? a) "We wear gowns and gloves to administer chemotherapy drugs because they're very dangerous." b) "You look anxious, don't worry you will get used to this place." c) "As a precaution, we wear gowns, goggles, and gloves to administer the medication." d) "You may have a seat right over here."

c) "As a precaution, we wear gowns, goggles, and gloves to administer the medication." Telling the client about the personal protective equipment worn to administer the chemotherapy drugs educates the client about the administration process and helps allay his anxiety. Telling the client to have a seat, saying that chemotherapy drugs are dangerous, and telling the client not to worry dismiss the client's feelings of anxiety.

A client's husband expresses concern that his dying wife keeps saying, "I have to go to the store." Which statement by the nurse will be most effective in assisting the husband to understand the dying process? a) "Many dying clients are restless and can be treated with sedatives." b) "You can tell your wife that you will take her to the store." c) "Comments related to going somewhere or leaving on a trip are common in dying clients." d) "The client may be fighting death, and you should leave her alone."

c) "Comments related to going somewhere or leaving on a trip are common in dying clients." Mental changes and decreased level of consciousness are common in the dying process, and the client may talk about travel, trips, or going somewhere. Suggesting that the client be sedated ignores the husband's question about what his wife is experiencing. Suggesting that the client is fighting death and that the husband should leave her alone is inappropriate and denies the husband time to spend with his wife. The husband should not make misleading statements to his wife.

A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000/mm3. Which statement by the client indicates a need for additional teaching? a) "I take a stool softener every morning." b) "I use an electric razor to shave." c) "I floss my teeth every morning." d) "I removed all the throw rugs from the house."

c) "I floss my teeth every morning." A client with a platelet count of 30,000/mm3 is at risk for bleeding and shouldn't floss his teeth. Flossing may increase the risk of bleeding in a client with a platelet count less than 40,000/mm3. Using an electric razor is appropriate because doing so helps minimize the risk of cutting when shaving. Taking a stool softener helps decrease potential trauma to the GI tract that may cause bleeding. Removing throw rugs from the house helps prevent falls, which could lead to uncontrolled bleeding.

When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching? a) "I will administer the enema while lying on my back with both knees flexed." b) "I will administer the enema while lying on my right side with my left knee flexed." c) "I will administer the enema while lying on my left side with my right knee flexed." d) "I will administer the enema while sitting on the toilet."

c) "I will administer the enema while lying on my left side with my right knee flexed." Lying on the left side allows the enema solution to flow downward by gravity into the rectum and sigmoid colon. The other options don't accomplish this goal and, therefore, are less effective in evacuating the lower bowel.

After receiving information on various forms of birth control, a young couple decides to use a barrier method because they would like to try and conceive in 1 to 2 years. Which barrier method uses a rubber barrier to hold spermicide against the cervix? a) A cervical cap. b) A vaginal sponge. c) A diaphragm. d) A condom.

c) A diaphragm. A diaphragm is a dome-shaped device made from latex rubber that mechanically prevents semen from coming in contact with the cervix. It also holds a spermicidal jelly in place against the cervix. A condom rolls over an erect penis and collects the semen after ejaculation. A cervical cap is placed over the cervix and may be left in place for up to 3 days. A vaginal sponge contains spermicide and is a reservoir to hold the semen.

The nurse is caring for a client with a Jackson-Pratt drain. Which of the following would be the most appropriate action by the nurse? a) Attach the tube to straight drainage to monitor the output. b) Irrigate the drain with normal saline to ensure patency. c) Ensure that the drainage receptacles are kept compressed to maintain suction. d) Leave the drain open to the air to ensure maximum drainage.

c) Ensure that the drainage receptacles are kept compressed to maintain suction. Portable wound drainage systems are self-contained and can be emptied and compressed to reestablish negative pressure, which promotes drainage. The other choices are incorrect because a Jackson-Pratt drain needs negative pressure in the bulb to promote drainage.

A nurse is administering daunorubicin through a peripheral I.V. line when the client complains of burning at the insertion site. The nurse notes no blood return from the catheter and redness at the I.V. site. The client is most likely experiencing which complication? a) Erythema b) Flare c) Extravasation d) Thrombosis

c) Extravasation The client is exhibiting signs of extravasation, which occurs when the medication leaks into the surrounding tissues and causes swelling, burning, or pain at the injection site. Erythema is redness of the skin that results from skin irritation. Flare is a spreading of redness that occurs as a result of drawing a pointed instrument across the skin. Thrombosis is the formation of clot within the vascular system.

A client has a wound with a drain. When performing wound cleansing around the drain, the nurse should cleanse in which direction? a) From the superior portion of the wound to the inferior b) Laterally, from one side of the wound to the opposite side c) In a widening circle around the drain, outward from the center d) Laterally, from the distal area to the center

c) In a widening circle around the drain, outward from the center When cleaning the area around the drain, the nurse should wipe in a circle around the drain, working from the center outward. The nurse wipes laterally, from the center to the opposite side, when cleaning a large horizontal wound and wipes from the superior portion of the wound to the inferior when cleaning a vertical incision. Cleaning the wound laterally from the distal area to the center increases the client's risk for infection.

A primary unit nurse tells the nurse-manager that a newly hired registered nurse needs an additional week of orientation in order to function effectively on the staff. Which action is most appropriate for the nurse-manager to take? a) Schedule a staff meeting to find out if there are deficiencies or flaws in the orientation process. b) Fire the new nurse because the unit is short-staffed and needs nurses who can complete the orientation process in the normal length of time. c) Meet with the new nurse and the primary nurse and help set up an additional week of orientation. d) Tell the primary nurse that the new nurse must finish orientation within 6 weeks because of a staffing shortage.

c) Meet with the new nurse and the primary nurse and help set up an additional week of orientation. The nurse-manager is responsible for adequate orientation of new staff. A need for additional orientation doesn't mean that a nurse isn't competent. However, the new nurse should know what's expected of her and how soon she must fulfill those expectations. Firing the new nurse isn't the answer because she's apparently close to completing orientation and the primary nurse says she has good skills. Periodically reviewing and revising the orientation process is a good idea. However, in this case, the most appropriate course of action is to help the new nurse complete her orientation as efficiently as possible.

A nurse is caring for a 15-year-old male recently diagnosed with osteosarcoma of the right femur with lung metastasis. He and his visiting parent are discussing their uncertainty about the need for surgery or other therapies. How can the nurse best demonstrate the advocacy role? a) Provide additional educational resources and materials. b) Ask the client and his parent what they are unsure about. c) Notify the physician to meet with the family. d) Refer the family to ancillary support services.

c) Notify the physician to meet with the family. Discussing uncertainty about the need for treatment and surgery involves the issue of informed consent. The physician or provider who will perform the procedure must secure this consent. Asking what the family is unsure about, providing additional educational resources and materials, or referring the family to ancillary support services does not eliminate the need for the physician to speak with the family to obtain informed consent.

After a mastectomy for breast cancer, the nurse teaches the client how to avoid the development of lymphedema. The nurse should teach the client to: a) apply an elastic bandage to the affected extremity. b) use diuretics as necessary to decrease swelling. c) elevate the affected arm on a pillow. d) limit range-of-motion exercises in the shoulder and elbow.

c) elevate the affected arm on a pillow. The client should be taught to elevate the affected arm on a pillow to promote venous return and lymphatic drainage of the area. Applying an elastic bandage is inappropriate because constriction of the extremity should be avoided. Range-of-motion exercising is not limited. Rather, it is encouraged. Diuretics are not used to control lymphedema.

The client with a laryngectomy does not want to be observed by the family because the opening in the throat is "disgusting." The nurse should: a) inform the client of the benefits of family support. b) initiate teaching about the care of a stoma. c) explore why the client believed the stoma is "disgusting." d) explain that the stoma will not always look as it does now.

c) explore why the client believed the stoma is "disgusting." Changes in body image are expected after a laryngectomy, and the nurse should first explore what is upsetting the client the most at this time. Many clients are concerned about how their family members will respond to the physical changes that have occurred as a result of a laryngectomy, but discussing the importance of family support is not helpful; instead, the nurse should allow the client to communicate any negative feelings or concerns that exist because of the surgery. The client's feelings are not related to a knowledge deficit, and therefore, it is too early to begin teaching about stoma care. It is also not helpful to offer reassurances about the change in appearance; the client will require time to adjust to the changed body image.

A client has a reddened area over a bony prominence. The nurse finds an unlicensed nursing personnel (UAP) massaging this area. The nurse should: a) inform the UAP that massage is even more effective when combined with the use of lotion. b) explain to the UAP that massage is effective because it improves blood flow to the area. c) instruct the UAP that massage is contraindicated because it decreases blood flow to the area. d) reinforce the UAP's use of this intervention over the bony prominence.

c) instruct the UAP that massage is contraindicated because it decreases blood flow to the area. Massaging an area that is reddened due to pressure is contraindicated because it further reduces blood flow to the area. In the past, massaging reddened areas was thought to improve blood flow to the area, and some nursing personnel may still believe that massaging the area is effective in preventing pressure ulcer formation.

An alert and oriented older adult female with metastatic lung cancer is admitted to the medical-surgical unit for treatment of heart failure. She was given 80 mg of furosemide in the emergency department. Although the client is ambulatory, the unlicensed assistive personnel (UAP) are concerned about urinary incontinence because the client is frail and in a strange environment. The nurse should instruct the UAP to assist with implementing the nursing plan of care by: a) requesting an indwelling urinary catheter to avoid incontinence b) prescribing adult diapers for the client so she will not have to worry about incontinence c) placing a commode at the bedside and instructing the client in its use d) padding the bed with extra absorbent linens

c) placing a commode at the bedside and instructing the client in its use A bedside commode should be near the client for easy, safe access. Measurement of urine output is also important in a client with heart failure. Putting diapers on an alert and oriented individual would be demeaning and inappropriate. Indwelling catheters are associated with increased risk of infection and are not a solution to possible incontinence. There is no reason to think that the client would not be able to use the bedside commode.

An elderly couple who have just relocated to a long-term care facility have been unable to obtain a shared room. A staff member at the facility states that this should not be a concern and implies that sexual activity between the couple likely ceased many years ago. How should the nurse best respond to this individual's assertion? a) "Research has shown the nature of sexual activity changes with age but that it actually becomes more frequent." b) "It's true that they've probably stopped having sexual activity, but it's important for them to have companionship." c) "That's true, but it's important for us to give them the teaching they need in order to resume this part of their relationship." d) "Actually it's not true that older people always stop having sexual activity when they get older."

d) "Actually it's not true that older people always stop having sexual activity when they get older." Sexual activity need not be hindered by age. There is no evidence, however, that it becomes increasingly frequent in late adulthood.

For a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome is appropriate for this client? a) "Client stops seeking information." b) "Client doesn't guess at prognosis." c) "Client uses any effective method to reduce tension." d) "Client verbalizes feelings of anxiety."

d) "Client verbalizes feelings of anxiety." Verbalizing feelings is the client's first step in coping with the situational crisis. It also helps the health care team gain insight into the client's feelings, helping guide psychosocial care. An outcome in which the client doesn't guess at the prognosis is inappropriate because suppressing speculation may prevent the client from coming to terms with the crisis and planning accordingly. An outcome in which the client uses any effective method to reduce tension is undesirable because some methods of reducing tension, such as illicit drug or alcohol use, may prevent the client from coming to terms with the threat of death as well as cause physiologic harm. An outcome in which the client stops seeking information isn't appropriate because seeking information can help a client with cancer gain a sense of control over the crisis.

The nurse has completed discharge teaching with new parents who will be bottle-feeding their normal term newborn. Which statement by the parents reflects the need for more teaching? a) "The baby should burp during and after each feeding with no projective vomiting." b) "Our baby should have 1 to 3 soft, formed stools a day." c) "Our baby will require feedings through the night for several weeks or months after birth." d) "We should weigh our baby daily to make sure he is gaining weight."

d) "We should weigh our baby daily to make sure he is gaining weight." Healthy infants are weighed during their visits to their health care provider (HCP) , so it is not necessary to monitor weights at home. Infants may require 1 to 3 feedings during the night initially. By 3 months, 90% of babies sleep through the night. Projective vomiting may indicate pyloric stenosis and should not be seen in a normal newborn. Bottle-fed infants may stool 1 to 3 times daily.

In which circumstance may the nurse legally and ethically disclose confidential information about a client? a) A diagnosis of pancreatic cancer to a client's significant other b) The fact that a woman is 32 weeks pregnant with twins to the husband from whom she is legally separated c) A single male client's human immunodeficiency virus (HIV) status to his family members d) A taxi driver's diagnosis of an uncontrolled seizure disorder to a state agency

d) A taxi driver's diagnosis of an uncontrolled seizure disorder to a state agency A nurse may lawfully disclose confidential information about a client when the welfare of a person or group of people is at stake. A health care provider must inform the Department of Motor Vehicles that the taxi driver has an uncontrolled seizure disorder; disclosing the condition is in the best interest of public safety and the client's well-being. Confidentiality of HIV testing is required, but the client, who's HIV positive, should be encouraged to share the information with his family. Many state legislatures require maintaining confidentiality of HIV testing. The nurse may not disclose a diagnosis of pancreatic cancer or a pregnancy because these situations don't affect the welfare of a group of people.

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? a) A red blood cell count of 3.5 million/mm3 b) A retculocyte count of 1% c) A platelet count of 90,000 per microliter d) A white blood cell count of 2200/mm3

d) A white blood cell count of 2200/mm3 The normal number of WBCs in the blood is 4,500-10,000 white blood cells per microliter (mcL). Less than 4,500 is considered neutropenia and places the client at risk for infection. The platelet count ranges from 150,000 to 450,000/mcL. Platelets are responsible for blood clotting. The nurse needs to institute bleeding precautions for this, not neutropenic precautions. Red blood cells are responsible for oxygen transport. The reticulocyte count is normal.

A nursing instructor is instructing group of new nursing students. The instructor reviews that surgical asepsis will be used for which of the following procedures? a) Colostomy irrigation b) Nasogastric tube irrigation c) Instilling eye drops d) I.V. catheter insertion

d) I.V. catheter insertion Caregivers must use surgical asepsis when performing wound care or any procedure that involves entering a sterile body cavity or breaking skin integrity. To achieve surgical asepsis, objects must be sterilized or kept free of all pathogens. Because inserting an I.V. catheter disrupts skin integrity and involves entry into a sterile cavity (a vein), surgical asepsis is required. Medical asepsis is used when instilling eye drops. The GI tract isn't sterile; therefore, irrigating a nasogastric tube or a colostomy requires only clean technique.

Which nursing intervention is appropriate for a client with an arm restraint? a) Applying the restraint loosely to prevent pressure on the skin b) Positioning the restrained arm in full extension c) Tying the restraint to the side rail d) Monitoring circulatory status every 2 hours

d) Monitoring circulatory status every 2 hours A nurse must assess the circulatory status of a restrained extremity every 2 hours to prevent circulatory impairment. To make sure the restraint is secure without compromising the circulation, the nurse should leave approximately one fingerbreadth between the restraint and the extremity. Tying a restraint to the side rail or an immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. The restrained arm or leg should be flexed slightly to allow joint movement without reducing the effectiveness of the restraint.

A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem? a) Place the client in semi-Fowler's position while feeding. b) Give the feedings at room temperature. c) Change the feeding container daily. d) Stop the feedings and check for residual volume.

d) Stop the feedings and check for residual volume. Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Stopping the feeding and checking for residual volume helps assess the reason for the client's nausea and discomfort. If residual volume is greater than 100 ml, hold the feeding and notify the physician. Feedings are normally given at room temperature to minimize abdominal cramping; however, this action doesn't help assess why nausea and discomfort are occurring. Elevating the head of the client's bed to at least 30 degrees prevents aspiration during feeding. Also, feeding containers are changed daily to prevent bacterial growth.

The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. When coaching the client about the diet, the nurse should first: a) determine the client's knowledge level about cholesterol. b) ask the client to name foods that are high in fat, cholesterol, and salt. c) explain the importance of complying with the diet. d) assess the client's and family's typical food preferences.

d) assess the client's and family's typical food preferences. Before beginning dietary instructions and interventions, the nurse must first assess the client's and family's food preferences, such as pattern of food intake, lifestyle, food preferences, and ethnic, cultural, and financial influences. Once this information is obtained, the nurse can begin teaching based on the client's current knowledge level and then building on this knowledge base.

A client with cancer is uncertain about how to cope with all the issues that will arise. The nurse can best support the coping behaviors of a client with cancer by: a) encouraging compliance with treatment regimens. b) assisting the client to prepare for adverse treatment effects. c) relieving the client of decision making as much as possible. d) helping the client identify available resources.

d) helping the client identify available resources. Helping the client to identify available resources allows the client respect and time to make informed decisions and encourages the client to become actively involved with treatment options. Encouraging compliance with treatment regimens discourages the client from becoming actively involved in his treatment and diminishes coping ability. Relieving the client of decision making as much as possible is not appropriate and encourages feelings of helplessness and powerlessness. Assisting the client to prepare for adverse treatment effects may foster hopelessness and increase anxiety by focusing on adverse outcomes too soon.

A client with metastatic brain cancer is admitted to the oncology floor. According to the Self-Determination Act of 1991 concerning the execution of an advance directive, the hospital is required to: a) respect individuals' moral rights. b) decide on a treatment plan if the client can't. c) advise clients not to execute their advance directives because they limit treatment options. d) inform the client or legal guardian of their rights to execute an advance directive.

d) inform the client or legal guardian of their rights to execute an advance directive. The client Self-Determination Act of 1991 requires all health care facilities to notify clients upon admission of their right to execute an advance directive. The facility's ethics committee can decide on a treatment plan if the client is unable and a health care power of attorney hasn't been appointed. Hospital employees aren't required by law to respect an individual's moral rights; however, the health care professional should respect the client's individual rights as part of his professional responsibility. Health care professionals are sometimes concerned that advance directives prevent treatment that might help the client. However, the hospital isn't required to advise clients not to execute their advance directive.

The client with hepatitis A is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. The most appropriate goal for this client is to: a) adapt to new levels of energy. b) gradually increase activity tolerance. c) increase mobility. d) learn new self-care skills.

gradually increase activity tolerance. Correct Explanation: The most appropriate goal for this client with hepatitis is to increase activity gradually as tolerated. Periods of alternating rest and activity should be included in the plan of care. There is no evidence that the client is physically immobile, unable to provide self-care, or needs to adapt to new energy levels.

The teaching plan for the client with rheumatoid arthritis includes rest promotion. What position of the involved joints should the nurse tell the client to avoid when at rest? a) elevating the affected joints b) lying in a prone position c) keeping all joints aligned d) maintaining the joints in a flexed position

maintaining the joints in a flexed position Correct Explanation: Positions of flexion should be avoided to prevent loss of functional ability of affected joints. Proper body alignment during rest periods is encouraged to maintain correct muscle and joint placement. Lying in the prone position is encouraged to avoid further curvature of the spine and internal rotation of the shoulders.

On the fourth day after surgery, a client's incision is red and inflamed. There is moderate drainage from the incision. The client has a temperature of 102° F (38.9° C). The total white blood count (WBC) 10,000/mm3 (10 × 109/L). The nurse should first: a) encourage the client to increase the fluid intake. b) cleanse the incision site with soap and water. c) ask the client about the level of pain. d) notify the health care provider (HCP).

notify the health care provider (HCP). Correct Explanation: The findings (WBC count above normal; inflammation and drainage at the incision site; and an elevated temperature) indicate the client has an infection. The nurse should first notify the HCP. Encouraging fluids will be helpful, but it is not the first action. The client may have incisional pain, and after the nurse has contacted the HCP, the nurse can determine if the client needs pain management. The nurse should not cleanse the site until the HCP writes a prescription to do so.

The nurse is teaching a client about preventing toxic shock syndrome (TSS). Which action is a risk factor for toxic shock syndrome? a) changing tampons every 3 hours b) alternating tampons with sanitary pads c) avoiding use of deodorized tampons d) using only tampons at night

using only tampons at night Explanation: Risk factors for TSS include the use of tampons at night, when the tampon would be in place for 7 to 9 hours. TSS can occur in other situations, but it is commonly associated with women during menses, particularly women who use tampons. The longer the tampon is left in place, the greater the risk for TSS. Changing tampons every 3 hours or more frequently, avoiding use of deodorized tampons, and alternating tampons with sanitary pads are actions that decrease the risk of TSS.

The nurse is providing discharge teaching for a client with a compromised immune system and on neutropenic precautions. When discussing types of fruits and vegetables that the client likes, which are encouraged? Select all that apply. a) Canned peaches b) Carrot sticks c) Broccoli florets d) Bananas e) Cooked corn f) A green salad

• Canned peaches • Cooked corn Explanation: A client with a compromised immune system and low white blood cell count (neutropenia) is at high risk for infection. Foods can introduce infections; thus, the client is encourages to eat cooked or prepared fruits and vegetables. Canned peaches have been processed and thoroughly cooked corn is appropriate. Raw fruits and vegetables are not allowed because they may contain microbial contamination.

A multidisciplinary oncology team of physicians, nurses, and the social worker notes that a client who has been undergoing chemotherapy is now experiencing pancytopenia. When reviewing the laboratory data, which values support this diagnosis? Select all that apply. a) Decreased white blood cells b) Increased white blood cells c) Decreased platelets d) Decreased RBCs e) Increased RBCs f) Increased platelets

• Decreased white blood cells • Decreased platelets • Decreased RBCs Correct Explanation: Pancytopenia is a deficiency of all blood cells which includes a state of simultaneous leukopenia (decreased white blood cells), thrombocytopenia (decreased platelets), and anemia (decreased RBCs). Pancytopenia has widespread effects on the body by leading to oxygen shortage and immune function.