NS 254 exam 4 (cancer/peri-op)
hold the hands higher than the elbows
When scrubbing at the scrub sink, the nurse should
Ask the client if anyone else in her family has had trouble when they had surgery
Before surgery, a client states that she is afraid of surgery because her cousin died in surgery when having her tonsils removed. What is the nurse's best response?
Hemorrhage
Eight hours following bowel surgery, the nurse observes that the client's urine output has decreased from 50 to 20 ml/hr. The nurse should assess the client further for which of the following?
The cancer involves only the cervix
. A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is most appropriate?
Rinse the mouth before and after each meal and at bedtime with a saline solution.
A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient?
Encourage the patient to wear it for the surgery
A patient requests that the nurse give his hearing aid to a family member so it will not be lost in surgery. What is the appropriate action by the nurse?
erectile dysfunction can occur even with a nerve-sparing procedure.
A patient scheduled for a prostatectomy for prostate cancer expresses the fear that he will have erectile dysfunction. In responding to this patient, the nurse should keep in mind that
50 pack years (2.5 x 20 =50)
A patient smokes 2.5 packs of cigarettes every day for the last 20 years. How will the nurse document the patient's pack year in the chart?
The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs.
A patient who has severe pain associated with terminal breast cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective?
"Malignant tumors may spread to other tissues or organs."
A patient who is scheduled for a right breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct?
get instructions from her surgeon or HCP on any insulin adjustments
A patient who normally takes 40 units of glargine insulin (long acting) at be
PSA is a tumor marker that is elevated in patients with prostate cancer.
A patient with prostate cancer asks the nurse the meaning of his high prostate-specific antigen (PSA) level. Which response by the nurse is correct?
follow-up colonoscopies will be needed to ensure that the cancer does not recur.
A patient with stage I colorectal cancer is scheduled for surgery. Patient teaching for this patient would include an explanation that
administering ordered analgesia.
A priority nursing intervention for a patient who has just undergone a chemical pleurodesis for recurrent pleural effusion is
explain the pain management plan, including the use of a pain rating scale.
A priority nursing intervention to assist a preoperative patient in coping with fear of postoperative pain would be to
preparing the instrument table. passing instruments to the surgeon and assistants.
Activities that the nurse might perform in the role of a scrub nurse during surgery include
O2 saturation of 85%
After admission of the postoperative patient to the clinical unit, which assessment data require the most immediate attention?
teach the patient how to cough effectively to bring secretions to the mouth.
An appropriate nursing intervention for a patient with pneumonia with the nursing diagnosis of ineffective airway clearance related to thick secretions and fatigue would be to
Autoimmune disorders
Association between HLA antigens and diseases is most commonly found in what disease conditions?
Offer the patient to use a urinal or bedpan after explaining the need to maintain safety
Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks to get up to go to the bathroom to urinate. What is the most appropriate action for the nurse to take?
doing range-of-motion exercises on the affected upper limb.
Following a pneumonectomy, an appropriate nursing intervention is
Patient with seizures. Patient with head injury. Patient who is receiving nasogastric tube feeding
For which patients with pneumonia would the nurse suspect aspiration as the likely cause of pneumonia
Has a body mass index of 48.8 kg/m2
The nurse is doing a preoperative assessment on a male patient who has type 2 diabetes mellitus; weighs 146 kg; and is 5 feet 8, inches tall. Which patient assessment is a priority related to anesthesia?
induction is rapid and pleasant.
IV induction for general anesthesia is the method of choice for most patients because
Acute rejection can be treated with OKT3. Acute rejection is common after a transplant and can be treated with drug therapy.
In a person having an acute rejection of a transplanted kidney, what would help the nurse understand the course of events
release of chemical mediators from IgE-bound mast cells and basophils
In a type I hypersensitivity reaction the primary immunologic disorder appears to be
painless mass and heaviness sensation in the scrotal area.
In assessing a patient for testicular cancer, the nurse understands that the manifestations of this disease often include
Call the physician for specific prescriptions based on the glucose level
On the day of surgery, a client with DM who take insulin on a sliding scale is to be NPO and all medications withheld. The client's 0600 glucose level is 300 mg/dL. The nurse should:
surveillance for malignant cell changes.
One function of cell-mediated immunity is
Determine that there will a be a latex-safe environment for surgery. Report symptoms experienced with the latex allergy. Notify the HCP at the surgery center
The client has a latex allergy. What should the nurse teach the client to do before having surgery?
capture antigens by phagocytosis and present them to lymphocytes.
The function of monocytes in immunity is related to their ability to
a combination of treatment modalities is effective for controlling many cancers.
The goals of cancer treatment are based on the principle that
drugs.
The most common cause of secondary immunodeficiencies is
use a central venous access device.
The most effective method of administering a chemotherapy agent that is a vesicant is to
immunotherapy should only be administered in a setting where emergency equipment and drugs are available.
The nurse advises a friend who asks him to administer his allergy shots that
after successful treatment, a return to the person's previous functional level can be expected.
The nurse counsels the patient receiving radiation therapy or chemotherapy that
Some medications may interact with anesthetics, altering the potency and effect of the drugs.
The nurse is performing a preoperative assessment for a patient scheduled for a surgical procedure. What is the rationale for the nurse's careful documentation of the patient's current medication list?
Lateral
The nurse is positioning a patient after a surgical procedure. What is the best position unless contraindicated, for this patient to be placed in to prevent respiratory complications?
Remove the IV catheter and assess the client's VS
The nurse is preparing to start an IV infusion and has raised the HOB. After the nurse applies gloves to insert an IV catheter, the client begins to rub her eyes wipe away nasal drainage. Which of the following should the nurse do first?
Assess the patient's vital signs.
The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the post-anesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival?
continue to monitor the patient.
The nurse notes tidaling of the water level in the tube submerged in the water-seal chamber in a patient with closed chest tube drainage. The nurse should
White blood cell (WBC) count of 2700/μL
The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider?
developing an individualized plan of nursing care for the patient.
The nurse's primary responsibility for the care of the patient undergoing surgery is
"Early walking is the best way to prevent postoperative complications."
The patient donated a kidney, and early ambulation is included in the plan of care, but the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation?
surveillance for cells with tumor-associated antigens
The primary protective role of the immune system related to malignant cells is
Hyperacute reaction can usually be avoided if crossmatching is done before the transplantation.
What accurately describes rejection following transplantation?
Cells lack contact inhibition. Cells return to a previous undifferentiated state. New proteins characteristic of embryonic stage emerge on cell membrane.
What features of cancer cells distinguish them from normal cells
Assess for airway patency and quality of respirations and obtain vital signs.
When a patient is admitted to the PACU, what are the priority interventions the nurse performs?
Assess the patient's blood pressure and heart rate.
When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. What is the priority action by the nurse?
The client is at risk for difficult intubation
When attempting to check the pupils of a client scheduled to receive general anesthesia, the nurse notices that the client has trouble tilting the head back. Which of the following is the primary concern related to this finding?
auscultating lung sounds
When caring for a patient with acute bronchitis, the nurse will prioritize
using sequential compression devices.
When planning care for a patient at risk for pulmonary embolism, the nurse prioritizes
Maintaining the patient's hope
A patient has recently been diagnosed with early stages of breast cancer. What is most appropriate for the nurse to focus on?
stop the infusion if swelling is observed at the site.
When the nurse is administering a vesicant chemotherapeutic agent intravenously, an important consideration is to:
Assess breath sounds.
When the nurse is caring for a patient who has had a total laryngectomy and radical neck dissection during the first 24 hours after surgery, what is the priority nursing action?
Older than 65 years. Father diagnosed and treated for early stage prostate cancer
Which factors would place a patient at a higher risk for prostate cancer
Insert the obturator and attempt to reinsert the tracheostomy tube.
A patient with an uncuffed tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?
Avoid heat and cold to the treatment area.
A patient with breast cancer is having teletherapy radiation treatments after her surgery. What should the nurse teach the patient about the care of her skin?
Palliative surgery is done to increase the patient's comfort when cure is not possible.
A patient with cancer is scheduled for palliative surgery. Which explanation should the nurse use to describe the purpose of this surgery?
administer prescribed antiemetics 1 hour before the treatments.
A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. An important nursing intervention for the patient is to:
Ask the patient more about the concerns with stoma management.
A patient who has had a total proctocolectomy and permanent ileostomy tells the nurse, "I cannot bear to even look at the stoma. I do not think I can manage all these changes." Which is the best action by the nurse?
Ensure a smooth surface under the patient.
A patient having an open reduction internal fixation (ORIF) of a left lower leg fracture will receive regional anesthesia during the procedure. As the patient is prepared in the operating room, what should the nurse implement to maintain patient safety during surgery that is directly related to the type of anesthesia being used?
Medicate the patient and have them take deep breaths
A patient is 6 hours postop from having a chest tube placed and is refusing to take deep breaths because of the pain . Which intervention should the nurse implement?
position patient in lateral recovery position.
A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse he thinks he is going to "throw up." A priority nursing intervention is to
Increased carbon dioxide pressure
A patient is admitted to the post-anesthesia care unit (PACU) after abdominal surgery. Which assessment, if made by the nurse, is the best indicator of respiratory depression?
Patient, surgical procedure, and site are checked
A patient is being prepared for a surgical procedure. What is the priority intervention by the nurse prior to the start of the procedure according to the National Patient Safety Goal (NPSG)?
Discourage use of alcohol and tobacco. Advise the patient to avoid very cold foods and drinks.
A patient is experiencing mucositis as a result of radiation therapy. Which interventions should the nurse include in the plan of care?
Manage oxygenation status.
A patient is having elective cosmetic surgery performed on her face. The surgeon will keep her at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient?
Notify the anesthesia care provider of when and what the patient last ate.
A patient is scheduled for surgery requiring general anesthesia at an ambulatory surgical center. The nurse asks him when he ate last. He replies that he had a light breakfast a couple of hours before coming to the surgery center. What should the nurse do first?
exchange her plasma that contains antinuclear antibodies with a substitute fluid
A patient is undergoing plasmapheresis for treatment of systemic lupus erythematosus. The nurse explains that plasmapheresis is used in her treatment to
Temperature of 101.9° F, fatigue, and shortness of breath
A patient on chemotherapy and radiation for head and neck cancer has a WBC count of 1.9 × 103/µL, hemoglobin of 10.8 g/dL, and a platelet count of 99 × 103/µL. Based on the CBC results, what is the most serious clinical finding?
Advise the patient to experiment with spices and seasonings to enhance the flavor of food.
A patient on chemotherapy for 10 weeks started at a weight of 121 lb. She now weighs 118 lb and has no sense of taste. Which nursing intervention would be a priority?
take no further action with the collection device.
A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to:
Assist the client up to the toilet to attempt to void
A client has been unable to void since having abd surgery 7 hours ago. The nurse should first:
The clothing protects me from accidentally absorbing these drugs
A client receiving intravenous chemotherapy asks the nurse the reason for wearing a mask, gloves, and gown while administering drugs to the client. What is the nurse's best response?
Is responding to treatment
A client's most recent prostate-specific antigen level has decreased since starting treatment for prostate cancer.
Check the tubing for kinks or clots
A lung cancer patient just had a right sided chest tube inserted 2 hours ago. Which action should the nurse implement if there is no fluctuation (tidaling) in the water seal chamber?
Eat several servings of vegetables daily
A nurse is providing education to a group of people about preventing colon cancer. What information should be included in the presentation?
"Your family can be with you in the preoperative holding area."
A patient asks a student nurse if his family member may accompany him to the surgical area. What is the best response by the nurse?
Reduced dietary fat intake can lower cancer risk.
A patient asks what dietary changes can be made to help protect against cancer. The nurse should base his or her response to the patient's question on which of the following?
Vital signs baseline or stable. Responsible adult taking patient home. Minimal nausea and vomiting
A patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge
Witness the permit after consent is obtained by the surgeon.
A 17-year-old patient with a leg fracture who is scheduled for surgery is an emancipated minor. She has a statement from the court for verification. Which intervention is most appropriate?
prostate specific antigen (PSA) testing.
A 51-year-old man is scheduled for an annual physical exam at the outpatient clinic. The nurse will plan to teach the patient about the purpose of:
Inform the surgeon, since the procedure may have to be rescheduled.
A 59-year-old man scheduled for a herniorrhaphy in 2 days reports that he takes ginkgo daily. What is the priority intervention?
evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound.
A 70-kg postoperative patient has an average urine output of 25 mL/hr during the first 8 hours. The priority nursing intervention(s) given this assessment would be to
Hypercalcemia
A 70-year-old male patient has multiple myeloma. His wife calls to report that he sleeps most of the day, is confused when awake, and complains of nausea and constipation. Which complication of cancer is this most likely caused by?
Skin integrity
A 78-year-old patient is having surgery. What risk areas will the nurse need to be especially aware of for this patient during surgery?
proliferation of cancer cells despite host control mechanisms.
A characteristic of the stage of progression in the development of cancer is
Encourage the patient to purchase a wig or hat and wear it once hair loss begins.
A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to maintain the patient's self-esteem?
Ondansetron (Zofran)
An older adult patient is undergoing coronary artery bypass graft (CABG) surgery and has just experienced intraoperative vomiting. The nurse should consequently anticipate the use of which drug?
surgery will involve multiple small incisions
An overweight patient (BMI 28.1 kg/m2) is scheduled for a laparoscopic cholecystectomy at an outpatient surgery setting. The nurse knows that
The antibiotic is most effective in preventing infection if it is given 30-60 minutes before the operative incision is made
The surgeon prescribes cefazolin (Ancef) 1g to be given ay 0730 when the clients surgery is scheduled at 0800. What is the primary reason to start the antibiotic exactly at 0730?
Have the patient verify the procedure and the location of the surgery.
The surgical team in the operating room performs a surgical time-out just before starting hip replacement surgery. Which action would be part of the surgical time-out?
no respiratory depression, written discharge instructions understood, opioid pain medication given 45 minutes ago.
Discharge criteria for the Phase II patient include
The amount of garlic she is eating
During the pre-admission testing for same-day surgery, a client states that she has added two cloves of garlic each day to her diet to help control her blood pressure. The nurse should further inquire about which of the following?
pelvic floor muscle exercises.
Following a radical retropubic prostatectomy for prostate cancer, the patient is incontinent of urine. The nurse will plan to teach the patient:
Sit down and say, "Let's talk about what you are afraid of.
Following a visit from his family, the 55-year-old male patient with terminal cancer tearfully says, "I am so afraid" and begins to cry. The nurse's most supportive response is to:
Administering adequate analgesics to promote relief or control of pain
In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes?
Notify the surgeon of the client's expressed lack of understanding
When the nurse asks the client who is to have abdominal surgery today if the client understands the procedure, the client replies, "No, not really; I talked about several different things with my surgeon, and I am just not sure." The nurse should:
explain that this feeling is normal and that he should not try to urinate around the catheter.
Postoperatively, a patient who has had a laser prostatectomy has continuous bladder irrigation with a three-way urinary catheter with a 30-mL balloon. When he complains of bladder spasms with the catheter in place, the nurse should
recognizing that sensory deficits may be present. providing warm blankets to prevent hypothermia.
Preoperative considerations for older adults
A bland, low-fiber diet
Previous administrations of chemotherapy agents to a cancer patient have resulted in diarrhea. Which dietary modification should the nurse recommend?
surgical attire and head cover.
Proper attire for the semi-restricted area of the surgery department is
obstruction of the urethra.
Symptoms of BPH are primarily caused by
IgG.
The reason newborns are protected for the first 6 months of life from bacterial infections is because of the maternal transmission of
29-year-old male who has had Crohn's disease since the age of 13
The student nurse demonstrates an understanding of cancer risk factors by identifying which patient as being at the highest risk for developing colorectal cancer?
400 mL of blood in the collection chamber.
The health care provider inserts a chest tube in a patient with a hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most concerned about
Pap testing. Sunscreen Use. Mammography. Colorectal screening
The nurse at the clinic is interviewing a 64-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk
"I should only have to change the pouch every 4 to 7 days."
The nurse determines a patient undergoing ileostomy surgery understands the procedure when the patient states
requires the use of radioactive precautions during nursing care.
The nurse explains to a patient undergoing brachytherapy of the cervix that she
Discuss the risks associated with cigarettes during every patient encounter
The nurse in the outpatient clinic is caring for a 50-year-old who smokes heavily. To reduce the patient's risk of dying from lung cancer, which action will be best for the nurse to take?
edema and itching at the injection site.
The nurse is alerted to possible anaphylactic shock immediately after a patient has received IM penicillin by the development of
Fecal occult blood test
The nurse is assessing a 58-year-old patient. What yearly screening test for colorectal cancer should the nurse educate the patient about getting done?
Restlessness
The nurse is assessing a client recovering from anesthesia. Which of the following is an early indicator of hypoxemia?
let her communicate about the meaning of this experience.
The nurse is caring for a 59-year-old woman who had surgery 1 day ago for removal of a malignant abdominal mass. The patient is awaiting the pathology report. She is tearful and says that she is scared to die. The most effective nursing intervention at this point is to use this opportunity to
Universal protocol is followed. The patient's allergies are conveyed to the surgical team.
The nurse is caring for a patient undergoing surgery for a knee replacement. What is critical to the patient's safety during the procedure
The client has loose, decayed teeth. The client smokes two (2) packs of cigarettes a day. The client reports using herbs
The nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologist?
Help provide diversional activities that the patient enjoys
The nurse is planning care for a patient with a radioactive implant. Which intervention should the nurse select to help prevent social isolation in this patient?
Large tumor with extensive lymph node involvement
The nurse recognizes the staging T3, N3, M2 of the patient's cancer to mean that there is a:
Muscle rigidity
The nurse would be alerted to the occurrence of malignant hyperthermia when the patient demonstrates what manifestation?
Ask additional questions to assess for a possible latex allergy.
The patient tells the nurse in the preoperative setting that she has noticed she has a reaction when wearing rubber gloves. What is the most appropriate intervention?
The patient's father developed an elevated temperature during a recent surgery.
The perioperative nurse is reviewing the chart of a patient who is being admitted into the operating room for a laminectomy. What information obtained from the chart review should the nurse discuss with the anesthesiologist?
Use a spray-on tanning solution
The young nursing student who wants a tan before spring break asks the nurse what the safest method would be. The nurse's best response is:
acetaminophen
To prevent fever and shivering during an infusion of rituximab (Rituxan), the nurse should premedicate the patient with
African Americans have a higher death rate from cancer than whites.
Trends in the incidence and death rates of cancer include the fact that
Lateral
Unless contraindicated by the surgical procedure, which position is preferred for the unconscious patient immediately postoperative?
The NAP stands by the patients bed for 30 minutes talking with the patient.
When caring for a patient with a temporary radioactive cervical implant, which action by nursing assistive personnel (NAP) indicates that the RN should intervene?
incorrect musculoskeletal alignment.
When positioning a patient in preparation for surgery, the nurse understands that injury to the patient is most likely to occur as a result of
the cancer is localized to the breast.
When reviewing the chart for a patient with breast cancer, the nurse notes that the cancer is staged as Tis, N0, M0. The nurse will teach the patient that:
Call the surgeon to obtain consent for surgery
When reviewing the preoperative forms, the nurse notices that the informed consent form is not present or signed. What is the best action for the nurse to take?
Keeping track of irrigation solutions for monitoring of blood loss. Passing instruments and supplies to the surgeon by anticipating his or her needs. Performing the count of sponges, needles, and instruments used during the surgical procedure
Which intraoperative nursing responsibilities should be performed by the scrub nurse?
Apply the ordered anesthetic gel to oral lesions before meals.
Which nursing action will be most effective in improving oral intake for a patient with the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers?
"You may drink clear liquids up to 2 hours before surgery."
While performing preoperative teaching, the patient asks when he is no longer able to eat or drink. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, what is the best response by the nurse?
"Tell me what you would like done if it is determined that you need blood replacement during surgery."
While the perioperative nurse is transporting a patient to the operating room for general surgery, the patient states, "I am a Jehovah's Witness, and I am worried about blood transfusions." What would be the best response by the nurse to this patient's statement?
