NSG 420 Exam 4

The nurse should suggest which food choice when providing dietary teaching for a patient scheduled to receive external-beam radiation for abdominal cancer?

Baked chicken

Which patient requires the most rapid assessment and care by the emergency department nurse?

The patient with neutropenia who has a temperature of 101.8°f

The nurse is preparing a community presentation on oral cancer. Which is a primary risk factor for oral cancer that the nurse should emphasize in the presentation?

use of alcohol

Which statement by a patient would alert the nurse to a risk for decreased immune function?

"I had my spleen removed after a car accident."

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?

"I schedule afternoon rest periods for myself in addition to sleeping 10 hours every night."

Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate?

"I will call my health care provider if my stools turn black."

The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective?

"I will need follow-up examinations for many years after treatment before I can be considered cured."

A widowed mother of four school-age children is hospitalized with metastatic ovarian cancer. The patient is crying and tells the nurse that she does not know what will happen to her children when she dies. Which response by the nurse is most appropriate?

"Would you like to talk about options for the care of your children?"

A client with lymphoma tells the nurse that a holistic practitioner has offered to treat the client with coffee enemas. How does the nurse respond?

"You should speak with your oncologist about this treatment."

A male patient with hemophilia asks the nurse if his children will be hemophiliacs. Which response by the nurse is accurate?

"Your female children will be carriers for hemophilia."

Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first?

23-yr-old with no previous health problems who has a nontender lump in the axilla

. A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Discontinue the antibiotic. b. Give diphenhydramine IV. c. Inject epinephrine IM or IV. d. Prepare an infusion of dopamine. e. Provide 100% oxygen using a nonrebreather mask.

A, E, C, B, D

The nurse examines the lymph nodes of a patient during a physical assessment. Which assessment finding would be of most concern to the nurse?

A 2-cm nontender supraclavicular node

The charge nurse is assigning semiprivate rooms for new admissions. Which patient could safely be assigned as a roommate for a patient who has acute rejection of an organ transplant?

A patient who is recovering from an anaphylactic reaction to a bee sting

Which patient should the nurse assign as the roommate for a patient who has aplastic anemia?

A patient with chronic heart failure

Which nursing goal is appropriate for the nurse to make with a client who has multiple myeloma?

Achieve effective management of bone pain.

A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?

Administer a skin test by the cutaneous scratch method.

The nurse is developing a care plan for a client with cancer receiving hospice home care. Which would be the most appropriate action for managing the client's chronic pain?

Administer analgesics regularly and additionally as needed for break-through pain

which action will the nurse include in the plan of care for a patient who has thalassemia major?

Administer iron chelation therapy as needed.

The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan (select all that apply)?

Antibiotics may sometimes be prescribed to prevent infection. Continue taking antibiotics until all of the prescription is gone. Hand washing is effective in preventing many viral and bacterial infections.

A patient has been assigned the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers. Which nursing action will be most effective in improving oral intake?

Apply prescribed anesthetic gel to oral lesions before meals.

Which action is most important for the nurse to take to ensure culturally competent care for an alert, terminally ill Filipino patient?

Ask the patient and family about their preferences for care during this time.

A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first?

Assess for sensation and strength in the legs.

A patient is anxious and reports difficulty breathing after being stung by a wasp. What is the nurse's priority action?

Assess the patient's airway.

The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take before this procedure?

Assist the patient to a flat position.

Which instruction will the nurse plan to include in discharge teaching for a patient admitted with a sickle cell crisis?

Avoid exposure to crowds when possible.

Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider?

Calf swelling and pain

The daily white blood cell (WBC) count in a client with aplastic anemia drops overnight from 3,900 to 2,900/µl (3.9 to 2.9 X 109/L). Which is the appropriate nursing intervention?

Call the primary care provider, and request that the client be placed in reverse isolation.

External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation?

Clean the perianal area carefully after every bowel movement.

An older adult patient who is having an annual check-up tells the nurse, "I feel fine, and I don't want to pay for all these unnecessary cancer screening tests!" Which information should the nurse plan to teach this patient?

Consequences of aging on cell-mediated immunity

The nurse reviewing a clinic patient's medical record notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is appropriate?

Consult with the health care provider about giving a lower allergen dose.

A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan (select all that apply)?

Cook food thoroughly before eating. Avoid public transportation such as buses. Talk to the oncologist before having any dental work.

The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider?

Crackles heard at the lung bases

A client from a Mediterranean country is admitted with thalassemia, jaundice, splenomegaly, and hepatomegaly. Which should be the primary focus of nursing care for this client?

Decrease cardiac demands by promoting rest.

A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect?

Elevated reticulocyte count

The nurse is caring for a patient with lung cancer in a home hospice program. Which action by the nurse is appropriate?

Encourage the patient to discuss past life events and their meanings.

According to the Center for Disease Control and Prevention (CDC) guidelines, which personal protective equipment will the nurse put on before assessing a patient who is on contact precautions for Clostridium difficile diarrhea (select all that apply)?

Gown Gloves

The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect?

Hematuria

A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). The nurse will include which information in the patient's teaching plan?

Hospitalization is required for several weeks after the stem cell transplant.

The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in cancer therapy with the health care provider?

Increased carcinoembryonic antigen (CEA)

A patient who has non-Hodgkin's lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse?

Lip swelling

Hgb

M: 14-18 F: 12-16

A client with a suspected diagnosis of Hodgkin's disease is to have a lymph node biopsy. What should the nurse make sure that personnel involved with the procedure do?

Maintain sterile technique.

Following successful treatment of Hodgkin's lymphoma for a 55-yr-old woman, which topic will the nurse include in patient teaching?

Need for follow-up appointments to screen for malignancy

A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take?

Notify the health care provider.

The nurse at the clinic is interviewing a 64-yr-old woman who is 5 feet, 3 inches tall and weighs 125 lb (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine two or three times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk (select all that apply)?

Pap testing Sunscreen use Mammography Colorectal screening

The nurse will most likely prepare a medication teaching plan about antiretroviral therapy (ART) for which patient?

Patient who tested positive for HIV 2 years ago and now has cytomegalovirus (CMV) retinitis

Which nursing actions for the care of a dying patient can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)?

Provide postmortem care to the patient. Encourage the family members to talk with and reassure the patient. Administer the prescribed morphine sulfate sublingual as necessary for pain control.

A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon?

Results of patient-donor crossmatching are positive

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?

Rinse the mouth before and after each meal and at bedtime with a saline solution.

A client is undergoing a bone marrow aspiration and biopsy. The client is very worried about the procedure. What should the nurse do to prepare the client for the procedure?

Suggest the client request the health care provider prescribe a sedative.

Which action should the nurse take when caring for a patient who is receiving chemotherapy and complains of problems with concentration?

Suggest use of a daily planner and encourage adequate rest and sleep.

Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of the rash?

The donor T cells are attacking the patient's skin cells.

A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider?

There is a 2-cm wheal at the site of the allergen injection.

To evaluate the effectiveness of antiretroviral therapy (ART), which laboratory test result will the nurse review?

Viral load testing

The nurse reviews the laboratory test results of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider?

White blood cell (WBC) count 15,500/µL

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:

elevate the affected arm on a pillow.

A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see?

hypercalcemia

A right orchiectomy is performed on a client with a testicular malignancy. The client expresses concerns regarding his sexuality. What information should the nurse give the client to address his concerns?

should retain normal sexual drive and function.

A nurse is caring for a client receiving chemotherapy. Which assessment finding places the client at the greatest risk for an infection?

stage 3 pressure ulcer on the left heel

A client has moved into the acquired immunodeficiency syndrome (AIDS) phase of the human immunodeficiency virus (HIV) positive infection. The nurse advises the client to avoid what outdoor recreational activity?

swimming in rivers or lakes

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

"Keep the area covered when you go outdoors."

A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct?

"Malignant tumors may spread to other tissues or organs."

The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement, if made by the patient, indicates that teaching was effective?

"The biopsy will help decide the treatment for my enlarged prostate."

A patient who is diagnosed with cervical cancer classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is accurate?

"The cancer involves only the cervix."

A patient who has a positive test for human immunodeficiency virus (HIV) antibodies is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and a CD4+ T-cell count of less than 200 cells/L. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), which statement by the nurse is correct?

"The patient has developed acquired immunodeficiency syndrome (AIDS)."

A client with pernicious anemia asks why she must take vitamin B12 injections forever. Which is the nurse's best response?

"The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient amounts of a factor that allows the vitamin to be absorbed.

A patient in hospice is manifesting a decrease in all body system functions except for a heart rate of 124 beats/min and a respiratory rate of 28 breaths/min. Which statement, if made by the nurse to the patient's family member, is most appropriate?

"These vital signs are an expected response now but will slow down later."

The son of a dying patient tells the nurse, "Mother doesn't really respond anymore when I visit. I don't think she knows that I am here." Which response by the nurse is appropriate?

"Withdrawal can be a normal response in the process of dying."

A hospice nurse who has become close to a terminally ill patient is present in the home when the patient dies and feels saddened and tearful as the family members begin to cry. Which action should the nurse take at this time?

Cry along with the patient's family members.

The nurse is assessing a middle-aged client with cancer who has lost 1 lb (0.5 kg) in 4 weeks. The client is taking ondansetron for nausea and now has a temperature of 101°F (38.3°C). The nurse judges that the fever is a sign of what?

infection

A client with idiopathic thrombocytopenic purpura (ITP) is being treated with prednisone and rituximab. The nurse prioritizes what aspect of care planning?

infection control measures

A client is diagnosed with megaloblastic anemia caused by vitamin B12 deficiency. The physician begins the client on cyanocobalamin (Betalin-12), 100 mcg I.M. daily. Which substance influences vitamin B12 absorption?

intrinsic factor

Which lab values should the nurse report to the health care provider (HCP) when the client has anemia?

intrinsic factor, absent

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

lymphedema.

Which is an appropriate outcome for a client with rheumatoid arthritis who is receiving anti-inflammatory drugs and physical therapy? The client will:

manage joint pain and fatigue to perform activities of daily living.

A patient with a large stomach tumor attached to the liver is scheduled for a debulking procedure. Which information should the nurse teach the patient about the outcome of this procedure?

Decreasing the tumor size will improve the effects of other therapy.

The nurse admits a terminally ill patient to the hospital. What is the first action that the nurse should complete when planning this patient's care?

Determine the patient's wishes regarding end-of-life care.

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

Diphenhydramine decreases incidence of a reaction to the vincristine.

Which finding will the nurse expect when assessing a patient who has osteoarthritis (OA) of the knee?

Discomfort with joint movement

A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care?

Discontinue the heparin infusion.

A patient treated for human immunodeficiency virus (HIV) infection for 6 years has developed fat redistribution to the trunk with wasting of the arms, legs, and face. What recommendation will the nurse give to the patient?

Discuss a change in antiretroviral therapy.

The nurse is caring for a patient who smokes two packs/day. Which action by the nurse could help reduce the patient's risk of lung cancer?

Discuss risks associated with cigarette smoking during each patient encounter.

1. The nurse is caring for an unresponsive terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which action by the nurse would be appropriate?

Document Cheyne-Stokes respirations.

Following a simple mastectomy, the nurse is totaling the amount of drainage in 24 hours from a suction drain in the incision. The nurse notes there is 200 mL of serosanguineous drainage for the first 24 hours. What should the nurse do?

Document the findings.

Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient?

IL-2 enhances the body's immunologic response to tumor cells.

A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value?

IgE

A patient with terminal cancer is being admitted to a family-centered inpatient hospice. The patient's spouse visits daily and cheerfully talks with the patient about wedding anniversary plans for the next year. When the nurse asks about any concerns, the spouse says, "I'm busy at work, but otherwise things are fine." Which provisional nursing diagnosis is appropriate for the patient's spouse?

Ineffective coping related to lack of grieving

A client with metastatic brain cancer is admitted to the oncology floor. What action will the admitting nurse take regarding an advanced directive for this client?

Inform the client or legal guardian of the right to execute an advance directive.

Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do?

Inform the physician immediately.

An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hr in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider?

Patient has crackles up to the midline posterior chest.

After change-of-shift report on the oncology unit, which patient should the nurse assess first?

Patient who is neutropenic and has a temperature of 100.5° F (38.1° C)

Which patient should the nurse assess first?

Patient who is sneezing after subcutaneous immunotherapy

A patient who is human immunodeficiency virus (HIV)-infected has a CD4+ cell count of 400/µL. Which factor is most important for the nurse to determine before the initiation of antiretroviral therapy (ART) for this patient?

Patient's ability to follow a complex medication regimen

The nurse is caring for a terminally ill patient who is experiencing continuous and severe pain. How should the nurse schedule the administration of opioid pain medications?

Plan around-the-clock routine administration of analgesics.

What instructions about plasmapheresis should the nurse include in the teaching plan for a patient diagnosed with systemic lupus erythematosus (SLE)?

Plasmapheresis removes antibody-antigen complexes from circulation.

28. A patient with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets?

Platelet count is 42,000/[]L.

The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority?

Prevention of HIV transmission between sexual partners

A patient with a family history of cystic fibrosis (CF) asks for information about genetic testing. Which response by the nurse is most appropriate?

Refer the patient to a qualified genetic counselor.

A patient informed of a positive rapid antibody test result for human immunodeficiency virus (HIV) is anxious and does not appear to hear what the nurse is saying. What action by the nurse is most important at this time?

Remind the patient about the need to return for retesting to verify the results.

An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient's health history has implications for planning patient teaching about the medication at this time?

The patient drinks grapefruit juice every day.

When counseling a couple in which the man has an autosomal recessive disorder and the woman has no gene for the disorder, the nurse uses Punnett squares to show the couple the probability of their having a child with the disorder. Which statement by the nurse is accurate?

"Each child would be a carrier of the disorder."

A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about the management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective?

"I can buy aloe vera gel to use on my skin."

A client with rheumatoid arthritis arrives at the clinic for a checkup. Which statement by the client refers to the most overt clinical manifestation of rheumatoid arthritis?

"My finger joints are oddly shaped."

A client with chronic progressive multiple sclerosis is learning to use a walker. What instruction will best ensure the client's safety?

"Place the walker directly in front of you and step into it as you move it forward."

Which information about intradermal skin testing should the nurse teach to a patient with possible allergies?

"Plan to wait in the clinic for 20 to 30 minutes after the testing."

Which statement by a patient indicates good understanding of the nurse's teaching about prevention of sickle cell crisis?

"Risk for a crisis is decreased by having an annual influenza vaccination."

A patient who has acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate?

"The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy."

The sister of a patient diagnosed with BRCA gene-related breast cancer asks the nurse, "Do you think I should be tested for the gene?" Which response by the nurse is most appropriate?

"There are many things to consider before deciding to have genetic testing."

A client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing diagnosis is appropriate for this client?

Anticipatory grieving

A patient who has been diagnosed with inoperable lung cancer and has a poor prognosis plans a trip across the country "to settle some issues with family members." The nurse recognizes that the patient is manifesting which psychosocial response to death?

Anxiety about unfinished business

A middle-aged patient tells the nurse, "My mother died 4 months ago, and I just can't get over it. I'm not sure it is normal to still think about her every day." Which nursing diagnosis is most appropriate?

Anxiety related to lack of knowledge about normal grieving

A young adult female patient who is human immunodeficiency virus (HIV) positive has a new prescription for efavirenz (Sustiva). Which information is most important to include in the medication teaching plan?

Continue to use contraception while taking this medication.

A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to support the patient's self-esteem?

Encourage the patient to purchase a wig or hat to wear when hair loss begins.

A patient with Hodgkin's lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." Which intervention should the nurse add to the plan of care?

Establish time to take a short walk almost every day.

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

Expand the alveoli and increase lung surface available for ventilation.

A patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse expect to administer?

Hepatitis B vaccine

Which action will the nurse include in the plan of care for a patient admitted with multiple myeloma?

Monitor fluid intake and output

Which of these patients who have arrived at the human immunodeficiency virus (HIV) clinic should the nurse assess first?

Patient who has had 10 liquid stools in the last 24 hours

Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, the patient complains of itching at the site, weakness, and dizziness. What action should the nurse take first?

Place a tourniquet above the site.

Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia?

Potential complication: infection

The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which health screening should the nurse include in the teaching plan for this patient?

Screening for malignancies

28. Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider?

Serum calcium level is 15 mg/dL.

When caring for a patient who is pancytopenic, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene?

The UAP assists the patient to use dental floss after eating.

A client is to have radiation therapy after a modified radical mastectomy. What instructions should the nurse teach the client about caring for the skin at the site of the radiation therapy?

Wash the area with water.

A client, who had intracavity radiation treatment for cervical cancer 1 month earlier, reports small amounts of vaginal bleeding. This finding most likely represents

an expected effect of the radiation therapy.

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when the nurse notes tidal movements or fluctuations in which compartment of the system as the client breathes?

water-seal chamber

The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions?

"After a couple of years I will be able to stop taking the cyclosporine."

A patient tells the nurse, "I would like to use a home genetic test to see if I will develop breast cancer." Which is the nurse's best initial response?

"Are you concerned about developing breast cancer?"

The nurse is caring for an adolescent patient who is dying. The patient's parents are interested in organ donation and ask the nurse how the healthcare providers determine brain death. Which response by the nurse accurately describes brain death determination?

"Brain death has occurred if there is not any breathing or brainstem reflexes."

The nurse is caring for a patient diagnosed with stage I colon cancer. When assessing the need for psychologic support, which question by the nurse will provide the most information?

"Can you tell me what has been helpful to you in the past when coping with stressful events?"

A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best?

"Consider participating in a needle-exchange program."

A patient's complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding?

"Do you have any history of lung disease?"

The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient?

"Do you take medication containing salicylates?"

A 52-yr-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states,

"I could choose nasal spray rather than injections of vitamin B12."

The home health nurse is caring for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment?

"I rarely have the energy to get out of bed."

A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching?

"I will take oral antihistamines before going to work."

A client receiving chemotherapy has a nursing diagnosis of Deficient diversional activity related to decreased energy. Which client statement indicates an accurate understanding of appropriate ways to deal with this deficit?

"I'll play card games with my friends."

A nurse is teaching a client about rheumatoid arthritis. Which statement by the client indicates understanding of the disease process?

"It will get better and worse again."

The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care?

Avoid intramuscular injections.

WBC count

5,000-10,000

The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first?

A 24-yr-old patient who received neck radiation and has blood oozing from the neck

The nurse in the outpatient clinic has obtained health histories for these new patients. Which patient may need a referral for genetic testing?

A 30-yr-old patient who has a sibling with newly diagnosed polycystic kidney disease

After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first?

A 33-yr-old with a fever of 100.8° F (38.2° C)

Which patient should the nurse refer for hospice care?

A 40-yr-old patient with AIDS-related dementia who needs palliative care and pain management

The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective?

Blueberry yogurt

A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test?

Bone marrow biopsy

Which example should the nurse use to explain an infant's "passive immunity" to a new mother?

Breastfeeding

A patient who is diagnosed with acquired immunodeficiency syndrome (AIDS) tells the nurse, "I feel obsessed with morbid thoughts about dying." Which response by the nurse is appropriate?

Can you tell me more about the thoughts that you are having?"

Which action will the admitting nurse include in the care plan for a patient who has neutropenia?

Check temperature every 4 hours.

Which nursing action will be most useful in assisting a college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen?

Check the patient's class schedule to help decide when the drugs should be taken.

The nurse is caring for a client being discharged following kidney transplantation. The client is ordered mofetil to prevent organ rejection. Which nursing instruction is essential regarding medication use?

Contact the health care provider at first signs of an infection.

What instructions should the nurse provide to a client who develops cellulitis in the right arm after a right-modified radical mastectomy?

Antibiotics will need to be taken for 1 to 2 weeks.

As the nurse admits a patient in end-stage renal disease to the hospital, the patient tells the nurse, "If my heart or breathing stop, I do not want to be resuscitated." Which action should the nurse take first?

Ask if the decision has been discussed with the patient's health care provider.

Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy?

Absolute neutrophil count

Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)?

Activated partial thromboplastin time (PTT)

A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take?

Administer PRN acetaminophen (Tylenol).

A patient in the health care provider's office for allergen testing using the cutaneous scratch method develops itching and swelling at the skin site. Which action should the nurse take first?

Administer a dose of epinephrine.

A patient with metastatic cancer of the colon experiences severe vomiting after each administration of chemotherapy. Which action, if taken by the nurse, is appropriate?

Administer prescribed antiemetics 1 hour before the treatments.

Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?

Administering subcutaneous filgrastim (Neupogen) injection

A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient?

Administration of immunosuppressant medications

Which information about a patient population would be most useful to help the nurse plan for human immunodeficiency virus (HIV) testing needs?

Age

A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action would address the cause of the patient problem?

Avoid giving the patient foods that are strongly disliked.

Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura?

Avoid intramuscular (IM) injections.

The nurse taking a health history learns that the patient, who has worked in rubber tire manufacturing, has allergic rhinitis and multiple food allergies. Which action by the nurse is correct?

Document the patient's history and teach about clinical manifestations of a type I latex allergy.

A patient who has ovarian cancer is crying and tells the nurse, "My husband rarely visits. He just doesn't care." The husband indicates to the nurse that he does not know what to say to his wife. Which nursing diagnosis is appropriate for the nurse to add to the plan of care

Dysfunctional family processes related to effect of illness on family members

The health care provider's progress note for a patient states that the complete blood count (CBC) shows a "shift to the left." Which assessment finding will the nurse expect?

Elevated temperature

Eight years after seroconversion, a human immunodeficiency virus (HIV)-infected patient has a CD4+ cell count of 800/µL and an undetectable viral load. What is the priority nursing intervention at this time?

Encourage adequate nutrition, exercise, and sleep

A college student comes to the campus health care center with reports of headache, malaise, and a sore throat that has worsened over the past 10 days. The nurse measures a temperature of 102.6° F (39.2° C) and finds an enlarged spleen and liver and exudative tonsillitis. Laboratory tests reveal a leukocyte count of 20,000/mm3, antibodies to Epstein-Barr virus, and abnormal liver function tests. What are the nurse's priority action(s)?

Encourage fluids and treat fever

The nurse at the gynecologic clinic is teaching the client about the results of her Papanicolaou test, which demonstrated dysplasia. Which represents the nurse's best intervention?

Explain that the results show cervical changes that require follow up.

The nurse palpates enlarged cervical lymph nodes on a patient diagnosed with acute human immunodeficiency virus (HIV) infection. Which action would be appropriate for the nurse to take?

Explain to the patient that this is an expected finding

The nurse should assess the patient undergoing plasmapheresis for which clinical manifestation?

Extremity numbness

A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure?

Have the patient lie on the left side for 1 hour.

The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered?

Hemoglobin level

A client undergoing antineoplastic therapy is prescribed subcutaneous epoetin. What indicates to the nurse that the drug has been effective?

Hemoglobin levels rise.

The nurse is reviewing laboratory results and notes a patient's activated partial thromboplastin time (aPTT) level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication?

Heparin

A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature of 102° F (38.9° C), and severe back pain. Which prescribed action will the nurse implement first?

Infuse normal saline 500 mL over 30 minutes.

A client has a routine Papanicolaou (Pap) test during a yearly gynecologic examination. The result reveals a class V finding. What should the nurse tell the client about this finding?

It calls for a biopsy as soon as possible.

During a routine checkup, a nurse assesses a client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the most common AIDS-related cancer?

Kaposi's sarcoma

Hct

Males: 42-52% Females: 37-47%

An older adult with chronic human immunodeficiency virus (HIV) infection who takes medications for coronary artery disease and hypertension has chosen to begin early antiretroviral therapy (ART). Which information will the nurse include in patient teaching?

Many drugs interact with antiretroviral medications.

A pregnant woman with asymptomatic chronic human immunodeficiency virus (HIV) infection is seen at the clinic. The patient states, "I am very nervous about making my baby sick." Which information will the nurse include when teaching the patient?

Most infants born to HIV-positive mothers are not infected with the virus.

28. The nurse has obtained the health history, physical assessment data, and laboratory results shown in the accompanying figure for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider? History • Fatigue, which has increased over last month • Frequent constipation Physical Assessment • Conjunctiva pale pink, moist • Multiple bruises • Clear lung sounds Laboratory Results • Hct 33% • WBC 1500/µL. <---- low WBC • Platelets 70,000/µL

Neutropenia

The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect?

Numbness of the extremities

The health care provider asks the nurse whether a patient's angioedema has responded to prescribed therapies. Which assessment should the nurse perform?

Observe for swelling of the patient's lips and tongue.

During a routine health examination, a 40-yr-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next?

Obtain more information about the family history.

The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)?

Obtain the temperature, blood pressure, and pulse before the transfusion

Which menu choice indicates that the patient understands the nurse's teaching about recommended dietary choices for iron-deficiency anemia?

Omelet and whole wheat toast

1. The nurse prepares to administer the following medications to a hospitalized patient with human immunodeficiency (HIV). Which medication is most important to administer at the scheduled time?

Oral saquinavir (Invirase)

During the teaching session for a patient who has a new diagnosis of acute leukemia, the patient is restless and looks away without making eye contact. The patient asks the nurse to repeat the information about the complications associated with chemotherapy. Based on this assessment, which nursing diagnosis is appropriate for the patient?

Risk for ineffective health maintenance related to possible anxiety about leukemia diagnosis

When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care?

Schedule immunization with the pneumococcal vaccine (e.g., Pneumovax).

Which patient information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis?

Serum iron level

The nurse is caring for a patient with left-sided lung cancer. Which finding would be most important for the nurse to report to the health care provider?

Serum sodium of 126 mEq/L

The nurse assesses a patient with non-Hodgkin's lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse?

Shortness of breath

A young adult patient with metastatic cancer, who is very close to death, appears restless. The patient keeps repeating, "I am not ready to die." Which action is best for the nurse to take?

Sit at the bedside and ask if there is anything the patient needs

The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)?

Stock the patient's room with the necessary personal protective equipment.

The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take?

Stop the infusion if swelling is observed at the site.

Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the health care provider?

Tarry stools

When caring for a young adult patient who has abnormalities in the cytochrome P450 (CYP 450) gene, which action will the nurse include in the patient's plan of care?

Teach that some medications may not work effectively

A patient who has acute myelogenous leukemia develops an absolute neutrophil count of 850/µL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate?

Teach the patient to administer filgrastim (Neupogen) injections.

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?

Tell the client as much as she wants to know and is able to understand.

The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention?

The UAP stands by the patient's bed for 30 minutes talking with the patient.

Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider?

The patient is difficult to arouse.

The nurse is caring for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care?

The patient reports missing some doses of zidovudine (AZT).

The nurse is caring for a patient with colon cancer who is scheduled for external radiation therapy to the abdomen. Which information obtained by the nurse would indicate a need for patient teaching?

The patient swims several days each week.

A patient who has severe pain associated with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective?

The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs.

A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care?

The patient will maintain intact perineal skin

A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching?

The patient's visitors bring in fresh peaches.

A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient?

Transfuse only leukocyte-reduced PRBCs.

The nurse is caring for a patient who is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching?

Wash hands and avoid persons who are ill.

A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding?

White blood cell (WBC) count of 2800/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?

White blood cells (WBC) 2700/µL

The nurse is advising a clinic patient who was exposed a week ago to human immunodeficiency virus (HIV) through unprotected sexual intercourse. The patient's antigen and antibody test has just been reported as negative for HIV. What instructions should the nurse give to this patient?

You will need to be retested in 2 weeks."

The nurse is assessing a client with chronic hepatitis B who is receiving lamivudine. What information about the client is most important to communicate to the health care provider?

a 3-kg weight gain over 2 days

A 62-year-old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory test findings to include

a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).

A few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing which problem?

a hemolytic allergic reaction caused by an antigen reaction

The nurse is caring for a patient infected with human immunodeficiency virus (HIV) who has just been diagnosed with asymptomatic chronic HIV infection. Which prophylactic measures will the nurse include in the plan of care (select all that apply)?

a. Hepatitis B vaccine b. Pneumococcal vaccine c. Influenza virus vaccine

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan?

avoiding using deodorant soap on the irradiated areas

An adult 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 nutritional status, the nurse should review the results of which test?

albumin level

An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to

alternate periods of rest and activity.

Which is a priority assessment for the client in shock who is receiving an IV infusion of packed red blood cells and normal saline solution?

anaphylactic reaction

A patient who has acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to

ask whether there are questions or concerns about HSCT.

Which patient exposure by the nurse is most likely to require postexposure prophylaxis when the patient's human immunodeficiency virus (HIV) status is unknown?

b. Needle stick with a needle and syringe used for a venipuncture

The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the

bilirubin level.

A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the

bleeding time.

A routine complete blood count for an active older man indicates possible myelodysplastic syndrome. The nurse will plan to teach the patient about

bone marrow biopsy.

A 42-year-old female is interested in making dietary changes to reduce her risk of colon cancer. What dietary selections should the nurse suggest?

bran muffin, skim milk, stir-fried broccoli

A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be

disconnect the transfusion and infuse normal saline.

1. It is important for the nurse providing care for a patient with sickle cell crisis to

evaluate the effectiveness of opioid analgesics.

The nurse is performing a breast examination on a client. Which findings most strongly suggest that a client has breast cancer?

fixed nodular mass, breast pain, dimpling of the skin

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of

folic acid.

A client had a right pneumonectomy for lung cancer yesterday and now has dyspnea. What position in bed will be best for this client?

head of bed elevated

A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, N0, M0. What does this classification mean?

carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis

An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/µL during chemotherapy is

check all stools for occult blood.

The nurse is teaching a client about risk factors for the development of colon cancer. What risk factor would the nurse include in the discussion?

history of inflammatory bowel disease

A client with suspected lung cancer is undergoing a thoracentesis. Which outcomes of the procedure are expected? Select all that apply.

diagnosis of underlying disease palliation of symptoms relief of acute respiratory distress

The nurse is caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee. The nurse should

immobilize the knee joint

An expected action by the nurse caring for a patient who has an acute exacerbation of polycythemia vera is to

monitor fluid intake and output.

After being seen in the oncology clinic, a client with severe bone marrow suppression is admitted to the hospital. The client's cancer therapy consisted of radiation and chemotherapy. When developing the care plan for this client, the nurse prioritizes which nursing intervention?

monitoring temperature and blood cell count

At a public health fair, a nurse teaches a group of women about breast cancer awareness. What is most important for the nurse to include in teaching about the warning signs of breast cancer?

nipple discharge and a breast nodule

Which finding is an early indicator of bladder cancer?

painless hematuria

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?

platelet count, prothrombin time, and partial thromboplastin time

For a cancerous tumor, a client must undergo modified radical mastectomy, which includes axillary node removal and immediate reconstruction. What will the nurse include in teaching about the reason for axillary node removal?

provides prognostic information

A client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis?

red, open sores on the oral mucosa

After surgery for head and neck cancer, a client has a permanent tracheostomy. Which is the most important point for the nurse to include in the teaching plan for the client and family?

using humidifiers to prevent thick, tenacious secretions

The nurse is assessing a client who is suspected of being in the early symptomatic stages of human immunodeficiency virus (HIV) infection. Which indication of infection should the nurse detect during this stage?

whitish yellow patches in the mouth