NU351: Exam 1
The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient? A. "Are you taking any oral contraceptives?" B. "Have you been prescribed antiseizure drugs?" C. "Do you take medication containing salicylates?" D. "How long have you taken antihypertensive drugs?"
C
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? A. "The cancer involves only the cervix." B. "The cancer cells look like normal cells." C. "Further testing is needed to determine the spread of the cancer." D. "It is difficult to determine the original site of the cervical cancer."
A
A patient with pancytopenia of unknown origin is scheduled for diagnostic tests. The nurse will ensure a consent form was signed before which test? A. Bone marrow biopsy B. Abdominal ultrasound C. Complete blood count (CBC) D. Activated partial thromboplastin time (aPTT)
A
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? a. Shortness of breath b. Shivering and chills c. Muscle aches and pains d. Temperature of 100.2° F (37.9° C)
a
When caring for a patient who is pancytopenic, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene? A. The UAP assists the patient to use dental floss after eating. B. The UAP adds baking soda to the patient's saline oral rinses. C. The UAP puts fluoride toothpaste on the patient's toothbrush. D. The UAP has the patient rinse after meals with a saline solution.
A
Which menu choice indicates that the patient understands the nurse's recommendations about dietary choices for iron-deficiency anemia? A. Omelet and whole wheat toast B. Cantaloupe and cottage cheese c. Strawberry and banana fruit plate d. Cornmeal muffin and orange juice
A
Which nursing intervention is appropriate for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/μL during chemotherapy? A. Test all stools for occult blood. B. Encourage fluids to 3000 mL/day. c. Provide oral hygiene every 2 hours. d. Check the temperature every 4 hours.
A
The nurse observes scleral jaundice in a patient being admitted with hemolytic anemia. Which laboratory result the nurse should check? A. Schilling test B. Bilirubin level C. Stool occult blood D. Gastric acid analysis
B
Which nursing intervention is important when providing care for a patient with sickle cell crisis? A. Limiting the patient's intake of oral and IV fluids B. Evaluating the effectiveness of opioid analgesics C. Encouraging the patient to ambulate as much as tolerated D. Teaching the patient about high-protein, high-calorie foods
B
Which is an appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia? A. Provide a diet high in vitamin K. B. Teach the patient how to avoid injury. C. Encourage alternating rest and activity. D. Place the patient on protective isolation.
C
Which information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis? A. Skin color B. Hematocrit C. Liver function D. Serum iron level
D
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? A. IL-2 enhances the body's immunologic response to tumor cells. B. IL-2 prevents bone marrow depression caused by chemotherapy. C. IL-2 protects normal cells from harmful effects of chemotherapy. D. IL-2 stimulates cancer cells in their resting phase to enter mitosis.
A
The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care? A. Avoid intramuscular injections. B. Encourage increased oral fluids. C. Check temperature every 4 hours. D. Increase intake of iron-rich foods.
A
The nurse examines the lymph nodes of a patient during a physical assessment. Which finding would be of most concern to the nurse? A. A 2-cm nontender supraclavicular node B. A 1-cm mobile and nontender axillary node C. An inability to palpate any superficial lymph nodes D. Firm inguinal nodes in a patient with an infected foot
A
A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to support the patient's self-esteem? A. Suggest that the patient limit social contacts until hair regrowth occurs. B. Encourage the patient to purchase a wig or hat to wear when hair loss begins. C. Teach the patient to wash hair gently with mild shampoo to minimize hair loss. D. Inform the patient that hair usually grows back once chemotherapy is complete.
B
A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). Which information should the nurse include in the patient's teaching plan? A. Donor bone marrow is transplanted through a sternal or hip incision. B. Hospitalization is required for several weeks after the stem cell transplant. C. The transplant procedure takes place in a sterile operating room to decrease the risk for infection. D. Transplant of the donated cells can be very painful because of the nerves in the tissue lining the bone.
B
A routine complete blood count for an active older man indicates possible myelodysplastic syndrome. What should the nurse plan to explain to the patient? A. Blood transfusion B. Bone marrow biopsy C. Filgrastim administration D. Erythropoietin administration
B
The nurse is planning to administer a transfusion of packed blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? A. Verify the patient identification (ID) according to hospital policy. B. Obtain the patient's temperature and blood pressure before the transfusion. c. Double-check the product numbers on the PRBCs with the patient ID band. d. Monitor the patient for shortness of breath or chest pain during the transfusion.
B
A patient who has severe pain with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching about pain management has been effective? A. The patient uses the ordered opioid pain medication whenever the pain is greater than 5 (0 to 10 scale). B. The patient agrees to take the medications by the IV route to improve analgesic effectiveness. C. The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs. D. The patient states that nonopioid analgesics may be used if the maximal dose of the opioid is reached without adequate pain relief.
C
A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is accurate? A. "Benign tumors do not cause damage to other tissues." B. "Benign tumors are likely to recur in the same location." C. "Malignant tumors may spread to other tissues or organs." D. "Malignant cells reproduce more rapidly than normal cells."
C
After change-of-shift report on the oncology unit, which patient should the nurse assess first? A. Patient who has a platelet count of 82,000/μL after chemotherapy. B. Patient who has xerostomia after receiving head and neck radiation. C. Patient who is neutropenic and has a temperature of 100.5° F (38.1° C). D. Patient who is worried about getting the prescribed long-acting opioid on time.
C
After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first? A. A 23-yr-old who reports severe fatigue B. A 56-yr-old with frequent explosive diarrhea C. A 33-yr-old with a fever of 100.8° F (38.2° C) D. A 66-yr-old who has white pharyngeal lesions
C
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? A. Test all stools for the presence of blood. B. Maintain a high-residue, high-fiber diet. C. Clean the perianal area carefully after every bowel movement. D. Inspect the mouth and throat daily for the appearance of thrush.
C
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? A. "How long ago were you diagnosed with this cancer?" B. "Do you have any concerns about body image changes?" C. "Can you tell me what has been helpful when coping with past stressful events?" D. "Are you familiar with the stages of emotional adjustment to cancer of the colon?"
C
The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect? a. Nausea b. Alopecia c. Hematuria d. Xerostomia
C
The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement by the patient indicates that teaching was effective? A. "The biopsy will remove the cancer in my prostate gland." B. "The biopsy will determine how much longer I have to live." C. "The biopsy will help decide the treatment for my enlarged prostate." D. "The biopsy will indicate whether the cancer has spread to other organs."
C
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? A. "After cancer has not recurred for 5 years, it is considered cured." B. "The cancer will be cured if the entire tumor is surgically removed." C. "I will need follow-up examinations for many years after treatment before I can be considered cured." D. "Cancer is never cured, but the tumor can be controlled with surgery, chemotherapy, and radiation."
C
Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/VN)? A. Assessing the patient for signs and symptoms of infection B. Teaching the patient the purpose of neutropenic precautions C. Administering subcutaneous filgrastim (Neupogen) injection D. Developing a discharge teaching plan for the patient and family
C
A nurse reviews the laboratory data for an older adult. The nurse would be most concerned about which finding? A. Hematocrit of 35% B. Hemoglobin of 11.8 g/dL C. Platelet count of 400,000/μL D. White blood cell count of 2800/μL
D
A patient in the emergency department reports back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. What should the nurse's first action be? A. Administer oxygen therapy at a high flowrate. B. Obtain a urine specimen to send to the laboratory. C. Notify the health care provider about the symptoms. D. Disconnect the transfusion and infuse normal saline.
D
A patient is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching? A. Check often for swollen lymph nodes. B. Watch for excess bleeding or bruising. C. Take iron supplements to prevent anemia. D. Wash hands and avoid persons who are ill.
D
An adult male with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. Which laboratory data would the nurse identify as consistent with these symptoms? A. RBC count of 4,500,000/uL B. Hematocrit (Hct) value of 38% C. Normal red blood cell (RBC) indices D. Hemoglobin (Hgb) of 8.6 g/dL (86 g/L)
D
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? A. Patient reports having severe fatigue. B. Patient voids every hour during the day. C. Patient takes only 50% of meals and refuses snacks. D. Patient has crackles up to the midline posterior chest.
D
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? A. Frequent loose stools B. Nausea and vomiting C. Elevated white blood count (WBC) d. Increased carcinoembryonic antigen (CEA)
D
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? A. Hematocrit 30% B. Platelets 95,000/μL C. Hemoglobin 10 g/L D. White blood cells (WBC) 2700/μL
D
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? A. Monocytes 4% B. Hemoglobin 13.6 g/dL C. Platelet count 168,000/μL D. White blood cell count 15,500/μL
D
What action is expected by the nurse caring for a patient who has an acute exacerbation of polycythemia vera? A. Place the patient on bed rest. B. Administer iron supplements. C. Avoid use of aspirin products. D. Monitor fluid intake and output.
D
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? A. Prepare for platelet transfusion. B. Discontinue the heparin infusion. c. Administer prescribed warfarin (Coumadin). d. Give low-molecular-weight heparin (LMWH).
B
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? A. Platelet count is 42,000/uL. B. Blood pressure is 94/56 mm Hg. C. Petechiae are present on the chest. D. Blood is oozing from the venipuncture site.
A
Which action should the nurse take when caring for a patient who is receiving chemotherapy and reports problems with concentration? A. Suggest use of a daily planner and encourage adequate sleep. B. Teach the patient to rest the brain by avoiding new activities. C. Teach that "chemo-brain" is a short-term effect of chemotherapy. D. Report patient symptoms immediately to the health care provider.
A
Which action will the nurse include in the plan of care for a patient admitted with multiple myeloma? A. Monitor fluid intake and output. B. Administer calcium supplements. C. Assess lymph nodes for enlargement. D. Limit weight bearing and ambulation.
A
Which action will the nurse include in the plan of care for a patient who has thalassemia major? A. Administer chelation therapy as needed. B. Teach the patient to use iron supplements. C. Avoid the use of intramuscular injections. D. Notify health care provider of hemoglobin 11 g/dL.
A
Which patient should the nurse assign as the roommate for a patient who has aplastic anemia? A. A patient with chronic heart failure B. A patient who has viral pneumonia C. A patient who has right leg cellulitis D. A patient with multiple abdominal drains
A
A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery. Which laboratory value should the nurse monitor? A. Platelet count B. Bleeding time c. Thrombin time d. Prothrombin time
B
A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse indicates a need for further teaching? A. The patient ambulates around the room. B. The patient's visitors bring in fresh peaches. C. The patient cleans with a warm washcloth after having a stool. d. The patient uses soap and shampoo to shower every other day.
B
A patient receiving outpatient chemotherapy for myelogenous leukemia develops an absolute neutrophil count of 850/μL. Which collaborative action should the outpatient clinic nurse anticipate?? A. Discuss the need for hospital admission to treat the neutropenia. B. Teach the patient to administer filgrastim (Neupogen) injections. C. Plan to discontinue the chemotherapy until the neutropenia resolves. D. Order a high-efficiency particulate air (HEPA) filter for the patient's home.
B
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? A. Infuse PRBCs slowly over 4 hours. B. Transfuse leukocyte-reduced PRBCs. C. Administer the prescribed diuretic before the transfusion. D. Give the PRN dose of antihistamine before the transfusion.
B
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? A. "If you do not want to have chemotherapy, other treatment options include stem cell transplantation." B. "The side effects of chemotherapy are difficult, but AML often goes into remission with chemotherapy." C. "The decision about treatment is one that you and the doctor need to make rather than asking what I would do." D. "You don't need to make a decision about treatment right now because leukemias in adults tend to progress slowly."
B
A patient who has acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). What is the best approach for the nurse to assist the patient with this treatment decision? A. Discuss the need for insurance to cover post-HSCT care. B. Inquire whether there are questions or concerns about HSCT. C. Emphasize the positive outcomes of a bone marrow transplant. D. Explain that a cure is not possible with any treatment except HSCT.
B
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? A. Give the patient the prescribed PRN opioid. B. Assess for sensation and strength in the legs. C. Notify the health care provider about the symptoms. D. Teach the patient how to use relaxation to reduce pain.
B
A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. Which nutrient supplement should the nurse plan to explain to the patient? A. Iron B. Folic acid C. Cobalamin (vitamin B12) D. Ascorbic acid (vitamin C)
B
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? A. Minimize activity until the treatment is completed. B. Establish time to take a short walk almost every day. C. Consult with a psychiatrist for treatment of depression. D. Arrange for delivery of a hospital bed to the patient's home.
B
A patient with a large stomach tumor attached to the liver is scheduled for a debulking procedure. What should the nurse teach the patient about the outcome of this procedure? A. Pain will be relieved by cutting sensory nerves in the stomach. B. Decreasing the tumor size will improve the effects of other therapy. C. Relieving the pressure in the stomach will promote optimal nutrition. D. Tumor growth will be controlled by removing all the cancerous tissue.
B
A widowed mother of 4 school-age children is hospitalized with metastatic ovarian cancer. The patient is crying and tells the nurse that she does not know what will happen to her children when she dies. Which response by the nurse is most appropriate? A. "Don't you have any friends that will raise the children for you?" B. "Would you like to talk about options for the care of your children?" C. "For now you need to concentrate on getting well and not worrying about your children." D. "Many patients with cancer live for a long time, so there is time to plan for your children."
B
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? A. Schedule a sigmoidoscopy to provide baseline data. B. Obtain more information about the patient's relatives. C. Teach the patient about the need for a colonoscopy at age 50. D. Teach the patient how to do home testing for fecal occult blood.
B
During the teaching session for a patient who has a new diagnosis of acute leukemia, the patient is restless and looks away without making eye contact. The patient asks the nurse to repeat the information about the complications associated with chemotherapy. Based on this assessment, which patient problem should the nurse identify? A. Denial B. Anxiety C. Acute confusion D. Ineffective adherence to treatment
B
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? A. A 44-yr-old with sickle cell anemia who says his eyes always look yellow B. A 23-yr-old with no previous health problems who has a nontender axillary lump C. A 50-yr-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue D. A 19-yr-old with hemophilia who wants to learn to self-administer factor VII replacement
B
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? A. "I have frequent muscle aches and pains." B. "I rarely have the energy to get out of bed." C. "I experience chills after I inject the interferon." D. "I take acetaminophen (Tylenol) every 4 hours."
B
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? a. Bruising b. Neutropenia c. Increasing fatigue d. Thrombocytopenia
B
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? A. The patient has a history of dental caries. B. The patient swims several days each week. C. The patient snacks frequently during the day. D. The patient showers each day with mild soap.
B
The nurse is reviewing laboratory results and notes a patient's activated partial thromboplastin time (aPTT) level is 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication? A. Aspirin b. Heparin c. Warfarin d. Erythropoietin
B
The nurse should suggest which food choice for a patient scheduled to receive external-beam radiation for abdominal cancer? A. Fruit salad B. Baked chicken C. Creamed broccoli D. Toasted wheat bread
B
The nurse teaches a patient with liver cancer about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective? A. Lime sherbet B. Blueberry yogurt C. Fresh strawberries D. Cream cheese bagel
B
When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care? A. Recommend ibuprofen for left upper quadrant pain. B. Schedule immunization with the pneumococcal vaccine c. Avoid the use of acetaminophen (Tylenol) for 2 weeks prior to surgery. d. Discourage deep breathing and coughing to reduce risk for splenic rupture.
B
Which action will the admitting nurse include in the care plan for a patient who has neutropenia? A. Avoid intramuscular injections. B. Check temperature every 4 hours. C. Place a "No Visitors" sign on the door. D. Omit fruits and vegetables from the diet.
B
Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider? A. Bruises on the patient's back. B. The patient is difficult to arouse. C. Purpura on the patient's oral mucosa. D. The patient's platelet count is 52,000/μL.
B
A patient with pancytopenia will have a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure? a. Elevate the head of the bed to 45 degrees. b. Use a -in sterile gauze to pack the wound. c. Have the patient lie on the left side for 1 hour. d. Apply a sterile 2-in gauze dressing to the site.
C
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? A. Avoid other venipunctures. B. Apply dressings to the sites. C. Notify the health care provider. D. Give prescribed proton-pump inhibitors.
C
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 should the nurse expect? A. Cool extremities B. Pallor and weakness c. Elevated temperature d. Low oxygen saturation
C
The nurse assesses a patient with pernicious anemia. Which finding would the nurse expect? A. Yellow-tinged sclerae B. Shiny, smooth tongue C. Tender, bleeding gums D. Numbness of extremities
C
The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first? A. A 35-yr-old patient who has wet desquamation associated with abdominal radiation B. A 42-yr-old patient who is sobbing after receiving a new diagnosis of ovarian cancer C. A 24-yr-old patient who received neck radiation and has blood oozing from the neck D. A 56-yr-old patient who developed a new pericardial friction rub after chest radiation
C
Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? A. Hematocrit 55% B. Presence of plethora C. Calf swelling and pain D. Platelet count 450,000/uL
C
Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? A. "I could take a stool softener if I feel constipated." B. "I can take the iron with orange juice before eating." C. "I should notify my health care provider if my stools turn black." D. "I will increase my fluid and fiber intake while I am taking iron."
C
Which patient statement to the nurse indicates that the patient understands self-care for pernicious anemia? A. "I need to start eating more red meat and liver." B. "I will stop having a glass of wine with dinner." C. "I could choose nasal spray rather than injections of vitamin B12." D. "I will need to take a proton pump inhibitor such as omeprazole (Prilosec)."
C
Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)? A. Prothrombin time B. Erythrocyte count C. Fibrinogen degradation products D. Activated partial thromboplastin time
D
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? A. Platelet count B. Reticulocyte count C. Total lymphocyte count D. Absolute neutrophil count
D
A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is labeled: 1 mL equals 10 drops. How many drops per minute will the nurse infuse?
21 To infuse 250 mL over 2 hours, the calculated drip rate is 20.8 drops/min or 21 drops/min.
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? A. "Have you had a recent weight loss?" B. "Do you have any history of lung disease?" C. "Have you noticed any dark or bloody stools?" D. "What is your dietary intake of meat and protein?"
B
A patient has inadequate nutrition due to painful oral ulcers. Which nursing action will be most effective in improving oral intake? A. Offer the patient frequent small snacks between meals. B. Assist the patient to choose favorite foods from the menu. C. Apply prescribed anesthetic gel to oral lesions before meals. D. Teach the patient about the importance of nutritional intake.
C
A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect? A. Hematocrit of 46% B. Hemoglobin of 13.8 g/dL C. Elevated reticulocyte count D> Decreased white blood cell count
C
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? A. Administer morphine sulfate 4 mg IV. B. Give acetaminophen (Tylenol) 650 mg. C. Infuse normal saline 500 mL over 30 minutes. D. Schedule complete blood count and coagulation studies.
C
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? a. Remove food debris from the teeth and oral mucosa with a stiff toothbrush. b. Use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth. c. Gargle and rinse the mouth several times a day with an antiseptic mouthwash. d. Rinse the mouth before and after each meal and at bedtime with a saline solution.
D
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? a. "I can use ice packs to relieve itching." b. "I will scrub the area with warm water." c. "I will expose my skin to a sun lamp each day." d. "I can buy some aloe vera gel to use on my skin."
D
The nurse is caring for a patient who smokes 2 packs/day. Which action by the nurse could help reduce the patient's risk of lung cancer? A. Teach the patient about the seven warning signs of cancer. B. Plan to monitor the patient's carcinoembryonic antigen (CEA) level. C. Teach the patient about annual chest x-rays for lung cancer screening. D. Discuss risks associated with cigarettes during each patient encounter.
D
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? A. Send a urine specimen to the laboratory. B. Administer PRN acetaminophen (Tylenol). C. Draw blood for a new type and crossmatch. D. Give the prescribed PRN diphenhydramine.
B
The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? A. Infuse the medication over a short period of time. B. Stop the infusion if swelling is observed at the site. c. Administer the chemotherapy through a small-bore catheter. d. Hold the medication unless a central venous line is available.
B
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? A. Platelet count B. Neutrophil count C. Hemoglobin level D. White blood cell count
C
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? A. Anorexia B. Vomiting C. Oral ulcers D. Lip swelling
D
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 2 or 3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk? (Select all that apply.) A. Pap testing B. Tobacco use C. Sunscreen use D. Mammography E. Colorectal screening
A, C, D, E
A 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.) A. Cook food thoroughly before eating. B. Choose low fiber, low residue foods. C. Avoid public transportation such as buses. D. Use rectal suppositories if needed for constipation. E. Talk to the oncologist before having any dental work.
A, C, E
Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura? A. Assign the patient to a private room. B. Avoid intramuscular (IM) injections. C. Use rinses rather than a soft toothbrush for oral care. D. Restrict activity to passive and active range of motion.
B
Which patient requires the most rapid assessment and care by the emergency department nurse? A. The patient with hemochromatosis who reports abdominal pain. B. The patient with neutropenia who has a temperature of 101.8° F. C. The patient with thrombocytopenia who has oozing gums after a tooth extraction. D. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours.
B
The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider? A. Generalized muscle aches B. Crackles at the lung bases C. Reports of nausea and anorexia D. Oral temperature of 100.6° F (38.1° C)
B
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. Which action should the nurse take? A. Apply heat to the knee. B. Immobilize the knee joint. C. Assist the patient with light weight bearing. D. Perform passive range of motion to the knee.
B
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? A. The UAP flushes the toilet once after emptying the patient's bedpan. B. The UAP stands by the patient's bed for 30 minutes talking with the patient. C. The UAP places the patient's bedding in the laundry container in the hallway. D. The UAP gives the patient an alcohol-containing mouthwash to use for oral care.
B
Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider? A. Patient reports severe back pain. B. Serum calcium level is 15 mg/dL. C. Patient reports no stool for 5 days. D. Urine sample has Bence-Jones protein.
B
Which information shown in the table below about a patient who has just arrived in the emergency department is most urgent for the nurse to communicate to the health care provider? A. Heart rate B. Platelet count C. Abdominal pain D. White blood cell count
B
Which instruction will the nurse plan to include in discharge teaching for a patient admitted with a sickle cell crisis? A. Limit fluids to 2 to 3 quarts per day. B. Avoid exposure to crowds when possible. C. Take a daily multivitamin supplement with iron. D. Drink no more than two caffeinated beverages daily.
B
Which potential complication should the nurse identify as a high risk for a patient admitted to the hospital with idiopathic aplastic anemia? A. Seizures B. Infection C. Neurogenic shock D. Pulmonary edema
B
Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the health care provider? A. Leg bruises B. Tarry stools C. Skin abrasions D. Bleeding gums
B
A patient with cancer is eating very little due to altered taste sensation. Which nursing action would address the cause of the patient problem? A. Add protein powder to foods such as casseroles. B. Tell the patient to eat foods that are high in nutrition. C. Avoid giving the patient foods that are strongly disliked. D. Add spices to enhance the flavor of foods that are served.
C
A patient with metastatic colon cancer has severe vomiting after each administration of chemotherapy. Which action by the nurse is appropriate? A. Have the patient eat large meals when nausea is not present. B. Offer dry crackers and carbonated fluids during chemotherapy. C. Administer prescribed antiemetics 1 hour before the treatments. D. Give the patient a glass of a citrus fruit beverage during treatments.
C
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? A. Hematocrit of 32% B. Pain with deep inspiration C. Serum sodium of 126 mEq/L D. Decreased breath sounds on left side
C
A patient who has ovarian cancer is crying and tells the nurse, "My husband rarely visits. He just doesn't care." The husband tells the nurse that he does not know what to say to his wife. Which problem is appropriate for the nurse to address in the plan of care? A. Anxiety B. Death anxiety C. Difficulty coping D. Lack of knowledge
D
Following successful treatment of Hodgkin's lymphoma for a 55-yr-old woman, which topic will the nurse include in patient teaching? A. Potential impact of chemotherapy treatment on fertility B. Application of soothing lotions to treat residual pruritus C. Use of maintenance chemotherapy to maintain remission D. Need for follow-up appointments to screen for malignancy
D
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 to prepare the patient for this procedure? A. Check for any iodine allergy. B. Insert a large-bore IV catheter. C. Administer prescribed sedatives. D. Assist the patient to a flat position.
D
Which statement by a patient indicates good understanding of the nurse's teaching about preventing sickle cell crisis? A. "Home oxygen therapy is frequently used to decrease sickling." B. "There are no effective medications that can help prevent sickling." C. "Routine continuous dosage opioids are prescribed to prevent a crisis." D. "Risk for a crisis is decreased by having an annual influenza vaccination."
D
