test 3
12. A 61-year-old man is being admitted for bariatric surgery. Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP)?
C) Assist with IV insertion by holding adipose tissue out of the way.
38. A 45-year-old woman has just undergone a radical hysterectomy for invasive cervical cancer. Prior to the surgery the physician explained to the patient that after the surgery a source of radiation would be placed near the tumor site to aid in reducing recurrence. What is the placement of the source of radiation called?
C) Brachytherapy
1. A nurse is working with a patient who has chronic constipation. What should be included in patient teaching to promote normal bowel function?
C) Consume high-residue, high-fiber foods.
5. A few months after bariatric surgery, a 56-year-old man tells the nurse, My skin is hanging in folds. I think I need cosmetic surgery. Which response by the nurse is most appropriate?
C) Cosmetic surgery is a possibility once your weight has stabilized.
25. A patient with a diagnosis of cirrhosis has developed variceal bleeding and will imminently undergo variceal banding. What psychosocial nursing diagnosis should the nurse most likely prioritize during this phase of the patients treatment?
C) Death Anxiety
4. A nurse is planning the care of a patient who has been admitted to the medical unit with a diagnosis of multiple myeloma. In the patients care plan, the nurse has identified a diagnosis of Risk for Injury. What pathophysiologic effect of multiple myeloma most contributes to this risk?
C) Decreased bone density
33. A nurse is assessing a patients stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding?
C) Document that the stoma appears healthy and well perfused.
18. A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. What action has the greatest potential to prevent esophageal cancer?
C) Early diagnosis and treatment of gastroesophageal reflux disease
16. The nurse is caring for a 54-year-old female patient on the first postoperative day after a Roux-en-Y gastric bypass procedure. Which assessment finding should be reported immediately to the surgeon?
C) Emesis of bile-colored fluid past the nasogastric (NG) tube
20. A client just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority?
C) Ensure an adequate airway.
10. A 23-year-old woman comes to the free clinic stating I think I have a lump in my breast. Do I have cancer? The nurse instructs the patient that a diagnosis of breast cancer is confirmed by what?
C) Fine-needle aspiration
36. A nurse has entered the room of a patient with cirrhosis and found the patient on the floor. The patient states that she fell when transferring to the commode. The patients vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurses most appropriate action?
C) Have the patient assessed by the physician due to the risk of internal bleeding.
21. A nurse is working with a patient who is learning to care for a continent ileostomy (Kock pouch). Following the initial period of healing, the nurse is teaching the patient how to independently empty the ileostomy. The nurse should teach the patient to do which of the following actions?
C) Insert the catheter approximately 5 cm into the pouch.
24. A patient is undergoing diagnostic testing for a tumor of the small intestine. What are the most likely symptoms that prompted the patient to first seek care?
C) Intermittent pain and bloody stool
37. A patient has just been diagnosed with breast cancer and the nurse is performing a patient interview. In assessing this patients ability to cope with this diagnosis, what would be an appropriate question for the nurse to ask this patient?
C) Is there someone you trust to help you make treatment choices?
2. The nurse leading an educational session is describing self-examination of the breast. The nurse tells the womens group to raise their arms and inspect their breasts in a mirror. A member of the womens group asks the nurse why raising her arms is necessary. What is the nurses best response?
C) It will help to observe for dimpling more closely.
12. Diagnostic testing has revealed that a patients hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this patients plan of care will focus on what intervention?
C) Lobectomy
10. What information will the nurse include for an overweight 35-year-old woman who is starting a weight- loss plan?
C) Low carbohydrate diets lead to rapid weight loss but are difficult to maintain.
39. A nurse is providing discharge education to a patient who has undergone a laparoscopic cholecystectomy. During the immediate recovery period, the nurse should recommend what foods?
C) Low-fat foods high in proteins and carbohydrates
13. A 30-year-old patient has come to the clinic for her yearly examination. The patient asks the nurse about ovarian cancer. What should the nurse state when describing risk factors for ovarian cancer?
C) Most cases of ovarian cancer are considered to be random, with no obvious causation.
11. An emergency department nurse is triaging a 77-year-old man who presents with uncharacteristic fatigue as well as back and rib pain. The patient denies any recent injuries. The nurse should recognize the need for this patient to be assessed for what health problem?
C) Multiple myeloma
2. A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patients liver?
C) Place hand under right lower rib cage and press down lightly with the other hand.
22. A patient has undergone surgery for oral cancer and has just been extubated in postanesthetic recovery. What nursing action best promotes comfort and facilitates spontaneous breathing for this patient?
C) Placing the patient in Fowlers position
31. A patient who underwent surgery for esophageal cancer is admitted to the critical care unit following postanesthetic recovery. Which of the following should be included in the patients immediate postoperative plan of care?
C) Positioning the patient to prevent gastric reflux
35. A patient diagnosed with cervical cancer will soon begin a round of radiation therapy. When planning the patients subsequent care, the nurse should prioritize actions with what goal?
C) Protecting the safety of the patient, family, and staff
23. A nurse is caring for a patient who is being treated for leukemia in the hospital. The patient was able to maintain her nutritional status for the first few weeks following her diagnosis but is now exhibiting early signs and symptoms of malnutrition. In collaboration with the dietitian, the nurse should implement what intervention?
C) Provide the patient with several small, soft-textured meals each day.
8. A patient who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this patient knows to immediately report what assessment finding to the physician?
C) Rigidity of the abdomen
37. Fresh-frozen plasma (FFP) has been ordered for a hospital patient. Prior to administration of this blood product, the nurse should prioritize what patient education?
C) Signs and symptoms of a transfusion reaction
17. The nurses review of a patients most recent blood work reveals a significant increase in the number of band cells. The nurses subsequent assessment should focus on which of the following?
C) Signs and symptoms of infection
11. A patient has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize which of the following topics?
C) Signs and symptoms of intra-abdominal complications
11. A nurse is planning discharge teaching for a 21-year-old patient with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the patients coping after discharge?
C) The familys ability to provide emotional support
39. Which of the following circumstances would most clearly warrant autologous blood donation?
C) The patient has elective surgery pending.
9. A patients screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this patients health problem?
C) The patients polyps constitute a risk factor for cancer.
24. An older adult has a diagnosis of Alzheimers disease and has recently been experiencing fecal incontinence. However, the nurse has observed no recent change in the character of the patients stools. What is the nurses most appropriate intervention?
C) Toilet the patient on a frequent, scheduled basis.
31. A patient is being discharged home after a hysterectomy. When providing discharge education for this patient, the nurse has cautioned the patient against sitting for long periods. This advice addresses the patients risk of what surgical complication?
C) Venous thromboembolism
1. Which statement by the nurse is most likely to help a morbidly obese 22-year-old man in losing weight on a 1000-calorie diet?
C) You are likely to notice changes in how you feel with just a few weeks of diet and exercise.
13. After successfully losing 1 lb weekly for several months, a patient at the clinic has not lost any weight for the last month. The nurse should first
C) ask the patient whether there have been any changes in exercise or diet patterns.
18. A nurse is performing an admission assessment for an 81-year-old patient who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what finding?
D) A slightly decreased size of the liver
8. A 35-year-old male is admitted to the hospital complaining of severe headaches, vomiting, and testicular pain. His blood work shows reduced numbers of platelets, leukocytes, and erythrocytes, with a high proportion of immature cells. The nurse caring for this patient suspects a diagnosis of what?
D) ALL (Acute Lymphocytic Leukemia)
38. A 35-year-old mother of three young children has been diagnosed with stage II breast cancer. After discussing treatment options with her physician, the woman goes home to talk to her husband, later calling the nurse for clarification of some points. The patient tells the nurse that the physician has recommended breast conservation surgery followed by radiation. The patients husband has done some online research and is asking why his wife does not have a modified radical mastectomy to be sure all the cancer is gone. What would be the nurses best response?
D) According to current guidelines, breast conservation combined with radiation is as effective as a modified radical mastectomy.
23. A nurse is amending a patients plan of care in light of the fact that the patient has recently developed ascites. What should the nurse include in this patients care plan?
D) Administration of diuretics as ordered
18. A nurse is educating a patient about the role of B lymphocytes. The nurses description will include which of the following physiologic processes?
D) Antibody production
34. A patient with liver cancer is being discharged home with a biliary drainage system in place. The nurse should teach the patients family how to safely perform which of the following actions?
D) Assessing the patency of the drainage catheter
33. An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction?
D) Be vigilant in identifying the patient and the blood component.
6. A woman is being treated for a tumor of the left breast. If the patient and her physician opt for prophylactic treatment, the nurse should prepare the woman for what intervention?
D) Bilateral mastectomy
15. A patient returns to the floor after a laparoscopic cholecystectomy. The nurse should assess the patient for signs and symptoms of what serious potential complication of this surgery?
D) Bile duct injury
19. A nurse is teaching a group of adults about screening and prevention of colorectal cancer. The nurse should describe which of the following as the most common sign of possible colon cancer?
D) Change in bowel habits
37. A patient with liver cancer is being discharged home with a hepatic artery catheter in place. The nurse should be aware that this catheter will facilitate which of the following?
D) Delivery of a continuous chemotherapeutic dose
23. A patient has been experiencing disconcerting GI symptoms that have been worsening in severity. Following medical assessment, the patient has been diagnosed with lactose intolerance. The nurse should recognize an increased need for what form of health promotion?
D) Frequent screening for osteoporosis
40. A patient presents to the emergency department (ED) complaining of severe right upper quadrant pain. The patient states that his family doctor told him he had gallstones. The ED nurse should recognize what possible complication of gallstones?
D) Gangrene of the gallbladder
12. A home health nurse is caring for a patient with multiple myeloma. Which of the following interventions should the nurse prioritize when addressing the patients severe bone pain?
D) Helping the patient manage the opioid analgesic regimen
27. A patient has completed the full course of treatment for acute lymphocytic leukemia and has failed to respond appreciably. When preparing for the patients subsequent care, the nurse should perform what action?
D) Identify the patients specific wishes around end-of-life care.
40. Which of the following is the most plausible nursing diagnosis for a patient whose treatment for colon cancer has necessitated a colonostomy?
D) Ineffective Sexuality Patterns Related to Changes in Self-Concept
35. A patient lives with a diagnosis of sickle cell anemia and receives frequent blood transfusions. The nurse should recognize the patients consequent risk of what complication of treatment?
D) Iron overload
14. A patient with non-Hodgkins lymphoma is receiving information from the oncology nurse. The patient asks the nurse why she should stop drinking and smoking and stay out of the sun. What would be the nurses best response?
D) Its important to reduce other factors that increase the risk of second cancers.
16. The nurse notes that a patient has a history of fibroids and is aware that this term refers to a benign tumor of the uterus. What is a more appropriate term for a fibroid?
D) Leiomyoma
14. A nurse is talking with a patient who is scheduled to have a hemicolectomy with the creation of a colostomy. The patient admits to being anxious, and has many questions concerning the surgery, the care of a stoma, and necessary lifestyle changes. Which of the following nursing actions is most appropriate?
D) Maintain an open dialogue with the patient and facilitate a referral to the wound-ostomy- continence (WOC) nurse.
34. A patient has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurses care should prioritize which of the following outcomes?
D) Maintaining fluid and electrolyte balance
21. A patient has been diagnosed with a malignancy of the oral cavity and is undergoing oncologic treatment. The oncologic nurse is aware that the prognosis for recovery from head and neck cancers is often poor because of what characteristic of these malignancies?
D) Metastases are common and respond poorly to treatment.
9. A community health nurse is preparing for an initial home visit to a patient discharged following a total gastrectomy for treatment of gastric cancer. What would the nurse anticipate that the plan of care is most likely to include?
D) Monthly administration of injections of vitamin B12
40. A nurse providing prenatal care to a pregnant woman is addressing measures to reduce her postpartum risk of cystocele, rectocele, and uterine prolapse. What action should the nurse recommend?
D) Performance of pelvic muscle exercises
40. A nurse is caring for patient whose diagnosis of multiple myeloma is being treated with bortezomib. The nurse should assess for what adverse effect of this treatment?
D) Peripheral neuropathy
32. A nurse is caring for an older adult who has been experiencing severe Clostridium difficile-related diarrhea. When reviewing the patients most recent laboratory tests, the nurse should prioritize which of the following?
D) Potassium level
35. A patients large bowel obstruction has failed to resolve spontaneously and the patients worsening condition has warranted admission to the medical unit. Which of the following aspects of nursing care is most appropriate for this patient?
D) Preparing the patient for surgical bowel resection
36. A patient has been experiencing occasional episodes of constipation and has been unable to achieve consistent relief by increasing physical activity and improving his diet. What pharmacologic intervention should the nurse recommend to the patient for ongoing use?
D) Psyllium hydrophilic mucilloid (Metamucil)
20. A patient has presented for her annual mammogram. The patient voices concerns related to exposure to radiation. What should the nurse teach the patient about a mammogram?
D) Radiation from a mammogram is equivalent to an hour of sunlight.
39. A 25-year-old patient diagnosed with invasive cervical cancer expresses a desire to have children. What procedure might the physician offer as treatment?
D) Radical trachelectomy
32. A 27-year-old female patient is diagnosed with invasive cervical cancer and is told she needs to have a hysterectomy. One of the nursing diagnoses for this patient is disturbed body image related to perception of femininity. What intervention would be most appropriate for this patient?
D) Reassure the patient that she will still be able to have intercourse with sexual satisfaction and orgasm.
23. A patients diagnosis of atrial fibrillation has prompted the primary care provider to prescribe warfarin (Coumadin), an anticoagulant. When assessing the therapeutic response to this medication, what is the nurses most appropriate action?
D) Review the patients international normalized ratio (INR).
1. A nurse is assessing a patient who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the patients pain, the nurse should anticipate that it may radiate to what region?
D) Right shoulder
20. A nurse is assessing an elderly patient with gallstones. The nurse is aware that the patient may not exhibit typical symptoms, and that particular symptoms that may be exhibited in the elderly patient may include what?
D) Signs and symptoms of septic shock
6. After vertical banded gastroplasty, a 42-year-old male patient returns to the surgical nursing unit with a nasogastric tube to low, intermittent suction and a patient-controlled analgesia (PCA) machine for pain control. Which nursing action should be included in the postoperative plan of care?
D) Support the surgical incision during patient coughing and turning in bed.
5. The nurse is caring for a 52-year-old woman whose aunt and mother died of breast cancer. The patient states, My doctor and I talked about Tamoxifen to help prevent breast cancer. Do you think it will work? What would be the nurses best response?
D) Tamoxifen is known to be a highly effective protective measure.
6. The nurse is providing preoperative education for a patient diagnosed with endometriosis. A hysterectomy has been scheduled. What education topic should the nurse be sure to include for this patient?
D) The bladder must be emptied prior to surgery and a catheter may be placed during surgery.
31. Two units of PRBCs have been ordered for a patient who has experienced a GI bleed. The patient is highly reluctant to receive a transfusion, stating, Im terrified of getting AIDS from a blood transfusion. How can the nurse best address the patients concerns?
D) The chances of contracting AIDS from a blood transfusion in the United States are exceedingly low.
4. A nurse is admitting a patient diagnosed with late-stage gastric cancer. The patients family is distraught and angry that she was not diagnosed earlier in the course of her disease. What factor contributes to the fact that gastric cancer is often detected at a later stage?
D) The early symptoms of gastric cancer are usually not alarming or highly unusual.
16. A patient newly diagnosed with breast cancer states that her physician suspects regional lymph node involvement and told her that there are signs of metastatic disease. The nurse learns that the patient has been diagnosed with stage IV breast cancer. What is an implication of this diagnosis?
D) The patient has a 15% chance of 5-year survival.
A nurse is caring for a patient who undergoing preliminary testing for a hematologic disorder. What sign or symptom most likely suggests a potential hematologic disorder?
D) severe fatigue
The nurse educating a patient with anemia is describing the process of RBC production. When the patients kidneys sense a low level of oxygen in circulating blood, what physiologic response is initiated?
Increased production of erythropoietin
The nurse is caring for a patient who has developed scar tissue in many of the areas that normally produce blood cells. What organs can become active in blood cell production by the process of extramedullary hematopoiesis?
Liver and spleen
A man suffers a leg wound which causes minor blood loss. As a result of bleeding, the process of primary hemostasis is activated. What occurs in primary hemostasis?
Severed blood vessels constrict.
22. A clients health history reveals daily consumption of two to three bottles of wine. The nurse should plan assessments and interventions in light of the patients increased risk for what hematologic disorder?
anemia
13. The nurse is describing normal RBC physiology to a patient who has a diagnosis of anemia. The nurse should explain that the RBCs consist primarily of which of the following?
hemoglobin
A patient with a hematologic disorder asks the nurse how the body forms blood cells. The nurse should describe a process that takes place where?
in the bone marrow
10. A patients wound has begun to heal and the blood clot which formed is no longer necessary. When a blood clot is no longer needed, the fibrinogen and fibrin will be digested by which of the following?
plasmin
29.A patient is being discharged home from the ambulatory surgery center after an incisional biopsy of a mass in her left breast. What are the criteria for discharging this patient home? Select all that apply.
1. Patient must have someone to accompany her home 2. Patient must understand activity restrictions 3. Patient must understand care of the biopsy site
11. A nurse who provides care in an ambulatory clinic integrates basic cancer screening into admission assessments. What patient most likely faces the highest immediate risk of oral cancer?
A) A 65-year-old man with alcoholism who smokes
40. A patient has come to the clinic complaining of pain just above her umbilicus. When assessing the patient, the nurse notes Sister Mary Joseph's nodules. The nurse should refer the patient to the primary care provider to be assessed for what health problem?
A) A GI malignancy
22. A 42-year-old man has come to the clinic for an annual physical. The nurse notes in the patients history that his father was treated for breast cancer. What should the nurse provide to the patient before he leaves the clinic?
A) A referral for a mammogram
8. A patient who came to the clinic after finding a mass in her breast is scheduled for a diagnostic breast biopsy. During the nurses admission assessment, the nurse observes that the patient is distracted and tense. What is it important for the nurse to do?
A) Acknowledge the fear the patient is likely experiencing.
29. A nurse is caring for a patient who has been admitted to the hospital with diverticulitis. Which of the following would be appropriate nursing diagnoses for this patient? Select all that apply.
A) Acute Pain Related to Increased Peristalsis and GI Inflammation B) Activity Intolerance Related to Generalized Weakness D) Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea
17. A nurse is caring for a patient admitted with symptoms of an anorectal infection; cultures indicate that the patient has a viral infection. The nurse should anticipate the administration of what drug?
A) Acyclovir (Zovirax)
36. A patient has been discharged home after a total mastectomy without reconstruction. The patient lives alone and has a home health referral. When the home care nurse performs the first scheduled visit this patient, what should the nurse assess? Select all that apply.
A) Adherence to the exercise plan B) Overall psychological functioning C) Integrity of surgical drains
38. The nurse is preparing to administer a unit of platelets to an adult patient. When administering this blood product, which of the following actions should the nurse perform?
A) Administer the platelets as rapidly as the patient can tolerate.
30. The nurse is providing care for a patient whose inflammatory bowel disease has necessitated hospital treatment. Which of the following would most likely be included in the patients medication regimen?
A) Anticholinergic medications 30 minutes before a meal
21. A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says I didnt know it would be this hard to live like this. What response by the nurse is best?
A) Assess the clients coping and support systems.
9. When teaching a patient about testing to diagnose metabolic syndrome, which topic would the nurse include?
A) Blood glucose test
9. A patient with leukemia has developed stomatitis and is experiencing a nutritional deficit. An oral anesthetic has consequently been prescribed. What health education should the nurse provide to the patient?
A) Chew with care to avoid inadvertently biting the tongue.
5. A nurse is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system. The nurses most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurses best response to this assessment finding?
A) Document the presence of normal bile output.
7. The nurse will be teaching self-management to patients after gastric bypass surgery. Which information will the nurse plan to include?
A) Drink fluids between meals but not with meals.
35. A patient has received a diagnosis of gastric cancer and is awaiting a surgical date. During the preoperative period, the patient should adopt what dietary guidelines?
A) Eat small, frequent meals with high calorie and vitamin content.
33. A nurse is caring for a patient who has had surgery for oral cancer. When addressing the patients long- term needs, the nurse should prioritize interventions and referrals with what goal?
A) Enhancement of verbal communication
32. A patient has received treatment for oral cancer. The combination of medications and radiotherapy has resulted in leukopenia. Which of the following is an appropriate response to this change in health status?
A) Ensure that none of the patients visitors has an infection.
8. A nurse in the postanesthesia care unit admits a patient following resection of a gastric tumor. Following immediate recovery, the patient should be placed in which position to facilitate patient comfort and gastric emptying?
A) Fowlers
19. A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a patient admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?
A) Fried chicken
7. A patient has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study?
A) Have the patient refrain from food and fluids after midnight.
28. A nurse at a blood donation clinic has completed the collection of blood from a woman. The woman states that she feels lightheaded and she appears visibly pale. What is the nurses most appropriate action?
A) Help her into a sitting position with her head lowered below her knees.
8. A nurse is presenting an educational event to a local community group. When speaking about colorectal cancer, what risk factor should the nurse cite?
A) High levels of alcohol consumption
7. A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this patients presentation?
A) How many alcoholic drinks do you typically consume in a week?
38. A nurse on a solid organ transplant unit is planning the care of a patient who will soon be admitted upon immediate recovery following liver transplantation. What aspect of nursing care is the nurses priority?
A) Implementation of infection-control measures
19. A client has been prescribed lorcaserin (Belviq). What teaching is most appropriate?
A) Increase the fiber and water in your diet.
7. A patient is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this patients care, which of the following nursing diagnoses should the nurse prioritize?
A) Ineffective Tissue Perfusion Related to Bowel Ischemia
5. A 35-year-old male patient presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize?
A) Insertion of a nasogastric tube
37. A patient with ongoing back pain, nausea, and abdominal bloating has been diagnosed with cholecystitis secondary to gallstones. The nurse should anticipate that the patient will undergo what intervention?
A) Laparoscopic cholecystectomy
36. A patient with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure?
A) Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure.
Through the process of hematopoiesis, stem cells differentiate into either myeloid or lymphoid stem cells. Into what do myeloid stem cells further differentiate? Select all that apply.
A) Leukocytes D) Platelets E) Erythrocytes
36. The nurse is caring for a 63-year-old patient with ovarian cancer. The patient is to receive chemotherapy consisting of Taxol and Paraplatin. For what adverse effect of this treatment should the nurse monitor the patient?
A) Leukopenia
9. A patient has been referred to the breast clinic after her most recent mammogram revealed the presence of a lump. The lump is found to be a small, well-defined nodule in the right breast. The oncology nurse should recognize the likelihood of what treatment?
A) Lumpectomy and radiation
2. A nurse is caring for a patient who has a diagnosis of acute leukemia. What assessment most directly addresses the most common cause of death among patients with leukemia?
A) Monitoring for infection
25. An oncology nurse recognizes a patients risk for fluid imbalance while the patient is undergoing treatment for leukemia. What relevant assessments should the nurse include in the patients plan of care? Select all that apply.
A) Monitoring the patients electrolyte levels C) Measuring the patients weight on a daily basis D) Measuring and recording the patients intake and output E) Auscultating the patients lungs frequently
19. The nurse is reviewing the physicians notes from the patient who has just left the clinic. The nurse learns that the physician suspects a malignant breast tumor. On palpation, the mass most likely had what characteristic?
A) Nontenderness
35. A patient has had a total mastectomy with immediate reconstruction. The patient asks the nurse when she can take a shower. What should the nurse respond?
A) Not until the drain is removed
22. A nurse is providing care for a patient who has a diagnosis of irritable bowel syndrome (IBS). When planning this patients care, the nurse should collaborate with the patient and prioritize what goal?
A) Patient will accurately identify foods that trigger symptoms.
39. A nurse is caring for a patient in the late stages of esophageal cancer. The nurse should plan to prevent or address what characteristics of this stage of the disease? Select all that apply.
A) Perforation into the mediastinum C) Erosion into the great vessels E) Obstruction of the esophagus
15. A patient with a liver mass is undergoing a percutaneous liver biopsy. What action should the nurse perform when assisting with this procedure?
A) Position the patient on the right side with a pillow under the costal margin after the procedure.
30. A public health nurse is participating in a campaign aimed at preventing cervical cancer. What strategies should the nurse include is this campaign? Select all that apply.
A) Promotion of HPV immunization B) Encouraging young women to delay first intercourse C) Smoking cessation E) Using safer sex practices
29. The nurse is caring for a patient who has just been told that her ovarian cancer is terminal and that no curative options remain. What would be the priority nursing care for this patient at this time?
A) Provide emotional support to the patient and her family.
19. A patients most recent blood work reveals low levels of albumin. This assessment finding should suggest the possibility of what nursing diagnosis?
A) Risk for imbalanced fluid volume related to low albumin
38. A teenage patient with a pilonidal cyst has been brought for care by her mother. The nurse who is contributing to the patients care knows that treatment will be chosen based on what risk?
A) Risk for infection
34. A patient is receiving a blood transfusion and complains of a new onset of slight dyspnea. The nurses rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurses most appropriate action?
A) Slow the infusion rate and monitor the patient closely.
15. An older adult client is exhibiting many of the characteristic signs and symptoms of iron deficiency. In addition to a complete blood count, what diagnostic assessment should the nurse anticipate?
A) Stool for occult blood
1. An oncology nurse is providing health education for a patient who has recently been diagnosed with leukemia. What should the nurse explain about commonalities between all of the different subtypes of leukemia?
A) The different leukemias all involve unregulated proliferation of white blood cells.
20. A 60-year-old patient with chronic myeloid leukemia will be treated in the home setting and the nurse is preparing appropriate health education. What topic should the nurse emphasize?
A) The importance of adhering to the prescribed drug regimen
22. A patient has been found to have an indolent neoplasm. The nurse should recognize what implication of this condition?
A) The patient faces a significant risk of malignancy.
26. The nurses brief review of a patients electronic health record indicates that the patient regularly undergoes therapeutic phlebotomy. Which of the following rationales for this procedure is most plausible?
A) The patient may chronically produce excess red blood cells.
17. A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patients current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?
A) Two to 3 soft bowel movements daily
4. The nurse is coaching a community group for individuals who are overweight. Which participant behavior is an example of the best exercise plan for weight loss?
A) Walking for 40 minutes 6 or 7 days/week
2. A nurse is preparing to provide care for a patient whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the patients stools will have what characteristics?
A) Watery with blood and mucus
15. A 40-year-old obese woman reports that she wants to lose weight. Which question should the nurse ask first?
A) What factors led to your obesity?
The nurse is describing the role of plasminogen in the clotting cascade. Where in the body is plasminogen present?
All body fluids
2. After the nurse teaches a patient about the recommended amounts of foods from animal and plant sources, which menu selections indicate that the initial instructions about diet have been understood?
B) 3 oz of roasted pork, a cup of corn, and a cup of carrot sticks
11. A 42 year-old patient tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. She says that she is afraid that she has cancer. Which assessment finding would most strongly suggest that this patients lump is cancerous?
B) A nonmobile mass with irregular edges
10. A nursing instructor is discussing hemorrhoids with the nursing class. Which patients would the nursing instructor identify as most likely to develop hemorrhoids?
B) A pregnant woman at 28 weeks gestation
27. A nurse has participated in organizing a blood donation drive at a local community center. Which of the following individuals would most likely be disallowed from donating blood?
B) A woman whose blood pressure is 88/51 mm Hg
13. A patient has been diagnosed with advanced stage breast cancer and will soon begin aggressive treatment. What assessment findings would most strongly suggest that the patient may have developed liver metastases?
B) Abdominal pain and hepatomegaly
24. A patient has been diagnosed with endometriosis. When planning this patients care, the nurse should prioritize what nursing diagnosis?
B) Acute pain related to misplaced endometrial tissue
28. A patient at high risk for breast cancer is scheduled for an incisional biopsy in the outpatient surgery department. When the nurse is providing preoperative education, the patient asks why an incisional biopsy is being done instead of just removing the mass. What would be the nurses best response?
B) An incisional biopsy is performed to confirm a diagnosis and so that special studies can be done that will help determine the best treatment.
14. A patient has had a laparoscopic cholecystectomy. The patient is now complaining of right shoulder pain.
B) Application of heat 15 to 20 minutes each hour
3. A patient has had an ileostomy created for the treatment of irritable bowel disease and the patient is now preparing for discharge. What should the patient be taught about changing this device in the home setting?
B) Apply a skin barrier to the peristomal skin prior to applying the pouch.
33. A patient is post-operative day 1 following a vaginal hysterectomy. The nurse notes an increase in the patients abdominal girth and the patient complains of bloating. What is the nurses most appropriate action?
B) Apply warm compresses to the patients lower abdomen.
3. Which nursing action is appropriate when coaching obese adults enrolled in a behavior modification program?
B) Asking the adults about situations that tend to increase appetite
12. An older adult who resides in an assisted living facility has sought care from the nurse because of recurrent episodes of constipation. Which of the following actions should the nurse first perform?
B) Assess the patients food and fluid intake.
24. A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this patients plan of care?
B) Assessment for variceal bleeding
24. A patient who is undergoing consolidation therapy for the treatment of leukemia has been experiencing debilitating fatigue. How can the nurse best meet this patients needs for physical activity?
B) Assist the patient to a chair during awake times, as tolerated.
15. A nurse is caring for a patient with constipation whose primary care provider has recommended senna (Senokot) for the management of this condition. The nurse should provide which of the following education points?
B) Avoid taking the drug on a long-term basis.
22. A client is awaiting bariatric surgery in the morning. What action by the nurse is most important?
B) Beginning venous thromboembolism prophylaxis
22. The nurse is caring for a patient who has just returned from the ERCP removal of gallstones. The nurse should monitor the patient for signs of what complications?
B) Bleeding and perforation
35. A patient with cirrhosis has experienced a progressive decline in his health; and liver transplantation is being considered by the interdisciplinary team. How will the patients prioritization for receiving a donor liver be determined?
B) By objectively determining the patients medical need
8. Which assessment action will help the nurse determine if an obese patient has metabolic syndrome?
B) Check the patients blood pressure.
19. A nurse is caring for a patient who has been diagnosed with leukemia. The nurses most recent assessment reveals the presence of ecchymoseson the patients sacral area and petechiae in her forearms. In addition to informing the patients primary care provider, the nurse should perform what action?
B) Check the patients most recent platelet level.
39. A patient has a diagnosis of multiple myeloma and the nurse is preparing health education in preparation for discharge from the hospital. What action should the nurse promote?
B) Close monitoring of urine output and kidney function
4. A patient admitted with acute diverticulitis has experienced a sudden increase in temperature and complains of a sudden onset of exquisite abdominal tenderness. The nurses rapid assessment reveals that the patients abdomen is uncharacteristically rigid on palpation. What is the nurses best response?
B) Contact the primary care provider promptly and report these signs of perforation.
34. A 31-year-old patient has returned to the post-surgical unit following a hysterectomy. The patients care plan addresses the risk of hemorrhage. How should the nurse best monitor the patients postoperative blood loss?
B) Count and inspect each perineal pad that the patient uses.
30. A patient on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurses most appropriate action?
B) Discontinue the remainder of the PRBC transfusion and inform the physician.
36. A patient is receiving the first of two ordered units of PRBCs. Shortly after the initiation of the transfusion, the patient complains of chills and experiences a sharp increase in temperature. What is the nurses priority action?
B) Discontinue the transfusion.
28. A nurse is providing care for a patient whose recent colostomy has contributed to a nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention best addresses this diagnosis?
B) Engage the patient in the care of the ostomy to the extent that the patient is willing.
16. The nurse is caring for a patient who is undergoing diagnostic testing for suspected malabsorption. When taking this patients health history and performing the physical assessment, the nurse should recognize what finding as most consistent with this diagnosis?
B) Foul-smelling diarrhea that contains fat
37. A patient with a diagnosis of colon cancer is 2 days postoperative following bowel resection and anastomosis. The nurse has planned the patients care in the knowledge of potential complications. What assessment should the nurse prioritize?
B) Frequent abdominal auscultation
40. A patients electronic health record states that the patient receives regular transfusions of factor IX. The nurse would be justified in suspecting that this patient has what diagnosis?
B) Hemophilia
5. When teaching patients about the risk factors of cervical cancer, what would the nurse identify as the most important risk factor?
B) Human papillomavirus (HPV)
12. A patient with ovarian cancer is admitted to the hospital for surgery and the nurse is completing the patients health history. What clinical manifestation would the nurse expect to assess?
B) Increased abdominal girth
25. An adult patient has been diagnosed with diverticular disease after ongoing challenges with constipation. The patient will be treated on an outpatient basis. What components of treatment should the nurse anticipate? Select all that apply.
B) Increased fiber intake D) Reduced fat intake
27. During a patients scheduled home visit, an older adult patient has stated to the community health nurse that she has been experiencing hemorrhoids of increasing severity in recent months. The nurse should recommend which of the following?
B) Increased fluid and fiber intake
21. An older adult patient is undergoing diagnostic testing for chronic lymphocytic leukemia (CLL). What assessment finding is certain to be present if the patient has CLL?
B) Increased lymphocyte levels
16. A nurse practitioner is assessing a patient who has a fever, malaise, and a white blood cell count that is elevated. Which of the following principles should guide the nurses management of the patients care?
B) Infection is the most likely cause of the patients change in health status.
17. Which information will the nurse prioritize in planning preoperative teaching for a patient undergoing a Roux-en-Y gastric bypass?
B) Instructing the patient on coughing and breathing techniques
11. Which adult will the nurse plan to teach about risks associated with obesity?
B) Man with a 42 in waist and 44 in hips
21. The nurse is providing care for an older adult who has a hematologic disorder. What age-related change in hematologic function should the nurse integrate into care planning?
B) Older adults are less able to increase blood cell production when demand suddenly increases.
1. A 45-year-old woman comes into the health clinic for her annual check-up. She mentions to the nurse that she has noticed dimpling of the right breast that has occurred in a few months. What assessment would be most appropriate for the nurse to make?
B) Palpate the area for a breast mass.
20. An individual has accidentally cut his hand, immediately initiating the process of hemostasis. Following vasoconstriction, what event in the process of hemostasis will take place?
B) Platelets will aggregate at the injury site.
7. The nurses comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages?
B) Presence of a painless sore with raised edges
11. A patient undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions?
B) Prevention of viral infections from another persons blood
15. An adult patient has presented to the health clinic with a complaint of a firm, painless cervical lymph node. The patient denies any recent infectious diseases. What is the nurses most appropriate response to the patients complaint?
B) Promptly refer the patient for medical assessment.
32. A 52-year-old woman has just been told she has breast cancer and is scheduled for a modified mastectomy the following week. The nurse caring for this patient knows that she is anxious and fearful about the upcoming procedure and the newly diagnosed malignancy. How can the nurse most likely alleviate this patients fears?
B) Provide the patient with relevant information about expected recovery.
20. A nurse caring for a patient with a newly created ileostomy assesses the patient and notes that the patient has had not ostomy output for the past 12 hours. The patient also complains of worsening nausea. What is the nurses priority action?
B) Report signs and symptoms of obstruction to the physician.
32. A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurses most recent assessment reveals subtle changes in the patients cognition and behavior. What is the nurses most appropriate response?
B) Report this finding to the primary care provider due to the possibility of hepatic encephalopathy.
13. A 16-year-old presents at the emergency department complaining of right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this patients nursing care, the nurse should prioritize what nursing diagnosis?
B) Risk for Infection Related to Possible Rupture of Appendix
The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take?
B) Stop the transfusion immediately.
35. A patient is admitted to the unit with acute cholecystitis. The physician has noted that surgery will be scheduled in 4 days. The patient asks why the surgery is being put off for a week when he has a sick gallbladder. What rationale would underlie the nurses response?
B) Surgery is delayed until the acute symptoms subside.
18. After bariatric surgery, a patient who is being discharged tells the nurse, I prefer to be independent. I am not interested in any support groups. Which response by the nurse is best?
B) Tell me what types of resources you think you might use after this surgery.
39. A nurse at an outpatient surgery center is caring for a patient who had a hemorrhoidectomy. What discharge education topics should the nurse address with this patient?
B) The correct procedure for taking a sitz bath
32. A patient is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this patients adverse reaction?
B) The donor blood was incompatible with that of the patient.
25. A patient is scheduled for a splenectomy. During discharge education, what teaching point should the nurse prioritize?
B) The need to report any signs or symptoms of infection promptly
17. The nurse is performing a comprehensive health history of a patient who is in her 50s. The nurse should identify what risk factor that may increase this patients risk for breast cancer?
B) The patient gave birth to her first child at age 38.
16. A patient is being treated for the effects of a longstanding vitamin B12 deficiency. What aspect of the patients health history would most likely predispose her to this deficiency?
B) The patient is a vegan.
34. A patient has recently received a diagnosis of gastric cancer; the nurse is aware of the importance of assessing the patients level of anxiety. Which of the following actions is most likely to accomplish this?
B) The patient is encouraged to express fears openly.
14. Which finding for a patient who has been taking orlistat (Xenical) is most important to report to the health care provider?
B) The patient is pale and has many bruises.
10. A nurse is caring for a patient who has been scheduled for endoscopic retrograde cholangiopancreatography (ERCP) the following day. When providing anticipatory guidance for this patient, the nurse should describe what aspect of this diagnostic procedure?
B) The use of moderate sedation
18. A nurse caring for a patient with colorectal cancer is preparing the patient for upcoming surgery. The nurse administers cephalexin (Keflex) to the patient and explains what rationale?
B) To reduce intestinal bacteria levels
6. A patient admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely the best choice for this patient?
B) Tofu
31. A patients colorectal cancer has necessitated a hemicolectomy with the creation of a colostomy. In the 4 days since the surgery, the patient has been unwilling to look at the ostomy or participate in any aspects of ostomy care. What is the nurses most appropriate response to this observation?
C) Acknowledge the patients reluctance and initiate discussion of the factors underlying it.
3. A woman aged 48 years comes to the clinic because she has discovered a lump in her breast. After diagnostic testing, the woman receives a diagnosis of breast cancer. The woman asks the nurse when her teenage daughters should begin mammography. What is the nurses best advice?
C) Age 38
26. A patients health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohns disease, rather that ulcerative colitis, as the cause of the patients signs and symptoms?
C) An absence of blood in stool
5. A patient with advanced leukemia is responding poorly to treatment. The nurse finds the patient tearful and trying to express his feelings, but he is clearly having difficulty. What is the nurses most appropriate action?
C) Ask if he would like you to sit with him while he collects his thoughts.
26. After receiving a diagnosis of acute lymphocytic leukemia, a patient is visibly distraught, stating, I have no idea where to go from here. How should the nurse prepare to meet this patients psychosocial needs?
C) Assess the patients specific needs for education and support.
29. A patients low hemoglobin level has necessitated transfusion of PRBCs. Prior to administration, what action should the nurse perform?
C) Assess the patients vital signs to establish baselines.
