WK 5 Principles MED SURG II

Question: The nurse determines the client has extravasation of a chemotherapeutic agent. Which of the following nursing interventions would follow. Select all that apply. Your Answer: Apply direct pressure to the site. Perform a neurovascular assessment to the affected extremity. Correct Answer: Administer the prescribed antidote. Perform a neurovascular assessment to the affected extremity. Aspirate for residual medication from site. Principle: Following an extravasation, neurovascular assessments of the affected extremity should be performed ; Page# Following an extravasation, neurovascular assessments of the affected extremity should be performed ; Page#

Question: A client returns from abdominal surgery with a patient-controlled anesthesia (PCA) pump. The client's spouse questions the need for so much medication. Which of the following is the nurse's best response? Your Answer: 'The PCA pump will help relieve pain so ambulation and cough and deep breathing exercises are tolerated.' Principle: Provide patient controlled analgesia to help reduce complicatons related to pain ; Page# Provide patient controlled analgesia to help reduce complicatons related to

Question: The nurse understands that a client receiving chemotherapy could develop hemorrhagic cystitis. To prevent this complication the nurse prepares to administer which of the following? Your Answer: Antibiotics. Correct Answer: Intravenous hydration. Principle: Some chemotherapy agents could induce hemorrhagic cystitis which could lead to a life-threatening hemorrhage so protect the bladder with intravenous hydration and diuresis ; Page# Some chemotherapy agents could induce hemorrhagic cystitis which could lead to a life-threatening hemorrhage so protect the bladder with intravenous hydration and diuresis ; Page#

Question: A client who had a stem cell transplant 4 weeks ago, now presents with fever of 100.4 degrees Fahrenheit, severe abdominal cramping and diarrhea, and an itchy, red skin rash. The nurse is aware that the probable reason for the client's symptoms is which of the following? Your Answer: Acute graft versus host disease. Principle: Graft versus host disease could present as a blistering skin rash, diffuse inflammation to the gastrointestinal tract with massive diarrhea, or hepatomegaly ; Page# Graft versus host disease could present as a blistering skin rash, diffuse inflammation to the gastrointestinal tract with massive diarrhea, or hepatomegaly ; Page#

Question: When caring for a client with human immunodeficiency virus (HIV), the nurse recognizes which of the following factors may contribute to the client's increased risk for opportunistic infections? Your Answer: Having a protein deficiency. Decreased creatinine level. Correct Answer: Having a protein deficiency. Principle: Protein deficiency increases the risk of infection ; Page# Protein deficiency increases the risk of infection ; Page#

Question: A client with human immunodeficiency virus (HIV) has developed Kaposi sarcoma. The nurse recognizes this complication is increased due to which causative factor? Your Answer: Weakened immune system. Principle: Cancer develops when the immune system fails to recognize and destroy abnormal cells ; Page# Cancer develops when the immune system fails to recognize and destroy abnormal cells ; Page#

Question: During morning rounds the nurse notes that a client is scheduled for a CT scan of the head with contrast. The client is scheduled to receive metformin (Glucophage). Which of the following interventions is the most appropriate? Your Answer: Speak to the prescriber prior to administering the medication. Principle: Metformin should be stopped 48 hours before and after the administration of iodinated contrast medium ; Page# Metformin should be stopped 48 hours before and after the administration of iodinated contrast medium ; Page#

Question: After receiving a report that a tumor biopsy is benign, a client demonstrates understanding by making which of the following statements to the nurse? Your Answer: 'I'm glad the tumor had normal cells.' Correct Answer: 'The tumor did not spread to other parts of my body.' Principle: Malignant neoplasms invade other areas (metastasis) and branch off while benign tumors do not metastasize ; Page# Malignant neoplasms invade other areas (metastasis) and branch off while benign tumors do not metastasize ; Page#

Question: The nurse administers subcutaneous filgrastim (Neupogen) to a client. Which laboratory value does the nurse monitor to evaluate this drug's effectiveness? Your Answer: Leukocyte count. Principle: Colony-stimulating factors stimulate red blood cell production decreasing the need for blood transfusions (erythropoietin) or stimulate neutrophil production to decrease the risk for infection (neupogen). ; Page# Colony-stimulating factors stimulate red blood cell production decreasing the need for blood transfusions (erythropoietin) or stimulate neutrophil production to decrease the risk for infection (neupogen). ; Page#

Question: The nurse administers methotrexate to a client with rheumatoid arthritis (RA). Which other medication does the nurse expect to be part of this client's treatment? Your Answer: Sulfonamides. Correct Answer: Folic acid supplements. Principle: Methotrexate contributes to folic acid deficiency and results in cell death (is typically prescribed with folic acid) ; Page# Methotrexate contributes to folic acid deficiency and results in cell death (is typically prescribed with folic acid) ; Page#

Question: During administration of an intravenous antibiotic to a client, the nurse observes signs of a Type I hypersensitivity reaction. What action does the nurse take next? Your Answer: Stop the intravenous antibiotic infusion. Principle: Monitor for hypersensitivity reactions which could be acute (withing 15-30 minutes) or delayed (several courses after the medication) and stop the medication immediately ; Page# Monitor for hypersensitivity reactions which could be acute (withing 15-30 minutes) or delayed (several courses after the medication) and stop the medication immediately ; Page#

Question: The nurse demonstrates knowledge of primary prevention measures when educating clients on which of the following teaching points? Select all that apply. Your Answer: Apply sunscreen protection (SPF) that provides an SPF 15 or higher. Use latex condoms correctly and consistently. Principle: Educate on avoiding carcinogens (smoking), limiting alcohol and caloric intake and increasing activity level, using sunscreen with a minimum SPF of 15, limiting sun exposure and using condoms ; Page# Educate on avoiding carcinogens (smoking), limiting alcohol and caloric intake and increasing activity level, using sunscreen with a minimum SPF of 15, limiting sun exposure and using condoms ; Page#

Question: The client is receiving intracavitary radiation. Which of the following nursing interventions will help prevent dislodgement of the implant? Select all that apply. Your Answer: Provide high fiber diet. Insert foley catheter. Position client by using log-roll technique. Correct Answer: Insert foley catheter. Position client by using log-roll technique. Principle: Prevent dislodgement of intracavitary low dose radiation by maintaining the client on bedrest, in a private room, provide low-residue foods, give antidiarrheal agents to prevent bowel movements, log-roll to prevent dislodgement of device, and insert a foley. ; Page# Prevent dislodgement of intracavitary low dose radiation by maintaining the client on bedrest, in a private room, provide low-residue foods, give antidiarrheal agents to prevent bowel movements, log-roll to prevent dislodgement of device, and insert a foley. ; Page#

Question: The nurse is caring for a client receiving brachytherapy for prostate cancer. Which of the following safety precautions should the nurse follow? Select all that apply. Your Answer: Minimize time in client's room when providing care. Utilize radiation dosimeter when in client's room. Keep children 6 feet away from the radiation source. Correct Answer: Minimize time in client's room when providing care. Utilize radiation dosimeter when in client's room. Principle: Radiation safety precautions (brachytherapy) include limiting time with client, wearing dosimeter badges, keeping pregnant staff or visitors and children out of room, limiting visits to 30 minutes and keeping 6 feet away from the radiation source ; Page# Radiation safety precautions (brachytherapy) include limiting time with client, wearing dosimeter badges, keeping pregnant staff or visitors and children out of room, limiting visits to 30 minutes and keeping 6 feet away from the radiation source ; Page#

Question: The nurse is caring for a client with an urinary tract infection. Which of the following laboratory abnormalities would most likely be present on this client's complete blood count? Your Answer: Elevated neutrophils Principle: An increase in neutrophils indicates a bacterial infection while an increase in lymphoctyes indicate a viral infection (although lymphocytes are also elevated in some bacterial infections as well) ; Page# An increase in neutrophils indicates a bacterial infection while an increase in lymphoctyes indicate a viral infection (although lymphocytes are also elevated in some bacterial infections as well) ; Page#

Question: The nurse is caring for a client with AIDS and pneumocystic jiroveci pneumonia (PCP). Which of the following pathological processes best explains the occurrence of PCP? Your Answer: A decrease in the number of CD4 cells Principle: The reduction in T cells increases the risk for opportunistic infections ; Page# The reduction in T cells increases the risk for opportunistic infections ; Page#

Question: The nurse recommends which of the following screening tests for cancer when educating clients on the importance of early detection? Select all that apply. Your Answer: Colonoscopy every 10 years starting at age 50. Fecal occult blood test annually starting at age 50. Pap test every 5 years starting at age 40. Correct Answer: Colonoscopy every 10 years starting at age 50. Fecal occult blood test annually starting at age 50. Principle: Screen for cancer; annual mammogram starting at age 40, colonoscopy at age 50 every 10 years, annual fecal occult blood test at age 50, prostate specific antigen at age 50, pap test every 3 years ; Page# Screen for cancer; annual mammogram starting at age 40, colonoscopy at age 50 every 10 years, annual fecal occult blood test at age 50, prostate specific antigen at age 50, pap test every 3 years ; Page# © 2015 Jersey College. All rights reserved.

Question: The nurse is caring for a client with a fever, sore throat and swollen cervical lymph nodes. The complete blood count shows a normal neutrophil count and an elevated lymphocyte count. Which of the following microorganisms is the most likely etiology for the client's symptoms? Your Answer: Virus Principle: An increase in neutrophils indicates a bacterial infection while an increase in lymphoctyes indicate a viral infection (although lymphocytes are also elevated in some bacterial infections as well) ; Page# An increase in neutrophils indicates a bacterial infection while an increase in lymphoctyes indicate a viral infection (although lymphocytes are also elevated in some bacterial infections as well) ; Page# © 2015 Jersey College. All rights reserved.

Question: The nurse receives report on a 72 year old client who fractured their left tibia two days ago. What nursing intervention is a priority? Your Answer: Encourage cough and deep breathing exercises. Principle: Reduce the risk for infection with elderly; drink plenty of fluids unless contraindicated, use lotion, assessing for signs of skin breakdown, change incontinence pads frequently, void after intercourse, pneumococcal and influenza vaccine, cough and deep breathing exercies, sit up while eating ; Page#

Question: The nurse is caring for a client with a urinary tract infection and is receiving sulfamethoxazole trimethroprim. The final culture report shows that the bacteria is resistant to the medication sulfamethoxazole trimethroprim (bactrim). Which of the following interventions should the nurse perform next? Your Answer: Notify the physician of the drug resistance Principle: Notify the provider if a culture and sensitivity reveals that the organism is resistant to the prescribed antibiotic ; Page# Notify the provider if a culture and sensitivity reveals that the organism is resistant to the prescribed antibiotic ; Page#

Question: Which of the following clients has clinical manifestations that suggest an impaired immune system? Your Answer: A client with a history of recurrent pneumonia Principle: Immunodeficiency is marked by frequent infections that could be severe, infection from organisms that do not typically cause a problem, poor treatment response and chronic diarrhea ; Page# Immunodeficiency is marked by frequent infections that could be severe, infection from organisms that do not typically cause a problem, poor treatment response and chronic diarrhea ; Page#

Question: The nurse is caring for a client with colon cancer and receives an order to draw a CEA. Which of the following is the most likely reason the physician ordered the test? Your Answer: It will help to evaluate treatment response Principle: Tumor markers (for example, CEA, CA 125) are monitored to help determine the effectiveness of chemotherapy ; Page# Tumor markers (for example, CEA, CA 125) are monitored to help determine the effectiveness of chemotherapy ; Page#

Question: The nurse is preparing to discharge a client receiving corticosteroid therapy. Which of the instructions should be included in the discharge teaching? Your Answer: Instructions on how to minimize infection Principle: Instruct on factors that increase the risk for infection; excess alcohol consumption, poor nutrition, smoking, glucocorticosteroids, and diabetes mellitus ; Page# Instruct on factors that increase the risk for infection; excess alcohol consumption, poor nutrition, smoking, glucocorticosteroids, and diabetes mellitus ; Page

Question: The nurse is preparing to receive a client from surgery after having a radioactive device implanted. What equipment must be kept at the bedside? Your Answer: A lead container Principle: Keep a lead container in the room in case a radioactive device dislodges ; Page# Keep a lead container in the room in case a radioactive device dislodges ; Page#

Question: Which of the following clinical signs would cause the nurse to suspect thrombocytopenia in a client undergoing chemotherapy treatment? Select all that apply. Your Answer: Scattered ecchymosis. Neutropenia. Petechiae. Correct Answer: Scattered ecchymosis. Petechiae. Principle: Common signs of thrombocytopenia include petechiae and ecchymosis ; Page# Common signs of thrombocytopenia include petechiae and ecchymosis ; Page# © 2015 Jersey College. All rights reserved.

Question: The nurse is providing discharge instructions to a client who has a peripherally inserted central catheter (PICC) line for chemotherapy. Which of the following reportable signs of infection does the nurse review with the client prior to discharge? Select all that apply. Your Answer: Drainage or leakage around insertion site. Chills and night sweats. Tenderness or discomfort around insertion site. Principle: Redness, swelling, tenderness, purulent drainage, fever and chills, and an elevated white blood cell count are classic signs of infection. ; Page# Redness, swelling, tenderness, purulent drainage, fever and chills, and an elevated white blood cell count are classic signs of infection. ; Page#

Question: When administering chemotherapy medications to a client, the nurse understands the need to instruct the client that there is an increased risk for which of the following? Your Answer: Opportunistic infections. Principle: Mylosuppression, induced by chemotherapy, results in pancytopenia and increases the risk for infection, bleeding and fatigue ; Page# Mylosuppression, induced by chemotherapy, results in pancytopenia and increases the risk for infection, bleeding and fatigue ; Page#

Question: The nurse would expect to observe which of the following laboratory findings in a client with symptomatic human immunodeficiency virus (HIV) infection? Your Answer: Decreased production of T-helper cells. Principle: CD4 cells (helper T cells) stimulate the immune system and help to destroy organisms ; Page# CD4 cells (helper T cells) stimulate the immune system and help to destroy organisms ; Page

Question: The laboratory calls the nurse to report an older adult male client's white blood cell count is 900/mm3. Which of the following teaching points is most important for the nurse to tell this client? Select all that apply. Your Answer: Use an electric razor for shaving. Avoid large crowds in public places. Principle: Reduce the risk for infection by implementing neutropenic precautions (WBC less than 1,000/mm3), avoiding rectal or vaginal procedures, using electric razors, avoid using stagnant water, and reduce exposure to sources of infection ; Page# Reduce the risk for infection by implementing neutropenic precautions (WBC less than 1,000/mm3), avoiding rectal or vaginal procedures, using electric razors, avoid using stagnant water, and reduce exposure to sources of infection ; Page# © 2015 Jersey College. All rights reserved.

Question: When administering an intravenous (IV) chemotherapeutic agent to a client through a peripheral site, which of the following signs indicate possible extravasation to the nurse? Select all that apply. Your Answer: Burning discomfort at the site. Resistance is met while flushing the IV catheter. Sudden temperature elevation. Correct Answer: Burning discomfort at the site. Resistance is met while flushing the IV catheter. Principle: Suspect an increase risk for extravasation if resisitance is met while flusing intravenous catheter, blood return is absent or there is burning pain or swelling to the site ; Page# Suspect an increase risk for extravasation if resisitance is met while flusing intravenous catheter, blood return is absent or there is burning pain or swelling to the site ; Page# © 2015 Jersey College. All rights reserved.

Question: When caring for a client with stomatitis, which of the following interventions does the nurse recommend to the client? Your Answer: Rinse mouth thoroughly after eating spicy foods. Correct Answer: Remove dentures except when eating. Principle: Advise client with stomatitis to avoid mouthwashes that contain alcohol or tobacco because they dry the mucosa, use a soft toothbrush, avoid rough, hot or spicy foods, and remove dentures unless eating ; Page# Advise client with stomatitis to avoid mouthwashes that contain alcohol or tobacco because they dry the mucosa, use a soft toothbrush, avoid rough, hot or spicy foods, and remove dentures unless eating ; Page#

Question: When caring for a client receiving radiation therapy for breast cancer, the nurse observes signs of moist desquamation in the skin folds near the radiation site. The nurse expects which of the following treatments in the care of this client's skin. Your Answer: Cleanse area frequently with sterile saline and leave site open to air. Correct Answer: Application of prescribed ointment and cover with non-adhesive pad. Principle: Treat wet desquamation by leaving blisters intact and notifying primary care provider, avoid frequent washing of area because of increased irritation, obtain an order for a cream or ointment and use a nonadhesive pad over the area ; Page# Treat wet desquamation by leaving blisters intact and notifying primary care provider, avoid frequent washing of area because of increased irritation, obtain an order for a cream or ointment and use a nonadhesive pad over the area ; Page# © 2015 Jersey College. All rights reserved.

Question: When administering chemotherapy agents to a client, the nurse is on alert for which of the following signs of extravasation? Your Answer: Red rash on face and chest. Correct Answer: Pain at infusion site. Principle: Extravasation of a vesicant could result in tissue necrosis so never use the hand or wrist and prevent extravasation by confirming patency of intravenous device ; Page# Extravasation of a vesicant could result in tissue necrosis so never use the hand or wrist and prevent extravasation by confirming patency of intravenous device ; Page#

Question: When caring for a client who underwent bone marrow transplantation, the nurse knows that the client is at risk for which early major complication? Select all that apply. Your Answer: Sepsis. Hypertension. Respiratory Arrest. Correct Answer: Sepsis. Hemorrhage. Principle: Sepsis and bleeding are major complications following bone marrow transplantation until new marrrow engraftment occurs ; Page# Sepsis and bleeding are major complications following bone marrow transplantation until new marrrow engraftment occurs ; Page#

Question: A client receiving chemotherapeutic agents has a decreased appetite and complains of being bothered by the smell of foods. Which of the following nursing interventions will help improve the client's oral intake? Select all that apply. Your Answer: Provide small, frequent meals. Assure proper pain management. Assist with oral hygiene. Increase client's activity level before eating. Correct Answer: Provide small, frequent meals. Assure proper pain management. Assist with oral hygiene. Principle: Improve oral intake in the setting of nausea by serving cold foods since they are less odorous, encourage oral hygiene, provide small frequent meals, and make sure pain is managed ; Page# Improve oral intake in the setting of nausea by serving cold foods since they are less odorous, encourage oral hygiene, provide small frequent meals, and make sure pain is managed ; Page#

Question: When creating a plan of care for a client who has tumor lysis syndrome, the nurse focuses on which of the following goals? Your Answer: Preventing hypokalemia Preventing hypophosphatemia Correct Answer: Preventing renal failure Principle: Preventing renal failure and achieving electrolyte balance is a priority in the setting of tumor lysis syndrome ; Page# Preventing renal failure and achieving electrolyte balance is a priority in the setting of tumor lysis syndrome ; Page#

Question: The nurse demonstrates knowledge of nonpharmacological pain management strategies when assisting the client with which of the following? Select all that apply. Your Answer: Positioning. Therapeutic touch. Guided imagery. Principle: Provide non-pharmacological pain management strategies such as physical modalities, mind-body methods, biologic and energy based therapies ; Page# Provide non-pharmacological pain management strategies such as physical modalities, mind-body methods, biologic and energy based therapies ; Page#

Question: When performing a comprehensive pain assessment, the nurse asks which of the following questions to determine the client's subjective perception of pain? Your Answer: 'How would you describe the pain?' Principle: A comprehensive pain assessment includes duration (includes when it started), type (incudes intensity, associated factors, influencing factors (what makes it better or worse), location ; Page# A comprehensive pain assessment includes duration (includes when it started), type (incudes intensity, associated factors, influencing factors (what makes it better or worse), location ; Page#

Question: The nurse has just completed the administration of the client's first round of chemotherapy for treatment of Burkitt lymphoma. The nurse closely monitors for which clinical indicators of tumor lysis syndrome? Select all that apply. Your Answer: Hypokalemia. Bradycardia. Tented T waves. Correct Answer: Bradycardia. Hyperphosphatemia. Tented T waves. Principle: Clinical manifestations of tumor lysis syndrome include hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia; bradydysrhythmias, wide QRS complexes, tented T waves, tetany, seizures and flank pain ; Page# Clinical manifestations of tumor lysis syndrome include hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia; bradydysrhythmias, wide QRS complexes, tented T waves, tetany, seizures and flank pain ; Page#

Question: When providing discharge instructions to a client undergoing treatment for cancer, the nurse includes which of the following reportable symptoms of hypercalcemia? Select all that apply. Your Answer: abdominal cramping and diarrhea. Fatigue and weakness. Muscle twitching in hands and feet. Correct Answer: Increase in lethargy. Fatigue and weakness. Increased thirst and urination. Principle: Hypercalcemia is an oncologic emergency and is marked by a progressive change in level of consciousness, hyporeflexia, ileus, constipation, polyuria and polydipsia ; Page# Hypercalcemia is an oncologic emergency and is marked by a progressive change in level of consciousness, hyporeflexia, ileus, constipation, polyuria and polydipsia ; Page#

Question: A client's breast biopsy report shows a 7 centimeter (cm) tumor with lymph node involvement. The nurse understands this client's treatment will be mainly based on which of the following? Your Answer: Node involvement Principle: Staging of a tumor is done to communicate the size of the tumor, if lymph nodes are involved, and if there is metastasis ; Page# Staging of a tumor is done to communicate the size of the tumor, if lymph nodes are involved, and if there is metastasis ; Page#

Question: When providing self-care instructions to a client with human immunodeficiency virus (HIV), the nurse includes which of the following symptoms that should be reported promptly to the health care provider. Your Answer: Temperature of 100.4 F Principle: Being immunocompromised reduces the clinical manifestations of infection so a temp greater than 100.4 for an hour is significant and should be reported ; Page# Being immunocompromised reduces the clinical manifestations of infection so a temp greater than 100.4 for an hour is significant and should be reported ; Page#

Question: A client is admitted with thrombocytopenia. When obtaining vital signs, the unlicensed assistive person (UAP) obtains a rectal temperature. Which action would the nurse take next? Your Answer: Instruct the UAP not to do a rectal temperature. Record the vital signs in the medical record. Check the client's most recent platelet level. Correct Answer: Instruct the UAP not to do a rectal temperature. Principle: Avoid the rectal route for medication administration for patients who are thrombocytopenic ; Page# Avoid the rectal route for medication administration for patients who are thrombocytopenic ; Page#

Question: While caring for a client receiving chemotherapeutic agents, the nurse receives an order for odansetron (Zofran). The nurse understands the action of this medication is to do which of the following? Your Answer: Relieve nausea and vomiting. Principle: Seratonin receptor blockers (ondansetron, granisetron), dopaminergic receptor blockers (metoclopramide, prochlorperazine), bland foods, and small, frequent meals are used to decrease nausea and vomiting ; Page# Seratonin receptor blockers (ondansetron, granisetron), dopaminergic receptor blockers (metoclopramide, prochlorperazine), bland foods, and small, frequent meals are used to decrease nausea and vomiting ; Page#