Health restoration 2 Nu214 final exam review
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. Encourage alternating rest and activity.
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. Hematuria
The nurse recording health histories in the outpatient clinic would plan a focused hearing assessment for adult patients taking which medication? A. Atenolol B. Albuterol C. Ibuprofen D. Acetaminophen
C. Ibuprofen
Which equipment does the nurse need to perform a Rinne test? A. Otoscope B. Tuning fork C. Audiometer D. Ticking watch
B. Tuning fork
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. Monitor fluid intake and output.
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. Tarry stools
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. Notify the health care provider.
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. Serum sodium of 126 mEq/L
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. Discuss risks associated with cigarettes during each patient encounter.
The charge nurse is observing a new nurse who is caring for a patient with vestibular disease. For what action by the nurse should the charge nurse intervene immediately? A. Facing the patient directly when speaking B. Speaking slowly and distinctly to the patient C. Administering both the Rinne and Weber tests D. Encouraging the patient to ambulate independently
D. Encouraging the patient to ambulate independently
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/μL 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. Hemoglobin (Hgb) of 8.6 g/dL (86 g/L)
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 patient with chronic heart failure
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. "The cancer involves only the cervix."
What is the priority problem for a patient experiencing an acute attack with Meniere's disease? A. Being at risk for falls B. Imbalanced nutritional intake C. Difficulty performing self-care D. Impaired verbal communication
A. Being at risk for falls
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. Cook food thoroughly before eating. C. Avoid public transportation such as buses. E. Talk to the oncologist before having any dental work.
A patient who has Ménière's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? A. Dim the lights in the patient's room. B. Encourage increased oral fluid intake. C. Change the patient's position every 2 hours. D. Keep the head of the bed elevated 45 degrees.
A. Dim the lights in the patient's room.
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. IL-2 enhances the body's immunologic response to tumor cells.
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. Omelet and whole wheat toast
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. Pap testing C. Sunscreen use D. Mammography E. Colorectal screening
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/μL. B. Blood pressure is 94/56 mm Hg. C. Petechiae are present on the chest. D. Blood is oozing from the venipuncture site.
A. Platelet count is 42,000/μL.
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. Shortness of breath
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. Suggest use of a daily planner and encourage adequate sleep.
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. Test all stools for occult blood.
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. The UAP assists the patient to use dental floss after eating.
The nurse is assessing a patient who was recently treated with amoxicillin for acute otitis media of the right ear. Which finding is a priority to report to the health care provider? A. The patient has a temperature of 100.6° F. B. The patient report frequent "popping" in the ear. C. Clear fluid is visible through the tympanic membrane. D. The patient frequently asks the nurse to repeat information.
A. The patient has a temperature of 100.6° F.
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. "I rarely have the energy to get out of bed."
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. "The side effects of chemotherapy are difficult, but AML often goes into remission with chemotherapy."
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. "Would you like to talk about options for the care of your children?"
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. Administer PRN acetaminophen (Tylenol).
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. Anxiety
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. Assess for sensation and strength in the legs.
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. Avoid exposure to crowds when possible.
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. Avoid intramuscular (IM) injections.
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. Baked chicken
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. Bilirubin level
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. Bleeding time
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. Blueberry yogurt
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. Bone marrow biopsy
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. Check temperature every 4 hours.
The nurse is observing a student who is preparing to perform an ear examination for a 30-year-old patient. Which action by the student indicates that the nurse should intervene? A. Pulls the auricle of the ear up and posterior. B. Chooses a speculum larger than the ear canal. C. Stabilizes the hand holding the otoscope on the patient's head. D. Stops inserting the otoscope after observing impacted cerumen.
B. Chooses a speculum larger than the ear canal.
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. Crackles at the lung bases
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. Decreasing the tumor size will improve the effects of other therapy.
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. Discontinue the heparin infusion.
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. Encourage the patient to purchase a wig or hat to wear when hair loss begins.
A patient with Hodgkin's lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." Which intervention should the nurse add to the plan of care? 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. Establish time to take a short walk almost every day.
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. Evaluating the effectiveness of opioid analgesics
A patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include when teaching the patient how to use the hearing aids? A. Keep the volume low on the hearing aids for the first week. B. Experiment with volume and hearing in a quiet environment. C. Add the second hearing aid after making adjustments to the first hearing aid. D. Begin wearing the hearing aids for an hour a day, gradually increasing the use.
B. Experiment with volume and hearing in a quiet environment.
Which action will the nurse take when performing ear irrigation for a patient with cerumen impaction? A. Assist the patient to a supine position for the irrigation. B. Fill the irrigation syringe with body-temperature solution. C. Use a sterile applicator to clean the ear canal before irrigating. D. Occlude the ear canal completely with the syringe while irrigating.
B. Fill the irrigation syringe with body-temperature solution.
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. Folic acid
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. Hospitalization is required for several weeks after the stem cell transplant.
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. Immobilize the knee joint.
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. Infection
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. Inquire whether there are questions or concerns about HSCT.
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. Obtain more information about the patient's relatives.
The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? 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. Monitor the patient for shortness of breath or chest pain during the transfusion
B. Obtain the patient's temperature and blood pressure before the transfusion.
Which information about a patient who had a stapedotomy yesterday is most important for the nurse to communicate to the health care provider? A. The patient reports ear "fullness." B. Oral temperature is 100.8° F (38.1° C). C. Small amount of dried drainage on dressing. D. The patient reports that hearing has gotten worse.
B. Oral temperature is 100.8° F (38.1° C).
When the patient turns his head quickly during the admission assessment, the nurse observes nystagmus. What is the indicated nursing action? A. Assess the patient with a Rinne test. B. Place a fall-risk bracelet on the patient. C. Ask the patient to watch the mouths of staff when they are speaking. D. Remind unlicensed assistive personnel to speak loudly to the patient.
B. Place a fall-risk bracelet on the patient
A patient reports dizziness when bending over and of nausea and dizziness associated with physical activities. What exam should the nurse expect to prepare the patient to undergo? A. Tympanometry B. Rotary chair testing C. Pure-tone audiometry D. Bone-conduction testing
B. Rotary chair testing
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. Stop the infusion if swelling is observed at the site.
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. Teach the patient to administer filgrastim (Neupogen) injections.
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. The UAP stands by the patient's bed for 30 minutes talking with the patient.
Which assessment finding should the nurse caring for a patient with thrombocytopenia communicate immediately to the health care provider? 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. The patient is difficult to arouse.
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 patient swims several days each week.
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 patient with neutropenia who has a temperature of 101.8° F.
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. The patient's visitors bring in fresh peaches.
A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient? 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. Transfuse leukocyte-reduced PRBCs.
Unlicensed assistive personnel (UAP) perform the following actions when caring for a patient with Ménière's disease who is experiencing an acute attack. Which action by UAP indicates that the nurse should intervene? A. UAP raises the side rails on the bed. B. UAP turns on the patient's television. C. UAP places an emesis basin at the bedside. D. UAP helps the patient turn to the right side.
B. UAP turns on the patient's television.
What should the nurse include when teaching a patient who has undergone a left tympanoplasty? A. "Remain on bed rest." B. "Keep your head elevated." C. "Avoid blowing your nose." D. "Irrigate your left ear canal."
C. "Avoid blowing your nose."
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. "Can you tell me what has been helpful when coping with past stressful events?"
When the nurse is taking a health history of a new patient at the ear clinic, the patient states, "I have to sleep with the television on." Which follow-up question is appropriate to obtain more information about possible hearing problems? A. "Do you grind your teeth at night?" B. "What time do you usually fall asleep?" C. "Have you noticed ringing in your ears?" D. "Are you ever dizzy when you are lying down?"
C. "Have you noticed ringing in your ears?"
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. "I could choose nasal spray rather than injections of vitamin B12."
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. "I should notify my health care provider if my stools turn black."
A patient diagnosed with external otitis is being discharged from the emergency department with an ear wick in place. Which statement by the patient indicates a need for further teaching? A. "I will apply the eardrops to the cotton wick in the ear canal." B. "I can use aspirin or acetaminophen (Tylenol) for pain relief." C. "I will clean the ear canal daily with a cotton-tipped applicator." D. "I can use warm compresses to the outside of the ear for comfort."
C. "I will clean the ear canal daily with a cotton-tipped applicator."
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. "I will need follow-up examinations for many years after treatment before I can be considered cured."
Which statement by the patient to the home health nurse indicates a need for further teaching about self-administering eardrops? A. "I will leave the ear wick in place while administering the drops." B. "I will hold the tip of the dropper above the ear to administer the drops." C. "I will refrigerate the medication until I am ready to administer the drops." D. "I should lie down before and for 5 minutes after administering the drops."
C. "I will refrigerate the medication until I am ready to administer the drops."
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. "Malignant tumors may spread to other tissues or organs."
The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement 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 biopsy will help decide the treatment for my enlarged prostate."
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. A 24-yr-old patient who received neck radiation and has blood oozing from the neck
Which assessment finding should the nurse report to the health care provider? A. Visible cone of light B. Dry skin in the ear canal C. A blue-tinged tympanum D. Cerumen in the auditory canal
C. A blue-tinged tympanum
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. Administer prescribed antiemetics 1 hour before the treatments.
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. Apply prescribed anesthetic gel to oral lesions before meals.
Which action should the nurse take when teaching a patient with mild presbycusis? A. Use patient education handouts rather than discussion. B. Use a high-pitched tone of voice to provide instructions. C. Ask for permission to turn off the television before teaching. D. Wait until family members have left before initiating teaching.
C. Ask for permission to turn off the television before teaching.
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. Avoid giving the patient foods that are strongly disliked.
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. Clean the perianal area carefully after every bowel movement.
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
C. Difficulty coping
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. Patient who is neutropenic and has a temperature of 100.5° F (38.1° C).
An older patient who is being admitted to the hospital repeatedly asks the nurse to "speak up so that I can hear you." Which action should the nurse take? A. Increase the speaking volume. B. Overenunciate while speaking. C. Speak normally but more slowly. D. Use more facial expressions when talking.
C. Speak normally but more slowly.
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. The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs.
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. "I can buy some aloe vera gel to use on my skin."
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. "Risk for a crisis is decreased by having an annual influenza vaccination."
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. Absolute neutrophil count
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. Activated partial thromboplastin time
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. Disconnect the transfusion and infuse normal saline.
To decrease the risk for future hearing loss, which action should the nurse implement with college students at the on-campus health clinic? A. Perform tympanometry. B. Schedule otoscopic examinations. C. Administer influenza immunizations. D. Discuss exposure to amplified music.
D. Discuss exposure to amplified music.
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. Increased carcinoembryonic antigen (CEA)
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. Monitor fluid intake and output.
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. Patient has crackles up to the midline posterior chest.
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. Rinse the mouth before and after each meal and at bedtime with a saline solution.
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. White blood cells (WBC) 2700/µL
Which information will the nurse include for a patient considering a cochlear implant? Cochlear implants: A. are not useful for patients with congenital deafness. B. are most helpful as an early intervention for presbycusis. C. improve hearing in patients with conductive hearing loss. D. require extensive training in order to reach the full benefit.
D. require extensive training in order to reach the full benefit.
