Immune and oncology

129. A client with liver cancer who is receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter, especially meats. The nurse should instruct the client to eat which foods instead of meat? Select all that apply. 1.Yogurt 2.Custard 3.Potatoes 4.Cantaloupe 5.Plain potato chips

Correct Answer: 1, 2, Rationale: Chemotherapy may cause distortion of taste. Frequently, beef and pork are reported to taste bitter or metallic. The nurse can promote client nutrition by assisting the client in choosing alternative sources of protein in the diet. Yogurt and custard are protein sources that may be more palatable, Potatoes, cantaloupe, and potato chips are not good sources of protein.

6. The nurse is caring for a client with an internal radiation implant. The nurse should observe which principle? Select all that apply. 1.Pregnant women are not allowed into the client's room. 2.Limit the time with the client to 1 hour per 8-hour shift. 3.Wear a lead apron while delivering bedside care to the client. 4.Remove the dosimeter badge when entering the client's room. 5.Individuals less than 16 years old are allowed in the room if they stay 6 feet away from the client.

Correct Answer: 1, 3 Rationale: A client receiving treatment for cancer with internal radioactive implant is emitting radioactive beams and others in the environment must take precautions to avoid injury. Pregnant persons are not allowed in the room. Nurses delivering bedside care must wear a lead apron which will stop the radioactive beams. The time that the nurse spends in the room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The dosimeter badge must be worn when in the client's room. Children less than 16 years old and pregnant women are not allowed in the client's room. These guidelines protect individuals from radiation exposure.

147. The nurse is instructing the client with a diagnosis of systemic lupus erythematosus (SLE) about dietary alterations. The nurse should remind the client to avoid which primary foods? Select all that apply. 1.Beef 2.Apples 3.Cheese 4.Chicken 5.Squash

Correct Answer: 1, 3 Rationale: The client with SLE is at risk for cardiovascular disorders, such as coronary artery disease and hypertension. The client is advised of lifestyle changes to reduce these risks, which include smoking cessation and prevention of obesity and hyperlipidemia. The client is advised to reduce intake of salt, fat, and cholesterol.

65. The nurse is developing a teaching plan for a client following a radical mastectomy and includes measures that will assist in preventing lymphedema of the affected arm. The nurse should include which interventions when reviewing instructions with the client to prevent this complication? Select all that apply. 1.Elevate the affected arm on a pillow higher than the heart. 2.Place a cool compress or ice bag on the affected arm at bedtime. 3.Instruct the client to perform simple arm exercises in the affected arm daily. 4.Inspect the arm daily and notify the primary health care provider of redness or swelling. 5.Make sure that clothing fits snugly around the arm and wrap the arm with an ace wrap at bedtime.

Correct Answer: 1, 3, 4 Rationale: The client needs to be aware of the signs of lymphedema and ways to prevent this complication. Following mastectomy, the arm should be elevated above the level of the heart per primary health care provider's prescription. Simple arm exercises should be encouraged. The client should inspect the arm daily and notify the primary health care provider if signs of infection or swelling occur. No blood pressure readings, injections, IV lines, or blood draws should be performed on the affected arm. Cool compresses or ice bags are not a suggested measure for lymphedema prevention. The client should not wear constrictive sleeves, and ace wraps are used as treatment, not prevention.

36. The nurse is collecting data from a client with a history of bladder cancer. Which signs/symptoms should the nurse expect the client to report? Select all that apply. 1.Dysuria 2.Headache 3.Hematuria 4.Urgency of urination 5.Frequency of urination 6.Dull ache in the flank area

Correct Answer: 1, 3, 4, 5 Rationale: The most common sign of bladder cancer is painless, intermittent hematuria. Other signs and symptoms include bladder irritability; infection, with dysuria, frequency, and urgency; and decreased stream of urine. Headache is not associated with bladder cancer and dull ache in the flank area is associated with renal cancer.

153. The nurse is explaining about antigens and antibodies when the client asks where antibodies come from. The nurse should include which areas as the most appropriate response? Select all that apply. 1.Tears 2.Skin 3.Spleen 4.Saliva 5.Blood serum 6.Lymph nodes

Correct Answer: 1, 3, 4, 5, 6 Rationale: Antibodies are found in tears, the spleen, saliva, blood, and lymph nodes. Each antibody is able to attach to the kind of antigen it is made for. The skin does not form antibodies but rather acts as a barrier.

155. Which signs/symptoms should indicate to the nurse that the client is experiencing an anaphylactic reaction? Select all that apply. 1.Hives 2.Pallor 3.Stridor 4.Dyspnea 5.Urticaria 6.Wheezing

Correct Answer: 1, 3, 4, 5, 6 Rationale: Hives are one symptom of anaphylaxis. Stridor, a high-pitched sound during inspiration, is a symptom. Dyspnea occurs as the airway swells. Urticaria is an allergic reaction with wheals that causes intense itching. Wheezing is a musical sound heard as the respiratory lumen narrows. Pallor is not specifically associated with an anaphylactic reaction.

51. The nurse is reviewing the medical history of a client admitted to the hospital with a diagnosis of colorectal cancer. The nurse understands that which information documented in the medical history are risk factors of this type of cancer? Select all that apply. 1.Family history of colon cancer 2.Regular consumption of a high-fiber diet 3.A history of inflammatory bowel disease 4.Regular consumption of red or processed meats 5.Regular consumption of a diet high in fats and carbohydrates

Correct Answer: 1, 3, 4, 6 Rationale: The incidence of colorectal cancer increases with age. Colorectal cancer most often occurs in populations with diets low in fiber and high in refined carbohydrates, fats, and meats. Other risk factors include a family history of the disease, rectal polyps, and active inflammatory disease of at least 10 years' duration. A diet high in fiber is considered protective again colorectal cancer.

15. The nurse is reviewing the laboratory results of a client who is receiving chemotherapy and notes that the platelet count is 10,000 mm3 (10 × 109/L). On the basis of this laboratory value, the nurse should perform which interventions? Select all that apply. 1.Monitor stools for occult blood. 2.Keep away from persons who have colds or feel ill. 3.Instruct the client not to bend over at the waist or lift. 4.Floss teeth and rinse mouth with mouthwash after every meal. 5.Instruct the client to blow nose very gently without blocking either nostril.

Correct Answer: 1, 3, 5 Rationale: Platelets or thrombocytes are necessary for a client to clot. A high risk of hemorrhage exists when the platelet count drops below 20,000 mm3 (20 × 109/L). Fatal central nervous system hemorrhage or massive GI hemorrhage can occur when the platelet count is less than 10,000 mm3 (10 × 109/L). The client may be treated with medications or platelet or blood transfusions to improve the platelet count. The nurse should monitor the client's stools for blood, both obvious and occult. The client should be very gentle if blowing the nose and not cause any pressure to build up in the head. The client also needs to avoid starting bleeding from epistaxis (nosebleed). The client should not bend over at the waist because this action would increase the pressure within the head and increase the risk for an intracerebral bleed. Clients with decreased immunity, which is not stated in the question, should avoid ill persons. The client should not floss the teeth and only use a soft toothbrush to avoid bleeding in the mouth.

17. The licensed practical nurse (LPN) is assisting the registered nurse (RN) to create a teaching plan for the client receiving an antineoplastic medication. The LPN expects which information to be included? Select all that apply. 1.Rinse mouth after meals and use a soft toothbrush. 2.Notify the PHCP if the temperature is above 101° F (37.7° C). 3.Maintain oral hygiene and inspect the mouth for sores daily. 4.A sore throat is expected so the client should suck on soothing throat lozenges. 5.Consult with primary health care provider (PHCP) before receiving immunizations.

Correct Answer: 1, 3, 5 Rationale: Clients with cancer treated with antineoplastic medications must be aware of how to care for themselves and it is important that client teaching is included in the care plan. Because antineoplastic medications affect the bone marrow, clients are often anemic, have lower immunity, and may be at risk for bleeding. Oral hygiene is important and clients should inspect their mouths daily, rinse after meals, and use a soft toothbrush. The client should check with the PHCP before receiving any immunizations. The client should notify the PHCP for a low grade temperature such as 99.5° F (39.7° C) and a sore throat. These are often associated with low white blood cell counts.

60. A client with cancer has undergone a total abdominal hysterectomy and has an indwelling Foley catheter in place. The nurse should expect to note which types of urinary drainage immediately following this surgery? Select all that apply. 1.Pale 2.Purulent 3.Bright red 4.Light amber 5.Blood tinged

Correct Answer: 1, 4 Rationale: Depending on the type of surgical technique and the amount of intravenous fluid the client receives during surgery, the urine could be pale or light amber. Purulent urine indicates infection; blood tinged and bright red indicate active bleeding. These are not expected findings.

22. Which interventions should be implemented in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. 1.Use nonlatex gloves. 2.Use medications from glass ampules. 3.Place the client in a private room only. 4.Do not puncture rubber stoppers with needles. 5.Keep a latex-safe supply cart available in the client's area. 6.Use a blood pressure cuff from an electronic device only to measure the blood pressure.

Correct Answer: 1,2, 4, 5 Rationale: If a client is allergic to latex and is at high risk for an allergic response, the nurse would use nonlatex gloves and latex-safe supplies and would keep a latex-safe supply cart available in the client's area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs and medication bottles with rubber stoppers that require puncture with a needle. It is not necessary to place the client in a private room.

110. The nurse should determine that which are risk factors for systemic lupus erythematous (SLE)? Select all that apply. 1.Male gender 2.Female gender 3.African-American origin 4.Age between 60 to 75 years 5.Being in the childbearing years

Correct Answer: 2, 3 ,5 Rationale: Systemic lupus erythematous affects females more commonly than males. It is more common in African-American females than in white females. The females are generally in the childbearing years.

92. The nurse is assisting in providing a session to community members about the risks associated with laryngeal cancer. A client indicates an understanding of the risks by listing which factors? Select all that apply. 1.Using mouthwash 2.Smoking cigarettes or cigars 3.Drinking alcohol, especially daily 4.Working in a dusty environment 5.Persistent exposure to chemicals in the air 6.Following a diet low in protein and vitamins

Correct Answer: 2, 3, 4, 5, 6 Rationale: The top risk factors for laryngeal cancer are tobacco and alcohol use. Exposure to environmental carcinogens such as dust and chemicals, poor oral hygiene, poor diet (low protein, low vitamins), voice abuse, and chronic laryngitis are also risk factors.

152. The client recently diagnosed with toxoplasmosis asks the nurse, "What is toxoplasmosis? How did I get it, and what do I have to do to get rid of it"? Which information should the nurse include in the response? Select all that apply. 1.Toxoplasmosis is caused by an amoeba. 2.Toxoplasmosis is treated with sulfadiazine. 3.Spores live up to 2 weeks in the environment. 4.Pregnant people should not empty litter boxes. 5.Toxoplasmosis is an organism found in rare pork. 6.Toxoplasmosis may cause a severe inflammatory response.

Correct Answer: 2, 4, 5, 6 Rationale: Treatment for toxoplasmosis includes pyrimethamine, folinic acid, and sulfadiazine for as long as 6 weeks. The organism is found in undercooked meats such as pork and venison. Symptoms range from flulike symptoms to severe inflammatory responses and may cause central nervous system (CNS) symptoms. Pregnant women should not empty litter boxes because cat feces are often sources of toxoplasmosis. Toxoplasmosis is caused by a protozoan called Toxoplasmosis gondii. Spores can remain in the environment for up to a year.

46. The home care nurse is collecting data from a client who has been diagnosed with an allergy to latex. In determining the client's risk factors associated with the allergy, the nurse should question the client about an allergy to which food items? Select all that apply. 1.Eggs 2.Kiwi 3.Milk 4.Yogurt 5.Bananas

Correct Answer: 2, 5 Rationale: Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts are at risk for developing a latex allergy. This is thought to be due to a possible cross-reaction between the food and the latex allergen. The incorrect options are unrelated to latex allergy

53. A client with ovarian cancer is scheduled to receive chemotherapy with cisplatin. The nurse assisting in caring for the client reviews the plan of care, expecting to note which interventions? Select all that apply. 1.Restrict fluids. 2.Encourage fluids. 3.Encourage a low-fat diet. 4.Encourage a high-protein diet. 5.Monitor serum blood urea nitrogen (BUN) and creatinine levels.

Correct Answer: 2, 5 Rationale: The client should receive prehydration before and during the infusion of this medication to minimize the risk of renal damage. The BUN and creatinine should be monitored to determine if renal impairment is occurring. Fluids are not restricted. Encouraging adequate dietary intake is appropriate, but a high-protein or low-fat diet is not necessary.

9. The nurse is assisting with creating a plan of care for a client with pancytopenia as a result of chemotherapy. The nurse should suggest including which in the plan of care? Select all that apply. 1.Restricting all visitors 2.Restricting fluid intake 3.Restricting fresh fruits and vegetables in the diet 4.Applying a face mask to the client if outside the client room. 5.Inserting an indwelling urinary catheter to prevent skin breakdown

Correct Answer: 3, 4 Rationale: A client who is experiencing pancytopenia (decrease in all blood cells types: red, white, and platelets) is at high risk for infection because of significantly low immunity. The client should not eat fresh fruits and vegetables because they are at a potential for ingesting bacteria. All foods should be cooked thoroughly. The client should wear a mask when outside of the room to avoid potential infection spread from persons in the hallways. Not all visitors are restricted, but the client is protected from people with known infections. Fluids should be encouraged because dehydration increases the risk for infection. Invasive measures such as an indwelling urinary catheter should be avoided to prevent infection.

14. The nurse is reinforcing discharge instructions to a client with cancer of the prostate after a suprapubic prostatectomy. The nurse should reinforce which discharge instruction? Select all that apply. 1.Avoid driving a car for 1 week. 2.Restrict fluid intake to prevent incontinence. 3.Take the prescribed stool softener every day. 4.Avoid lifting objects heavier than 20 pounds for 6 weeks. 5.Inspect the incision on the scrotum every day for any redness. 6.Notify the primary health care provider (PHCP) if small blood clots are noticed during urination.

Correct Answer: 3, 4 Rationale: A suprapubic approach involves a lower abdominal incision to remove the prostate to treat prostate cancer. The nurse will reinforce instructions about the incision activity, medications, and when to contact the urologist. The client should take the prescribed stool softener because constipation will lead to straining and cause pain and tension on the surgical site. The client should avoid lifting more than 20 pounds for 6 weeks to avoid tension on the surgical site. Driving a car and sitting for long periods of time are restricted for at least 3 weeks. A daily fluid intake of 2 L to 2.5 L per day (unless contraindicated) should be maintained to limit clot formation and prevent infection. The incision is not on the scrotum but in the lower abdominal area. Small pieces of tissue or blood clots can be passed during urination for up to 2 weeks after surgery and do not need to be reported.

84. The nurse is assisting in planning care for a client with Hodgkin's disease who is neutropenic as a result of radiation and chemotherapy. Which actions should be included in the client's plan of care? Select all that apply. 1.Provide a diet high in protein. 2.Monitor electrolyte levels daily. 3.Monitor white blood cell counts daily. 4.Ensure meticulous hand washing before caring for the client. 5.Ask visitors with respiratory infection symptoms to not visit the client.

Correct Answer: 3, 4, 5 Rationale: Low levels of neutrophils put the client at high risk for infection due to lack of immune response especially against bacteria. Clients who are undergoing radiation and chemotherapy are at increased risk of infection and should not be exposed to others with infections. Hand washing is the best means of preventing the spread of infection. Monitoring white blood cell counts will indicate the extent of neutropenia. High protein diets and electrolyte monitoring are also appropriate interventions for a client who is ill and receiving chemotherapy, but these interventions will not decrease the risk of infection.

10. The client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. Besides treatment of the lung cancer, the nurse anticipates that which interventions may be prescribed to treat the SIADH? Select all that apply. 1.Increase fluid intake. 2.Decrease sodium intake. 3.Institute safety measures. 4.Frequently monitor sodium blood levels. 5.Gather data about the neurological status frequently. 6.Administer medication that is antagonistic to antidiuretic hormone (ADH).

Correct Answer: 3, 4, 5, 6 Rationale: Syndrome of inappropriate ADH (SIADH) is a condition in which excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. SIADH is a potential complication associated with cancer, especially small cell lung cancer. SIADH is managed by treating the condition and its cause. The SIADH induces low sodium blood levels and results in altered neurological states, including confusion and unresponsiveness. Treatment of SIADH includes fluid restriction, increased sodium intake, and a medication with a mechanism of action that is antagonistic to ADH, such as demeclocycline. Sodium blood levels and neurological status are monitored closely and safety interventions must be instituted. The client should not be treated with an increase in fluid intake or a decrease in the sodium intake.

125. The nurse reinforces home care instructions to a client diagnosed with systemic lupus erythematosus and instructs the client about methods to manage fatigue. Which statement by the client indicates a need for further teaching? 1."I should take hot baths because they are relaxing." 2."I should sit whenever possible to conserve my energy." 3."I should avoid long periods of rest because it causes joint stiffness." 4."I should do some exercises, such as walking, when I am not fatigued."

1. " I should take hot baths because they are relaxing." Rationale: To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness.

118. The nurse determines that the client diagnosed with neutropenia needs further teaching if which statement is made by the client? 1."I will include plenty of fresh fruits in my diet." 2."If I develop a fever over 100° F, I will call my doctor." 3."Petting my dog is fine as long as I wash my hands after doing so." 4."My husband will just have to take over cleaning the cat's litter box."

1. " I will include plenty of fresh fruits in my diet. " Rationale: Fresh fruits and vegetables are eliminated from the diet to avoid the introduction of pathogens. Fever of 100.4° F or greater should be reported immediately. Feeding and petting cats and dogs are fine as long as hand washing follows. Handling pet excrement must be avoided to avoid exposure to pathogens.

88. The nurse is assessing the client who has small groups of vesicles over his chest and upper abdominal area. They are located only on the right side of his body. The client states his pain level is 8/10, and describes the pain as burning in nature. Which question is most appropriate to include in the data collection? 1."Did you have chicken pox as a child?" 2."How many sexual partners have you had?" 3."Did you use an electric blanket on your side?" 4."Why don't you try docosanol cream on your lesions?"

1. "Did you have chicken pox as a child?" Rationale: The client has the symptoms of herpes zoster, or shingles, which is caused by the same organism as chicken pox. Asking about sexual partners is inappropriate for this disorder. Use of an electric blanket does not cause this type of lesion. Docosanol is used on herpes simplex I (cold sores).

63. The nurse is obtaining data from a client admitted with a diagnosis of bladder cancer. Which question should the nurse ask the client to determine if the client experienced the most common symptom associated with this type of cancer? 1."Do you notice any blood in the urine?" 2."Do you have frequency with urination?" 3."Do you commonly feel the urge to urinate?" 4."Do you experience any pain when you urinate?"

1. "Do you notice any blood in the urine?" Rationale: The most common symptom in clients with cancer of the bladder is hematuria. The client may also experience irritative voiding symptoms such as frequency, urgency, and dysuria, which often are associated with cancer in situ. The nurse's question in option 4 will elicit information from the client regarding the most common symptom associated with bladder cancer.

54. A client receiving chemotherapy asks the nurse, "What will I do when my hair starts to fall out?" Which action by the nurse is therapeutic? 1.Assist her to express feelings. 2.Offer to help her select a new hairstyle. 3.Ignore the comment and change the subject. 4.Tell her that people don't pay attention to such things anymore.

1. Assist her to express feelings. Rationale: The nurse should encourage the client to express her feelings initially. Selecting a wig before the hair falls out will enable the client to better match hair color and texture of the wig with her natural hair. A new hairstyle will not be beneficial to the client because the hair will have fallen out. Option 3 is nontherapeutic, and option 4 can be considered false reassurance.

120. A client is diagnosed as having a bowel tumor, and several diagnostic tests are prescribed. The nurse reinforces instructions to the client and includes information that which test will confirm the diagnosis of malignancy? 1.Biopsy of the tumor 2.Abdominal ultrasound 3.Computed tomography (CT) scan 4.Magnetic resonance imaging (MRI)

1. Biopsy of the tumor. Rationale: A biopsy, removing a piece of tissue for analysis, is done to determine whether a tumor is malignant or benign. An MRI, CT scan, and ultrasound will visualize the presence of a mass but will not confirm a diagnosis of malignancy.

151 . The primary health care provider prescribes fluconazole for the client. When administering this medication the nurse should explain to the client that it is prescribed to treat which opportunistic infection? 1.Candidiasis 2.Cytomegalovirus 3.Herpes simplex 1 4.Mycobacterium tuberculosis

1. Candidiasis Rationale: Fluconazole is a broad-spectrum antifungal medication. Candidiasis is a fungal infection that causes thrush and vaginal yeast infections, so fluconazole would be an appropriate medication to treat this. Cytomegalovirus and herpes simplex 1 are viral diseases, and mycobacterium tuberculosis is classified in the bacterial/mycobacterial category. Thus, fluconazole, an antifungal medication, would not be appropriate treatment.

96. The nurse is assisting in the care of a client diagnosed with multiple myeloma who has been prescribed an intravenous solution of 0.9% normal saline at 125 mL per hour. Which finding would indicate a positive response to this treatment? 1.Creatinine of 1 mg/dL 2.Weight increase of 1 kg 3.White blood cell count of 6000 mm3 4.Respirations of 18 breaths per minute

1. Creatinine of 1 mg/dL Rationale: In multiple myeloma, hydration is essential to prevent renal damage from excessive calcium and uric acid in the blood that leads to stone formation. Creatinine is the most accurate measure of renal status, and the level is within the normal range. Weight gain in response to hydration indicates fluid excess, a negative response. The respiratory rate and white blood cell counts are not related to hydration.

45. The community health nurse is conducting a research study and is identifying clients in the community who are at risk for latex allergy. The nurse should determine that which client population is at risk for developing this type of allergy? 1.Hairdressers 2.The homeless 3.Children in day care centers 4.Individuals living in a group home

1. Hairdressers. Rationale: Individuals at risk for developing a latex allergy include health care workers; individuals who work in the rubber industry; individuals having multiple surgeries; individuals with spina bifida; individuals who wear gloves frequently such as food handlers, hairdressers, and auto mechanics; and individuals allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts.

76. The client who is diagnosed positive for human immunodeficiency virus (HIV) has had a tuberculin skin test. The results show a 7-mm area of induration. The nurse should interpret the test results as which response? 1.It is positive. 2.It is negative. 3.It is uncertain. 4.It is borderline.

1. It is positive. Rationale: The client with HIV is considered to have positive results on skin testing with an area of 5 mm of induration or greater. The client without tuberculin HIV is positive with induration greater than 10 or 15 mm if the client is at low risk. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is also possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor.

35. The nurse is reinforcing instructions to a community group regarding the risks and causes of bladder cancer. The nurse determines that there is a need for further teaching if a member of the community group makes which statement regarding this type of cancer? 1.It most often occurs in women. 2.It is generally seen in clients who are older than 40 years of age. 3.Environmental health hazards have been found to be a cause of this disease. 4.Using cigarettes, artificial sweeteners, and coffee drinking can increase the risk for this cancer.

1. It most often occurs in women. Rationale: The incidence of bladder cancer is greater among men than among women, and it affects the white population twice as often as the black population. Age over 40, environmental exposure to certain chemicals, and cigarettes especially are associated with the incidence of bladder cancer.

16. The nurse is caring for a client who is receiving an intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. During an inspection of the site, the nurse notes redness and swelling. The nurse should take which appropriate action? 1.Notify the registered nurse immediately. 2.Administer pain medication to reduce the discomfort. 3.Apply ice and maintain the infusion rate, as prescribed. 4.Elevate the extremity of the IV site, and slow the infusion.

1. Notify the registered nurse immediately. Rationale: When antineoplastic medications are administered via IV, great care must be taken to prevent extravasation, the condition in which the medication escapes into the tissues surrounding the injection site, because pain, tissue damage, and necrosis can result. The nurse monitors for signs of extravasation, such as redness or swelling at the insertion site. If extravasation occurs, the RN needs to be notified at once and the infusion will be stopped. The nurse will contact the PHCP. Depending on the specific medication, actions are taken to counteract the negative effects. The medication may be aspirated out, ice or warmth applied, and the area infiltrated with a neutralizing agent specific to the medication.

148. The client is diagnosed with an immune deficiency. The nurse focuses on which nursing responsibility as the highest priority when providing care to this client? 1.Protecting the client from infection 2.Providing emotional support to decrease fear 3.Identifying historical factors that placed the client at risk 4.Encouraging discussion about emotional impact of the disorder

1. Protecting the client from infection. Rationale: The client with immune deficiency has inadequate immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. The other options are also part of the plan of care but are not the highest priority.

112. The client calls the health care clinic and tells the nurse that he was bitten by a tick. The client asks the nurse about the first signs of Lyme disease. The nurse should respond with which characteristic of stage 1 of Lyme disease? 1.Skin rash 2.Painful joints 3.Tremors and weakness 4.Headaches and blurred vision

1. Skin rash. Rationale: The hallmark of stage I of Lyme disease is the development of a skin rash within 2 to 30 days of infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it a bull's-eye appearance (although some individuals do not develop a rash). The lesion enlarges up to 12 inches, and smaller lesions develop farther away from the original tick bite. It is important to note that in some individuals, a rash does not occur. In stage I, most infected people develop flulike symptoms that last 7 to 10 days, and these symptoms may recur later. Options 2, 3, and 4 are not the first symptoms related to Lyme disease.

106. The nurse is collecting data on the client with a diagnosis of rheumatoid arthritis. The nurse looks at the client's hands and notes characteristic deformities. The nurse should identify this as which deformity? Refer to figure. View Figure 1.Ulnar drift 2.Hallux valgus 3.Swan neck deformity 4.Boutonniere deformity

1. Ulnar drift Rationale: All of the conditions identified in the options can occur in rheumatoid arthritis. Ulnar drift occurs when synovitis stretches and damages the tendons, and eventually the tendons become shortened and fixed. This damage causes subluxation (drift) of the joints. A hallux valgus deformity is a deformity characterized by lateral deviation of the great toe. It is commonly called a bunion. A swan neck deformity is a deformed position of the finger, in which the joint closest to the fingertip is permanently bent toward the palm while the nearest joint to the palm is bent away from it. A boutonniere deformity is a deformed position of the fingers or toes, in which the joint nearest the knuckle is permanently bent toward the palm while the farthest joint is bent back away.

136. A client with which type of cancer is at greatest risk for experiencing the complication vena cava syndrome? 1.Leukemia 2.Lung cancer 3.Multiple myeloma 4.Early stages of cancer

2 . Lung cancer. Rationale: Vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Lung cancer is associated with development of vena cava syndrome. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens, the client experiences edema of the hands and arms. Mental status changes and cyanosis are late signs. Blood cancers such as leukemia and multiple myeloma are not associated with tumor formation. Early stages of cancers usually are abnormal cells in tissues that then develop into tumors that enlarge with time.

81. The nurse is assisting in developing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (AIDS) experiencing night fever and night sweats. Which nursing intervention should be included in the plan of care to manage this symptom? 1.Administer a sedative at bedtime. 2.Administer an antipyretic at bedtime. 3.Keep the call bell within reach for the client. 4.Provide a back rub and comfort measures before bedtime.

2. Administer an antipyretic at bedtime. Rationale: For clients with AIDS who experience night fever and night sweats, it is useful to offer an antipyretic at bedtime. It is also helpful to keep a change of bed linens and night clothes nearby for use. The pillow should have a plastic cover, and a towel may be placed over the pillowcase if there is profuse diaphoresis. The client should have liquids at the bedside to drink. Options 1, 3, and 4 are important interventions, but they are unrelated to the subject of fever and night sweats.

13. The nurse is caring for a client after a mastectomy. Which finding would indicate that the client is experiencing a complication that may become a chronic problem related to the surgery? 1.Pain at the incisional site 2.Arm edema on the operative side 3.Sanguineous drainage in the Jackson-Pratt drain 4.Complaints of decreased sensation near the operative site

2. Arm edema on the operative side. Rationale: Clients who undergo mastectomy for breast cancer, especially those with axillary node resection, may develop chronic lymphedema or excessive swelling in the arm and hand. Lymphedema is a complication that may develop immediately after mastectomy, months, or even years after surgery. Slight edema may occur in the immediate postoperative period, but should decrease especially if the client rests with the arm supported on a pillow. Women should avoid injury to the arm on the affected side and not allow venipunctures or blood pressures to be taken in that arm. Pain and numbness near the incision and drainage from the surgical site are expected occurrences after mastectomy and are not indicative of a complication.

24.The client calls the office of the primary health care provider (PHCP) and states to the nurse that they were just stung by a bumblebee while gardening. The client is afraid of a severe reaction because their neighbor experienced such a reaction just 1 week ago. Which should be the appropriate nursing action? 1.Advise the client to soak the site in hydrogen peroxide. 2.Ask the client if they ever sustained a bee sting in the past. 3.Tell the client to call an ambulance for transport to the emergency room. 4.Tell the client not to worry about the sting unless difficulty with breathing occurs.

2. Ask the client if they ever sustained a bee sting in the past Rationale: In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. Therefore, the appropriate action would be to ask the client if he ever received a bee sting in the past. Option 1 is not appropriate advice. Option 3 is unnecessary. The client should not be told "not to worry."

144. The clinic nurse periodically cares for the client diagnosed with acquired immunodeficiency syndrome. The nurse should assess for an early manifestation of Pneumocystis jiroveci infection by monitoring for which sign/symptom at each client visit? 1.Fever 2.Cough 3.Dyspnea at rest 4.Dyspnea on exertion

2. Cough Rationale: The client with P. jiroveci infection usually has a cough as the first symptom, which begins as nonproductive and then progresses to productive. Later signs include fever, dyspnea on exertion, and finally dyspnea at rest.

103. A client is receiving chemotherapy that carries a risk of phototoxicity as an adverse effect. Which finding indicates that the client experienced this side effect? 1.Squinting 2.Erythema 3.Petechiae 4.Ecchymoses

2. Erythema Rationale: Typical photosensitivity reactions involve a "sunburn" reaction of the skin. It is characterized by erythema and blister formation. Squinting is a reaction when the eyes are sensitive to light and that term is photophobic. Ecchymoses and petechiae indicate bleeding.

28. The client is diagnosed with stage I of Lyme disease. The nurse should check the client for which characteristic of this stage? 1.Arthralgia 2.Flu-like symptoms 3.Enlarged and inflamed joints 4.Signs of a neurological disorder

2. Flu-like symptoms Rationale: The hallmark of stage I is the development of a skin rash within 2 to 30 days of infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it a bull's-eye appearance. The lesion enlarges up to 50 cm to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons develop flu-like symptoms that last 7 to 10 days; these symptoms may reoccur later. Arthralgia and joint enlargements are most likely to occur in stage III. Neurological deficits occur in stage II.

130. A client is diagnosed with stage I Lyme disease. In addition to the rash, the nurse should check the client for which manifestation? 1.Arthralgias 2.Flulike symptoms 3.Neurologic deficits 4.Enlarged and inflamed joints

2. Flulike symptoms. Rationale: The hallmark of stage I is the development of a skin rash at the tick bite site. The rash develops into a concentric ring that has a bull's-eye appearance. The lesion enlarges up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons develop flulike symptoms that last 7 to 10 days, and these symptoms may recur later. The other options listed occur in stage II (neurological deficits) or stage III (arthralgias and enlarged, inflamed joints).

82. The nurse is assisting in preparing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (AIDS) who has nausea. Which dietary measure should the nurse most likely include in the plan? 1.Red meat daily 2.Foods that are at room temperature 3.Dairy products with each snack and meal 4.Adding spices to food to make the taste more palatable

2. Foods that are at room temperature. Rationale: The client with AIDS experiencing nausea should avoid fatty products, such as dairy products and red meat. Meals should be small and frequent to lessen the chance of vomiting. Spices and odorous foods should be avoided because they aggravate nausea. Foods are best tolerated either cold or at room temperature.

44. The nurse is assigned to care for a client admitted with a diagnosis of systemic lupus erythematosus (SLE). The nurse reviews the primary health care provider's prescriptions. Which medication should the nurse expect to be prescribed to aid in long-term control? 1.Aspirin 2.Hydroxychloroquine 3.Dehydroepiandrosterone 4.Nonsteroidal anti-inflammatory drugs

2. Hydroxychloroquine Rationale: Hydroxychloroquine, an antimalarial drug, aids in long-term control of SLE. Aspirin is not used in the treatment of SLE. Dehydroepiandrosterone (DHEA), a mild male hormone, is given to treat hair loss, joint pain, fatigue, and memory issues. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to reduce inflammation and control pain.

32. The nurse is assisting with identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy? 1.Children in day care centers 2.Individuals with spina bifida 3.Individuals with cardiac disease 4.Individuals living in group homes

2. Individuals with spina bifida. Rationale: Individuals at risk for developing a latex allergy include health care workers; individuals who work with manufacturing latex products; individuals with spina bifida; individuals who wear gloves frequently such as food handlers, hairdressers, and auto mechanics; and individuals allergic to kiwis, bananas, pineapples, passion fruit, avocados, and chestnuts.

116. The nurse reinforces the teaching plan for a client with a family history of breast cancer. Which teaching point should be included? 1.Diet low in saturated fat 2.Measures to prevent and screen for cancer 3.Yearly breast exam by a health care professional 4.Teaching the breast self-exam technique to be done every month

2. Measures to prevent and screen for cancer. Rationale: Teaching reinforcement should include interventions that prevent and detect breast cancer at an early stage through screening. Monthly breast self-examination and a yearly examination by a health care professional are recommended for all adult women. It is especially important for those with a familial history of breast cancer to have a healthy life style that includes a diet low in saturated fat and to maintain a healthy weight.

74. The nurse is reviewing the laboratory results of a client with bladder cancer and bone metastasis and notes that the calcium level is 15 mg/dL. The nurse should take which appropriate action? 1.Document the findings. 2.Notify the primary health care provider. 3.Increase calcium-containing foods in the diet. 4.Ask the unit secretary to file the report in the client's record.

2. Notify the primary health care provider. Rationale: The normal calcium level is 9 to 10.5 mg/dL. Hypercalcemia is a serum calcium level greater than 10.5 mg/dL. It most often occurs in clients who have bone metastasis and is a late manifestation of extensive malignancy. The presence of cancer in the bone causes the bone to release calcium into the bloodstream. Hypercalcemia is an oncological emergency, and the primary health care provider must be notified High calcium levels can lead to formation of stones in the urinary system and can lead to renal impairment. High calcium levels can affect the heart and neurological systems as well.

56.The nurse should monitor for which laboratory result as indicating an adverse reaction in the client who is receiving chemotherapy? 1.Hemoglobin 12.5 g/dL 2.Platelet count 20,000 mm3 3.Blood urea nitrogen (BUN) 20 mg/dL 4.White blood cell count (WBC) 7000 mm3

2. Platelet count 20,000 mm3 Rationale: A normal platelet count ranges from 150,000 mm3 to 400,000 mm3. A platelet count of 20,000 mm3 places the client at severe risk for bleeding. All of the other values, hemoglobin, BUN, and WBC are within normal limits.

61. A client with lung cancer receiving chemotherapy tells the nurse that the food on the meal tray tastes "funny." Which is the appropriate nursing intervention? 1.Keep the client NPO. 2.Provide oral hygiene care frequently. 3.Administer an antiemetic as prescribed. 4.Consult with the primary health care provider regarding a prescription for parenteral nutrition.

2. Provide oral hygiene care frequently. Rationale: Chemotherapy may cause distortion of taste. Frequent oral hygiene aids in preserving taste function. Keeping a client NPO increases nutritional risks. Antiemetics are used when nausea and vomiting are a problem. Parenteral nutrition is used when oral intake is not possible.

123 . A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which? 1.Rupture of the bladder 2.The development of a vesicovaginal fistula 3.Extreme stress resulting from the diagnosis of cancer 4.Altered perineal sensation as a side effect of radiation therapy

2. The development of vesicovaginal fistula. Rationale: A vesicovaginal fistula is a fistula connection that occurs between the bladder and the vagina. The fistula is an abnormal opening between these two body parts, and if this occurs, the client may experience drainage of urine through the vagina. Rupture of the bladder would cause pain. Stress is experienced in other ways. Altered perineal sensation would not be as specific as voiding through the vagina.

93. The client prescribed zidovudine has been diagnosed with severe neutropenia. The nurse anticipates which intervention should be implemented? 1.The medication dose will be reduced. 2.The medication will be temporarily discontinued. 3.Prednisone will be added to the medication regimen. 4.Epoetin alfa will be added to the medication regimen

2. The medication will be temporarily discontinued. Rationale: Hematological monitoring should be done every 2 weeks in the client taking zidovudine. If severe anemia or neutropenia develops, treatment should be interrupted until there is evidence of bone marrow recovery. If anemia or neutropenia is mild, a reduction in dosage may be sufficient. The administration of prednisone may further alter the immune function. Epoetin alfa is given to clients experiencing anemia.

19. The nurse prepares to give a bath and change the bed linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which should the nurse incorporate in the plan during the bathing of this client? 1.Wearing gloves 2.Wearing a gown and gloves 3.Wearing a gown, gloves, and a mask 4.Wearing a gown and gloves to change the bed linens and gloves only for the bath

2. Wearing a gown and gloves. Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items, such as wound drainage, or while caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.

108. The nurse is assisting in preparing a teaching plan of care for a client being discharged from the hospital following surgery for testicular cancer. Which instruction should the nurse suggest to include in the plan? 1."You can climb stairs after 1 week." 2."You can be fitted for a prosthesis in 6 months." 3."An elevation in temperature should be reported to the primary health care provider." 4."You can lift heavy objects (those weighing 20 pounds or more) after 1 week following surgery."

3. " An elevation in temperature should be reported to the primary health care provider. " Rationale: For the client who has had testicular surgery, the nurse should emphasize the importance of notifying the primary health care provider if chills, fever, drainage, redness, or discharge occurs. These symptoms may indicate the presence of an infection. Often a prosthesis is inserted during surgery, so the client does not have to wait 6 months. The nurse instructs the client that he will be able to resume most of his usual activities within 1 week after discharge, except for lifting heavy objects (those weighing 20 pounds or more) and stair-climbing.

85.The nurse is caring for a client who has undergone pelvic exenteration. In addressing psychosocial issues related to the surgery, which statement by the nurse should be therapeutic? 1."Would you like to talk?" 2."You are looking good today." 3."How do you feel about this surgery?" 4."Will your family and any friends help you deal with this?"

3. " How do you feel about this surgery?" Rationale: Postoperatively, a woman begins to deal with the trauma of the surgery by expressing grief about her mutilated body. Later she may become depressed or withdrawn or even angry or hostile. The woman needs intense emotional support if she is to adapt to her altered body image and functions. Option 3 is the only option that addresses the client's feelings.

119. The nurse caring for a client following a radical neck dissection and creation of a tracheostomy performed for laryngeal cancer is reinforcing discharge instructions to the client. Which statement by the client indicates the need for further teaching regarding care of the stoma? 1."I need to protect the stoma from water." 2."I need to keep powders and sprays away from the stoma site." 3."I need to use an air conditioner to provide cool air to assist in breathing." 4."I need to apply a thin layer of petrolatum to the skin around the stoma to prevent cracking."

3. " I need to use an air conditioner to provide cool air to assist in breathing." Rationale: Air conditioners must be avoided to protect from excessive coldness and dryness in the air. A humidifier in the home should be used if excessive dryness is a problem. Protecting the stoma from water, powders and sprays are correct measures. Preventing the skin around the stomach from cracking is also correct.

30. The nurse, a Cub Scout leader, is preparing a group of Cub Scouts for an overnight camping trip and instructs them about the methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further teaching? 1."I need to bring a hat to wear during the trip." 2."I should wear long-sleeved tops and long pants." 3."I should not use insect repellent because it will attract the ticks." 4."I need to wear closed shoes and socks that can be pulled up over my pants."

3. " I should not use insect repellent because it will attract the ticks. " Rationale: In the prevention of Lyme disease, individuals need to be instructed to use an insect repellent on the skin and clothes when in an area where ticks are likely to be found. Long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn. If possible, one should avoid heavily wooded areas or areas with thick underbrush. Socks can be pulled up and over the pant legs to prevent ticks from entering under clothing.

131. The nurse is reinforcing instructions to a group of high school males in a health class about how to perform a testicular self-examination (TSE). The nurse should make which statement? 1."Perform TSE at least every 3 months." 2."Examine the testicles while lying down." 3."Do the examination after a warm bath or shower." 4."Gently push on the testicle with one or two fingers to feel for a lump."

3. "Do the examination after a warm bath or shower." Rationale: Testicular cancer is rare but occurs most frequently in males 20 to 35 years of age; therefore, education of high school-aged males is important. TSE is recommended monthly after a warm bath or shower when the scrotal skin is relaxed. It also could be done near the end of the shower. The client should be standing to examine the testicles. The client should use both hands, placing fingers under the scrotum and thumbs on top, and should gently roll the testicles, feeling for any lumps.

12. When reinforcing teaching about signs and symptoms of ovarian cancer with a community group of women, the nurse emphasizes which sign/symptom as being a typical manifestation of the disease recognized by persons diagnosed with the condition? 1.Pelvic cramping 2.Sharp abdominal pain 3.Abdominal distention or fullness 4.Postmenopausal vaginal bleeding

3. Abdominal distention of fullness. Rationale: Ovarian cancer is the leading cause of death from gynecological cancers and occurs in women older than 50 years. The most common sign and symptom of ovarian cancer is abdominal distention or fullness. Less common are vague symptoms of urinary frequency and urgency, and GI symptoms such as a change in bowel habits. Pelvic cramping, sharp abdominal pain, or postmenopausal vaginal bleeding are not the most typical signs and symptoms.

100. The client arrives at the health care clinic requesting to be tested for Lyme disease. The client tells the nurse that he removed the tick and flushed it down the toilet. The nurse should respond with which most appropriate action? 1.Refer the client for a blood test immediately. 2.Inform the client that the tick is needed to perform a test. 3.Arrange for the client to return in 4 to 6 weeks to be tested. 4.Ask the client to describe the size, shape, and color of the tick.

3. Arrange for the client to return in 4 to 6 weeks to be tested. Rationale: There is a blood test available to detect Lyme disease; however, it is not a reliable test if performed before 4 to 6 weeks following the tick bite. Options 1, 2, and 4 are inaccurate.

34. The nurse is caring for a client dying of cancer. During care, the client states, "If I can just live long enough to attend my daughter's graduation, I'll be ready to die." Which phase of coping is this client experiencing? 1.Anger 2.Denial 3.Bargaining 4.Depression

3. Bargaining Rationale: Denial, bargaining, anger, depression, and acceptance are recognized stages that a person experiences when facing a life-threatening illness. The client's statement is indicative of bargaining. Denial is expressed as shock and disbelief and may be the first response to hearing bad news. Depression may be manifested by hopelessness, weeping openly, or remaining quiet or withdrawn. Anger may also be a first response to upsetting news, and the predominant theme is "Why me?" or the blaming of others.

117. The nurse is reviewing the medical record of the client who is suspected of having systematic lupus erythematosus (SLE). Which sign should the nurse expect to be documented in the record that is most related to this diagnosis? 1.Recurrent emboli 2.Ascites noted in the abdomen 3.Butterfly rash on cheeks and bridge of the nose 4.Presence of two hemoglobin S genes in the blood cell report

3. Butterfly rash on cheeks and bridge of the nose. Rationale: SLE primarily occurs in females 10 to 35 years of age and is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks and the bridge of the nose is a characteristic sign of SLE. Option 4 is found in sickle cell anemia. Options 1 and 2 are found in many conditions but are not usually noted in SLE.

150. The nurse is reviewing the health record of a client with laryngeal cancer. The nurse should expect to note which most common risk factor for this type of cancer documented in the record? 1.Urban living 2.Alcohol abuse 3.Cigarette smoking 4.Use of chewing tobacco

3. Cigarette smoking. Rationale: The most common risk factor associated with laryngeal cancer is cigarette smoking. Alcohol abuse may have a synergistic effect with cigarette smoking. Air pollution is also a contributing cause as are chronic laryngitis and consistent voice strain.

94. The client diagnosed with acquired immunodeficiency syndrome (AIDS) reports nausea, vomiting, and abdominal pain after beginning didanosine therapy. The clinic nurse should reinforce which instruction to this client? 1.Take crackers and milk with each dose of the medication. 2.Decrease the dose of the medication until the next clinic visit. 3.Come to the health care clinic to be seen by the primary health care provider. 4.This is an uncomfortable but expected side effect of the medication.

3. Come to the health care clinic to be seen by the primary health care provider. Rationale: Pancreatitis, which can be fatal, is the major dose-limiting toxicity associated with the administration of didanosine. The client should be seen by the primary health care provider and be monitored for indications of developing pancreatitis. The reported symptoms are not the primary subject, and so the options directed toward explaining or managing them are not correct. The nurse should not encourage the client to alter the medication dose without first notifying the primary health care provider.

50. A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric (NG) tube. Which action should the nurse take? 1.Irrigate the NG tube. 2.Measure abdominal girth. 3.Continue to monitor the drainage. 4.Ask the registered nurse to notify the primary health care provider (PHCP) immediately.

3. Continue to monitor the drainage. Rationale: Following gastrectomy, drainage from the NG tube is normally bloody for 24 hours postoperatively, changing to brown-tinged and then to yellow or clear. Because bloody drainage is expected in the immediate postoperative period, the nurse should continue to monitor the drainage. There is no need to notify the PHCP at this time. Measuring abdominal girth is performed to detect the development of distention. Following gastrectomy, an NG tube should not be irrigated.

149. The nurse is assisting in the care of the client diagnosed with systemic lupus erythematosus (SLE). The nurse should most appropriately administer which prescribed medication to manage the condition? 1.Antibiotic 2.Antidiarrheal 3.Corticosteroid 4.Opioid analgesic

3. Corticosteroid Rationale: Treatment of SLE is based on the systems involved and symptoms. Treatment normally consists of anti-inflammatory medications, corticosteroids, and immunosuppressants. The other options are not standard components of medication therapy for this disorder.

102. A client who has just been told by the primary health care provider that she has breast cancer responds by stating, "Oh, no, this has to be a big mistake." The nurse interprets the client's initial response as which type of reaction? 1.Fear 2.Rage 3.Denial 4.Anxiety

3. Denial Rationale: The client's response is one of denial. This is a common response to hearing distressing news and is a defense mechanism. The nurse understands that denial is a protective defense mechanism, and the client will need support to take in and work with this diagnosis. Denial is also the first stage of the grieving process, which is experienced by clients diagnosed with cancer. The client's statement does not acknowledge fear or anger (rage). Anxiety is a vague feeling of stress when the exact cause or fear is unknown, and this cause is known.

66. The nurse is assisting in caring for a client with an inoperable lung tumor and helps develop a plan of care by addressing complications related to the disorder. The nurse includes monitoring for the early signs of vena cava syndrome in the plan. Which early sign of this oncological emergency should the nurse include monitoring for in the plan of care? 1.Disorientation 2.Hand and arm edema 3.Edema of the face and eyes 4.Bluish skin discoloration around the mouth

3. Edema of the face and eyes Rationale: Vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens, the client experiences edema of the hands and arms. Mental status changes and cyanosis are late signs.

57. The nurse determines that a client with which history is most at risk for endometrial cancer? 1.Hysterectomy 2.Steroid replacement therapy 3.Estrogen replacement therapy 4.Occupational exposure to dust

3. Estrogen replacement therapy. Rationale: Endometrial cancer is related to the hormone estrogen because estrogen is the primary stimulant of endometrial proliferation. Steroid replacement therapy, occupational exposure to dust, and surgical interventions are not considered to be risk factors for endometrial cancer.

134. The nurse discusses the risk factors associated with gastric cancer as part of a health promotion program. The nurse determines that there is a need for further teaching if a member attending the program states that which factor is a risk? 1.History of gastric polyps 2.History of pernicious anemia 3.High meat and carbohydrate consumption 4.A diet of smoked, highly salted, and spicy food

3. High meat and carbohydrate consumption. Rationale: Gastric cancer usually begins in the mucosal cells of the stomach. High meat and carbohydrate consumption plays a role in the development of cancer of the pancreas, not gastric cancer. Options 1, 2, and 4 identify risk factors related to gastric cancer. The risk also is increased for males 50 years of age and older and clients with a history of precancerous lesions or chronic gastritis.

145. The nurse is providing instructions to the client diagnosed with acquired immunodeficiency syndrome (AIDS) experiencing night fever and night sweats. The nurse should advise the client to do which action to best increase comfort while minimizing symptoms? 1.Reduce fluid intake before bedtime. 2.Remove the plastic cover on the pillow. 3.Keep liquids on the nightstand at home. 4.Take an antipyretic after the fever spikes.

3. Keep liquids on the nightstand at home. Rationale: For clients with AIDS who experience night fever and night sweats, it is useful to keep liquids on the nightstand at home. The client should keep a plastic cover on the pillow and also place a towel over the pillowcase if needed. The client should not decrease fluid intake, and the client should take an antipyretic before going to sleep and before the fever spikes.

111.A client is receiving radiation therapy to the brain because of a diagnosis of a brain tumor. Which sign/symptom of the client is noted to be a positive outcome of the radiation therapy? 1.Fatigue 2.Nausea and vomiting 3.Less severe headache 4.Altered taste sensations

3. Less severe headache. Rationale: Radiation therapy for a brain tumor will decrease a headache, a common symptom, and this is a desired or positive outcome. Since the intracranial pressure will decrease with the shrinkage of the tumor, the headache should lessen. Radiation therapy often causes symptoms of fatigue and altered taste sensation. Clients may also experience nausea and vomiting because of the effects of the radiation on the brain's chemoreceptor trigger zone.

115.The client diagnosed with acquired immunodeficiency syndrome (AIDS) is experiencing shortness of breath related to Pneumocystis jiroveci pneumonia. Which measure should the nurse implement to assist the client in performing activities of daily living? 1.Offer low microbial food. 2.Provide small, frequent meals. 3.Provide supportive care with hygiene needs. 4.Provide meals and snacks with high protein, high calorie, and high nutritional value.

3. Provide supportive care with hygiene needs. Rationale: Providing supportive care with hygiene needs as needed reduces the client's physical and emotional energy demands and conserves energy resources for other functions such as breathing. Options 1, 2, and 4 are important interventions for the client with AIDS but do not address the subject of activities of daily living. Option 1 will decrease the client's risk of infection. Option 2 will assist the client in tolerating meals better. Option 4 will assist the client in maintaining appropriate weight and proper nutrition.

31.The client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse should determine that this has been confirmed by which finding? 1.Swelling in the genital area 2.Swelling in the lower extremities 3.Punch biopsy of the cutaneous lesions 4.Appearance of reddish-blue lesions on the skin

3. Punch biopsy of the cutaneous lesions. Rationale: Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.

59. The nurse is caring for a client with cancer receiving chemotherapy who has developed stomatitis. The nurse plans to give mouth care by using oral care agents and devices that meet which additional criterion? 1.The nurse prefers them. 2.The client requests them. 3.The severity of stomatitis. 4.They are readily available.

3. The severity of stomatitis. Rationale: Interventions used to treat stomatitis are based on the varying degrees and severity of the disorder. The incorrect options do not focus on the individual needs of the client with this complication of cancer chemotherapy.

79. The client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking didanosine. The nurse reinforces instructions to the client to watch for which signs/symptoms that the medication may have caused the adverse effect of pancreatitis? 1.Fatigue and aching joints 2.Low grade fever and malaise 3.Vomiting and abdominal pain 4.Dark urine and clay colored stools

3. Vomiting and abdominal pain . Rationale: Pancreatitis, which can be fatal, is the major dose-limiting toxicity associated with the administration of didanosine. Clients should be monitored for indications of developing pancreatitis, which include increased serum amylase in association with increased serum triglycerides; decreased serum calcium; and vomiting or abdominal pain. If evolving pancreatitis is diagnosed, the medication should be discontinued. Fatigue and aching joints are associated with hepatitis. Low grade fever and malaise is associated with cholecystitis. Dark urine and clay colored stools are associated with cirrhosis.

71. The nurse is collecting data from a client who is admitted to the hospital for diagnostic studies to rule out the presence of Hodgkin's disease. Which question should the nurse ask the client to elicit information specifically related to this disease? 1."Are you tiring easily?" 2."Do you have any weakness?" 3."Have you gained any weight?" 4."Have you noticed any swollen lymph nodes?"

4. " Have you noticed any swollen lymph nodes?" Rationale: Hodgkin's disease is a chronic progressive neoplastic disorder of lymphoid tissue characterized by the painless enlargement of lymph nodes with progression to extra-lymphatic sites, such as the spleen and liver. Weight loss is most likely to be noted. Fatigue and weakness may occur but are not significantly related to the disease.

80. Indinavir is prescribed for a client diagnosed with human immunodeficiency virus (HIV). The nurse has reinforced instructions to the client regarding ways to maximize absorption of the medication. Which statement by the client indicates an adequate understanding of the use of this medication? 1."I need to store the medication in the refrigerator." 2."I need to take the medication with a high-fat snack." 3."I need to take the medication with my large meal of the day." 4."I need to take the medication with water but on an empty stomach."

4. " I need to take the medication with water but on an empty stomach. " Rationale: To maximize absorption, the medication should be administered with water on an empty stomach. The medication can be taken 1 hour before a meal or 2 hours after a meal, or it can be administered with skim milk, coffee, tea, or a low-fat meal such as cornflakes with skim milk and sugar. It is not to be administered with a large meal. The medication should be stored at room temperature and protected from moisture because moisture can degrade the medication.

64. The nurse is preparing a client for an intravesical instillation of an alkylating chemotherapeutic agent into the bladder for the treatment of bladder cancer. The nurse provides instructions to the client regarding the procedure. Which client statement indicates an understanding of this procedure? 1."I need to stay on bed rest after the procedure is completed." 2."I will need to immediately urinate after the instillation is done." 3."After the instillation is done, I will need to retain the fluid for 30 minutes." 4."After the instillation is done, I will need to change position every 15 minutes from side to side."

4. "After the instillation is done, I will need to change position every 15 minutes from side to side. " Rationale: Normally the medication is injected into the bladder through a urethral catheter, the catheter is clamped or removed, and the client is asked to retain the fluid for 2 hours. The client is to change position every 15 to 30 minutes from side to side, and from supine to prone, or to resume all activity immediately during this time period. This allows the chemotherapeutic agent to be in contact with all areas inside the bladder. The client then voids and is instructed to drink water to flush the bladder.

72. The nurse is collecting data from a client suspected of having ovarian cancer. Which question should the nurse ask the client to elicit information specifically related to this disorder? 1."Have you been having diarrhea?" 2."Have you had any abnormal vaginal bleeding?" 3."Are you having any excessive vaginal bleeding?" 4."Does your abdomen feel as though it is swollen?"

4. "Does your abdomen feel as though it is swollen?" Rationale: Signs/symptoms of ovarian cancer include abdominal distention, urinary frequency and urgency, pleural effusion, malnutrition, pain from pressure caused by the growing tumor and the effects of urinary or bowel obstruction, and constipation. Ascites with dyspnea and ultimately general severe pain will occur as the disease progresses. Abnormal bleeding, often resulting in hypermenorrhea, is associated with uterine cancer.

101. The client diagnosed with stage I Lyme disease asks the nurse about the treatment for the disease. The nurse responds to the client, anticipating that which treatment should be included in the care plan? 1.Ultraviolet light therapy 2.No treatment unless symptoms develop 3.Treatment with intravenous (IV) penicillin G 4.A 3- to 4-week course of oral antibiotic therapy

4. A 3-to 4-week course of oral antibiotic therapy/ Rationale: A 3- to 4-week course of oral antibiotic therapy is recommended during stage 1. Later stages of Lyme disease may require therapy with intravenous antibiotics, such as penicillin G. Ultraviolet light therapy is not a component of the treatment plan for Lyme disease.

135. The nurse is reinforcing instructions to a group of adults about the seven warning signs of cancer. The nurse determines that a member of the group needs further teaching if the member states which sign/symptom is a warning sign? 1.Nagging cough or hoarseness 2.Change in bowel or bladder habits 3.Indigestion or difficulty swallowing 4.Absence or decreased frequency of menses

4. Absence or decreased frequency of menses Rationale: Each of the seven warning signs of cancer begins with a letter from the word CAUTION. The one that is not part of the seven is absence or decreased frequency of menses. This particular item could be indicative of pregnancy or menopause, as well as other pathological problems. Unusual bleeding or discharge, however, is one of the warning signs.

25. The nurse is assisting with the administration of immunizations at a health care clinic. The nurse should understand that immunization provides which protection? 1.Protection from all diseases 2.Innate immunity from disease 3.Natural immunity from disease 4.Acquired immunity from disease

4. Acquired immunity from disease Rationale: Acquired immunity can occur by receiving an immunization that causes antibodies to a specific pathogen to form. Natural (innate) immunity is present at birth. No immunization protects the client from all diseases.

138. The nurse is orienting a new nurse to the care of a client who has an internal radiation implant. Which statement by the new nurse demonstrates the need for further teaching? 1.Pregnant women should not enter the client's room. 2.The dosimeter badge is worn upon entering the client's room. 3.There is a 30 minutes per 8-hour shift time limit for contact with the client. 4.After visiting hours, the client may be put in a wheel chair and taken out of the room.

4. After visiting hours, the client may be put in a wheel chair and taken out of the room. Rationale: Precautions must be enforced to protect health care workers and visitors when a client has an internal radiation implant. The client must stay in the room and be taken out only for medical reasons approved by the radiologist. If the client sits in a wheelchair the implant may move. Children younger than 16 years of age and pregnant women are not allowed in the client's room. The time that the nurse spends in a room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The dosimeter badge must be worn when in the client's room.

91.The nurse is caring for a client with metastatic lung cancer. The client was medicated 2 hours ago and now reports a new and sudden sharp pain in the back. The nurse appropriately interprets this finding as possibly spinal cord compression. Which should the nurse do next? 1.Auscultate posterior breath sounds. 2.Notify the primary health care provider. 3.Administer the analgesic ordered for breakthrough pain. 4.Ask the client about numbness and tingling in all the extremities.

4. Ask the client about numbness and tingling in all extremities. Rationale: Spinal cord compression should be suspected in a client with metastatic disease, particularly when a new and sudden onset of back pain occurs. Spinal cord compression causes back pain before neurological changes occur. The nurse should gather more data and determine if the client has numbness or tingling and mobility changes in the extremities. Then the PHCP is notified. Spinal cord compression is an oncological emergency and needs to be reported. Additional pain medication and listening to breath sounds may be done, but these are not priority interventions.

107. The nurse is collecting data on a client complaining of fatigue, weakness, malaise, muscle pain, joint pain at multiple sites, anorexia, and photosensitivity. Systematic lupus erythematosus (SLE) is suspected. The nurse should further check for which manifestation that is also indicative of the presence of SLE? 1.Emboli 2.Ascites 3.Two hemoglobin S genes 4.Butterfly rash on the cheeks and bridge of the nose

4. Butterfly rash on the cheeks and bridge of the nose Rationale: Systematic lupus erythematosus is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks and on the bridge of the nose is a classic sign of SLE. Option 3 is found in sickle cell anemia. Options 1 and 2 may be found in many conditions but are not associated with SLE.

62. The nurse is reviewing the record of a client admitted to the hospital for treatment of bladder cancer. Which risk factor related to this type of cancer should the nurse likely note in the client's record? 1.Female African-American 2.Recorded age of 35 years 3.Occupation of computer analyzer 4.Drinks coffee and smokes cigarettes

4. Drinks coffee and smokes cigarettes. Rationale: The incidence of bladder cancer is greater in men than in women and affects the white population twice as often as African-Americans. It most often occurs after the age of 40 years. Environmental health hazards have been attributed as causes. Cigarette smoking and drinking coffee are some factors associated with bladder cancer.

87. The nurse is monitoring a client on chemotherapy for signs and symptoms related to tumor lysis syndrome. The nurse understands that which is an early sign of this oncological emergency? 1.Confusion 2.Disorientation 3.Periorbital edema 4.Elevated potassium

4. Elevated potassium. Rationale: Tumor lysis syndrome is a rapid release of by-products from cell destruction by cancer therapy; the first sign is an elevated potassium level, which may cause renal failure, cardiac dysrhythmias, or asystole.

70. The nurse is reviewing the record of a client with a diagnosis of cervical cancer. Which should the nurse expect to note in the client's record related to a risk factor associated with this type of cancer? 1.Single female, no children 2.Has never smoked cigarettes 3.Intercourse with only one partner 4.History of human papillomavirus infection

4. History of human papillomavirus infection Rationale: Risk factors associated with cervical cancer include smoking, intercourse with uncircumcised males, early frequent intercourse with multiple sexual partners, multiparity, chronic cervicitis, and history of genital herpes or human papillomavirus infection. Incidence of cervical cancer is also higher in African-Americans.

29. The client arrives at the health care clinic and states to the nurse that they were just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that they removed the tick and flushed it down the toilet. Which nursing action is appropriate? 1.Refer the client for a blood test immediately. 2.Inform the client that there is not a test available for Lyme disease. 3.Tell the client that testing is not necessary unless arthralgia develops. 4.Instruct the client to return in 4 to 6 weeks to be tested, because testing before this time is not reliable.

4. Instruct the client to return in 4 to 6 weeks to be tested, because testing before this time is not reliable. Rationale: A blood test is available to detect Lyme disease; however, the test is not reliable if performed before 4 to 6 weeks following the tick bite. Antibody formation takes place in the following manner: immunoglobulin M is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks, and then gradually disappears; immunoglobulin G is detected 2 to 3 months after infection and may remain elevated for years. Options 1, 2, and 3 are incorrect.

133. The nurse is teaching a local women's church group about the risks of cervical cancer. The nurse determines that there is a need for further teaching if a group member states that which is a risk factor? 1.Multiple sexual partners 2.History of genital herpes 3.Early frequent intercourse 4.Intercourse with a circumcised male

4. Intercourse with a circumcised male. Rationale: Risk factors associated with cervical cancer include intercourse with uncircumcised males, early frequent intercourse with multiple sexual partners, multiparity, chronic cervicitis, and history of genital herpes or human papillomavirus infection. Cervical cancer is also higher in African-Americans.

26. The nurse is assigned to care for a client diagnosed with systemic lupus erythematosus (SLE). The nurse should plan care considering which factor regarding this diagnosis? 1.A local rash occurs as a result of allergy. 2.It is a disease caused by overexposure to sunlight. 3.A continuous release of histamine in the body causes the disease. 4.It is an inflammatory disease of collagen contained in connective tissue.

4. It is an inflammatory disease of collagen contained in connective tissue. Rationale: SLE is an inflammatory disease of collagen contained in connective tissue. Options 1, 2, and 3 are not associated with this disease.

137. The nurse is reinforcing instructions to the client on how to maintain optimal skin integrity during external radiation therapy. The nurse determines that there is a need for further teaching if the client states plans to do which action? 1.Eat a high-protein diet. 2.Avoid exposure to sunlight. 3.Wash the skin with a mild soap using the hand and pat dry. 4.Keep at least 6 feet away from pregnant women especially in the first 3 months.

4. Keep at least 6 feet away from pregnant women especially in the first 3 months. Rationale: External radiation treatments cause changes to the skin that increase the risk for injury. The source of radiation is external and the client is not radioactive. Clients do not need to distance themselves from pregnant women. The client should be encouraged to eat a high-protein diet to have necessary nutrients available for tissue growth and replacement. Other common instructions are to avoid sunlight and to wash the skin with mild soap using the hand and pat dry.

A client who has been diagnosed with multiple myeloma asks the nurse about the diagnosis. The nurse bases the response on which characteristic of the disorder? 1.Altered red blood cell production 2.Altered production of lymph nodes 3.Malignant exacerbation in the number of leukocytes 4.Malignant proliferation of plasma cells and tumors within the bone

4. Malignant proliferation of plasma cells and tumors within the bone. Rationale: Multiple myeloma is a neoplastic condition that is characterized by the abnormal malignant proliferation of plasma cells and the accumulation of mature plasma cells in the bone marrow. Altered red blood cell production and altered production of lymph nodes are not characteristics of multiple myeloma. Exacerbation in the number of leukocytes describes the leukemic process.

86. A nursing student is assisting in caring for a client with a lung tumor; the client will be having a pneumonectomy. The nursing instructor reviews the postoperative plan of care developed by the student and suggests deleting which item from the plan? 1.Avoiding complete lateral positioning 2.Encouraging coughing and deep breathing 3.Checking the surgical dressing for drainage 4.Monitoring the closed chest tube drainage system

4. Monitoring the closed chest tube drainage system. Rationale: Pneumonectomy is the removal of the entire lung on one side and without the presence of lung tissue, a chest tube is unnecessary for the lung to reexpand. Closed chest drainage usually is not used following pneumonectomy. The serous fluid that accumulates in the empty thoracic cavity eventually consolidates. The consolidation prevents shifts of the mediastinum, heart, and remaining lung. Complete lateral positioning is avoided because the mediastinum is no longer held in place on both sides by lung tissue and extreme turning may cause mediastinal shift and compression of the remaining lung. Options 2 and 3 are general postoperative measures.

97. A client is diagnosed with stage II Lyme disease. The nurse should check the client for which characteristic of this stage? 1.Flulike symptoms 2.A "bull's-eye" rash 3.Stiffness in the joints 4.Nervous system disorders

4. Nervous system disorders. Rationale: If untreated stage II of Lyme disease begins 2 to 12 weeks after the first stage with carditis and nervous system disorders such as meningitis, peripheral neuritis, or a facial paralysis similar to Bell palsy. Flulike symptoms, "bull's-eye" rash and stiffness in the joints are symptoms seen in stage I of the disease.

41. The nurse is reinforcing instructions to a group of female clients about breast self-examination (BSE). When should the nurse instruct the pre-menopausal client to perform this examination? 1.At the onset of menstruation 2.Every month during ovulation 3.Weekly at the same time of day 4.One week after menstruation begins

4. One week after menstruation begins. Rationale: The BSE should be performed monthly about 7 days after the menstrual period begins. It is not recommended to perform the examination weekly; at the onset of menstruation and during ovulation, hormonal changes occur that may alter breast tissue.

73. The nurse is reinforcing instructions to a client scheduled for conization in 1 week for the treatment of microinvasive cervical cancer. The procedure has been explained by the primary health care provider, and the nurse is reviewing the complications associated with the procedure. The nurse determines that the client needs further teaching if the client states that which is a complication of this procedure? 1.Infertility 2.Infection 3.Incompetent cervix 4.Ovarian perforation

4. Ovarian perforation Rationale: Conization is the removal of a cone-shaped tissue sample from the cervix done to confirm and sometimes treat cervical cancer. This procedure generally is not performed on women who desire to bear children because it can lead to incompetence of the cervix or infertility. Complications of the procedure include hemorrhage, infection, and less frequently, cervical stenosis.

8. The client is hospitalized for the insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. Which is the immediate nursing action? 1.Reinsert the implant into the vagina. 2.Call the primary health care provider (PHCP). 3.Pick up the implant with gloved hands and flush it down the toilet. 4.Pick up the implant with long-handled forceps and place into a lead container.

4. Pick up the implant with long-handled forceps and place into a lead container. Rationale: A lead container and long-handled forceps should be kept in the client's room at all times during internal radiation therapy. Lead is an element that has a high density and high atomic number and is used to shield persons from radiation. If dislodged, the implant must be handled carefully to limit radiation exposure to the client and all persons in the environment. If the implant becomes dislodged, the nurse should pick up the implant with long-handled forceps and place it into the lead container. The radiation safety officer of the institution should be notified. Although the PHCP needs to be notified, this is not the immediate action. The nurse cannot reinsert the implant. A radioactive implant is specifically placed inside the client to kill the cancer while limiting damage to adjacent tissues and organs. Touching the implant with gloves and flushing this down the toilet exposes the nurse and the environment to unsafe levels of radiation.

122. A cervical radiation implant is placed in the client for treatment of cervical cancer. Which intervention would the nurse most likely expect to note in the primary health care provider's prescriptions? 1.Out of bed in a chair 2.Ambulate to the bathroom 3.Bed rest with bedside commode 4.Place an indwelling urinary catheter

4. Place an indwelling urinary catheter. Rationale: The client with a cervical radiation implant should be maintained on bed rest in the dorsal position to prevent movement of the radiation source. An indwelling urinary catheter is placed before the insertion of the cervical radiation implant. The head of the bed is elevated to a maximum of 10 to 15 degrees for comfort. Turning the client onto her side is avoided. If the client needs to be turned, a pillow is placed between the knees and, with the body in straight alignment, the client is logrolled. All efforts are made to limit client movement to avoid displacement of the implant.

20. The client is suspected of having systemic lupus erythematous (SLE). The nurse monitors the client, knowing that which is one of the initial characteristic signs of SLE? 1.Weight gain 2.Subnormal temperature 3.Elevated red blood cell count 4.Rash on the face across the nose and on the cheeks

4. Rash on the face across the nose and on the cheeks. Rationale: Skin lesions or a rash on the face across the bridge of the nose and on the cheeks is an initial characteristic sign of SLE. Fever and weight loss may also occur. Anemia is most likely to occur later in SLE.

140. A client with cancer develops white, dough-like patches on the mucous membranes of the oral cavity. Which action should the nurse take when noting this? 1.Do nothing because this is a normal finding. 2.Encourage the client to use better oral hygiene. 3.Check the client's most recent electrolyte results. 4.Report these symptoms, which are consistent with candidiasis.

4. Report these symptoms, which are consistent with candidiasis. Rationale: Candidiasis is an infection caused by the fungus Candida albicans. It appears as white plaques on the mucous membranes and corners of the mouth with an underlying red base and fissures. It is not a common infection, although it can occur in an immunocompromised client. The fungus overgrows due to a change in normal oral flora. The client requires treatment with an antifungal agent to eliminate the infection. The finding has nothing to do with electrolyte imbalance.

146. The nurse is providing general information to a group of high school students about preventing human immunodeficiency virus (HIV) transmission. The nurse should inform the students that which behavior is most unsafe? 1.Abstinence 2.Mutual monogamy 3.Use of latex condoms 4.Use of natural skin condoms

4. Use of natural skin condoms Rationale: The use of natural skin condoms is not considered safe because the pores in the condom are large enough for the virus to pass through. Abstinence is the safest way to avoid HIV infection. The next most reliable method is participation in a mutually monogamous relationship. The use of latex condoms is considered safe because the latex prevents the transmission of the HIV virus as long as the condom is used properly and remains in place and intact.

121. The nurse is preparing a client with a bowel tumor for surgery. The primary health care provider has informed the client that the surgery is palliative in the treatment of the tumor. Which rationale is the reason to perform this type of surgery? 1.To reduce pain 2.To cure the client 3.To eliminate high-risk factors for metastasis 4.To restore and improve physical appearance

1 . To reduce pain. Rationale: Palliative surgery that can benefit the client with cancer and improve quality of life includes procedures that reduce symptoms including pain, relieve airway obstructions, relieve obstruction in the gastrointestinal and urinary tracts, relieve pressure on the brain and spinal cord, and prevent hemorrhage. Palliative surgery is not curative, does not reduce risk for metastasis, or improve appearance (cosmetic surgery).

104. The nurse reviews the care plan of a client with cancer and notes that the client has a problem with adequate food intake related to side effects of therapy. In order to enhance appetite and nutrition, the nurse should offer which advice to the client? 1.Avoid strong-smelling foods. 2.Avoid small, frequent meals. 3.Avoid foods containing lean animal protein. 4.Avoid foods that are served at room temperature.

1. Avoid strong-smelling foods. Rationale: The client with cancer is advised to avoid strong-smelling foods that may aggravate anorexia or be distasteful to the client. The client should increase intake of calories and sources of lean protein. The client should also eat small, frequent meals. Foods that are near room temperature, or that are neither too hot nor too cold, are better tolerated by the client. Other measures that can help improve appetite include rinsing the mouth before eating and dining in an aesthetically pleasing environment.

109. The primary health care provider aspirates synovial fluid from a knee joint of a client diagnosed with rheumatoid arthritis. The nurse reviews the laboratory analysis of the specimen and should expect the results to best indicate which finding? 1.Cloudy synovial fluid 2.Bloody synovial fluid 3.Presence of organisms 4.Presence of urate crystals

1. Cloudy synovial fluid Rationale: Cloudy synovial fluid is diagnostic of rheumatoid arthritis. Organisms present in the synovial fluid are characteristic of a septic joint condition. Bloody synovial fluid is seen with trauma. Urate crystals are found in gout.

47. The home care nurse is assigned to care for the client who returned home following treatment for a sprained ankle. The nurse notes that the client was sent home with crutches that have rubber axillary pads and needs to reinforce instructions regarding crutch walking. On data collection, the nurse discovers that the client has an allergy to latex. Before providing instructions regarding crutch walking, the nurse should do which action? 1.Cover the crutch pads with cloth. 2.Contact the primary health care provider (PHCP). 3.Call the local medical supply store, and ask for a cane to be delivered. 4.Tell the client that the crutches must be removed immediately from the house.

1. Cover the crutch pads with cloth. Rationale: The rubber pads used on crutches may contain latex. If the client requires the use of crutches, the nurse can cover the pads with a cloth to prevent cutaneous contact. Telling the client that the crutches must be immediately removed from the house is inappropriate and may alarm the client. The nurse cannot prescribe a cane for a client. In addition, this type of assistive device may not be appropriate considering this client's injury. No reason exists to contact the PHCP at this time.

55.A client has just been told by the primary health care provider about her diagnosis of breast cancer. The client responds, "Oh no, does this mean I'm going to die?" The nurse interprets which response as the client's initial reaction? 1.Fear 2.Rage 3.Denial 4.Anxiety

1. Fear Rationale: The client's response is one of fear. The client has verbalized the object of fear (dying), which makes anxiety incorrect. The client's statement contains no evidence of denial or rage.

43. The nurse is reviewing the laboratory results of a client who has been diagnosed with multiple myeloma. Which finding should the nurse expect to note with this diagnosis? 1.Increased calcium level 2.Increased white blood cells 3.Decreased blood urea nitrogen (BUN) level 4.Decreased number of plasma cells in the bone marrow

1. Increased calcium level. Rationale: Findings that are indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia as a result of the release of calcium from the deteriorating bone tissue, and an elevated BUN level. An increased white blood cell count may or may not be present, but this is not specifically related to multiple myeloma.

49. The nurse is assisting in developing a plan of care for the client with immunodeficiency. The nurse should determine that which problem is a priority for the client? 1.Infection 2.Inability to cope 3.Lack of information about the disease 4.Feeling uncomfortable about body changes

1. Infection Rationale: The client with immunodeficiency has inadequate or an absence of immune bodies and is at risk for infection. The priority problem is infection. The question presents no data indicating that inability to cope, lack of information about the disease, and feeling uncomfortable about body changes are problems.

27. The camp nurse prepares to instruct a group of children about Lyme disease. Which information should the nurse include in the instructions? 1.Lyme disease is caused by a tick carried by deer. 2.Lyme disease is caused by contamination from cat feces. 3.Lyme disease can be contagious by skin contact with an infected individual. 4.Lyme disease can be caused by the inhalation of spores from bird droppings.

1. Lyme disease is caused by a tick carried by deer. Rationale: Lyme disease is a multisystem infection that results from a bite by a tick carried by several species of deer. Persons bitten by Ixodes ticks can be infected with the spirochete Borrelia burgdorferi. Lyme disease cannot be transmitted from one person to another. Toxoplasmosis is caused from the ingestion of cysts from contaminated cat feces. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings.

40. A client with cancer is receiving chemotherapy and develops thrombocytopenia. Which intervention is a priority in the nursing plan of care? 1.Monitor the client for bleeding. 2.Monitor the client's temperature. 3.Ambulate the client three times daily. 4.Monitor the client for pathological fractures.

1. Monitor the client for bleeding. Rationale: Thrombocytopenia indicates a decrease in the number of platelets in the circulating blood. A major concern is monitoring for and preventing bleeding. Monitoring the temperature relates to infection, particularly if leukopenia is present. The options indicating to ambulate the client and monitor for pathological fractures are also important to the plan of care but are not directly related to thrombocytopenia.

124. A nursing instructor asks a nursing student about the characteristics of Hodgkin's disease. The instructor determines that the student needs additional study if the student states that which is an associated characteristic? 1.Occurs most often in older adults 2.Presence of Reed-Sternberg cells 3.Involvement of lymph nodes, spleen, and liver 4.Is considered one of the most treatable cancers

1. Occurs most often in older adults. Rationale: Hodgkin's disease is a disorder of young adults and primarily occurs between the ages of 20 and 40.

23. The nurse is assisting with planning the care of a client with a diagnosis of immunodeficiency. The nurse should incorporate which intervention as a priority in the plan of care? 1.Protecting the client from infection 2.Providing emotional support to decrease fear 3.Encouraging discussion about lifestyle changes 4.Identifying factors that decreased the immune function

1. Protecting the client from infection. Rationale: The client with immunodeficiency has inadequate or absent immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. Options 2, 3, and 4 may be components of care but are not the priority.

114. The client diagnosed with acquired immunodeficiency syndrome (AIDS) has difficulty swallowing. The nurse has given the client suggestions to minimize the problem. The nurse determines that the client has understood the instructions if the client verbalizes the intent to increase intake of which food(s)? 1.Puddings 2.Hot soup 3.Peanut butter 4.Raw fruits and vegetables

1. Puddings Rationale: The client is instructed to avoid spicy, sticky, or excessively hot or cold foods. The client also is instructed to avoid foods that are rough, such as uncooked fruits or vegetables. The client is encouraged to take in foods that are mild, nonabrasive, and easy to swallow. Examples of these include baked fish, noodle dishes, well-cooked eggs, and desserts such as ice cream or pudding. Dry grain foods such as crackers, bread, or cookies may be softened in milk or another beverage before eating.

141. The nurse is caring for a client in the oncology unit who has developed stomatitis during chemotherapy. The nurse should plan which measure to treat this complication? 1.Rinse the mouth with dilute baking soda or saline solution. 2.Use lemon and glycerin swabs liberally on painful oral lesions. 3.Brush the teeth and use nonwaxed dental floss at least twice a day. 4.Place the client on nothing-by-mouth (NPO) status for 12 hours, and then resume liquids.

1. Rinse the mouth with dilute baking soda or saline solution. Rationale: Stomatitis, or mouth ulcerations, occurs with the administration of many antineoplastic medications and altered oral flora due to immunosuppression. The client's mouth should be examined daily for signs of ulceration. If stomatitis occurs, the client should be instructed to rinse the mouth with dilute baking soda or saline solution. Food and fluids are important and should not be restricted. If chewing and swallowing are painful, the client may switch to a liquid diet. The client is instructed to avoid spicy foods and foods with hard crusts or edges. The client should avoid tooth brushing and flossing when stomatitis is severe because of the risk of bleeding. Lemon and glycerin swabs may cause pain and further irritation.

126. The client with a diagnosis of acquired immunodeficiency syndrome has raised, dark purplish lesions on the trunk of the body. The nurse anticipates that which procedure will be done to confirm whether these lesions are due to Kaposi's sarcoma? 1.Skin biopsy 2.Lung biopsy 3.Western blot 4.Enzyme-linked immunosorbent assay

1. Skin biopsy. Rationale: The skin biopsy is the procedure of choice to diagnose Kaposi's sarcoma, which frequently complicates the clinical picture of the client with acquired immunodeficiency syndrome. Lung biopsy would confirm Pneumocystis jiroveci infection. The enzyme-linked immunosorbent assay and Western blot are tests to diagnose human immunodeficiency virus status.

128. The nurse is reinforcing dietary instructions to a client diagnosed with systemic lupus erythematosus. Which dietary items should the nurse most instruct the client to avoid? 1.Steak 2.Turkey 3.Broccoli 4.Cantaloupe

1. Steak. Rationale: The client with systemic lupus erythematosus is at risk for cardiovascular disorders such as coronary artery disease and hypertension. The client is advised of lifestyle changes to reduce these risks, which include smoking cessation and prevention of obesity and hyperlipidemia. The client is advised to reduce salt, fat, and cholesterol intake.

127. A client diagnosed with acquired immunodeficiency syndrome has a respiratory infection from Pneumocystis jiroveci and a client problem of impaired gas exchange written in the plan of care. Which indicates that the expected outcome of care has not yet been achieved? 1.The client limits fluid intake. 2.The client has clear breath sounds. 3.The client expectorates secretions easily. 4.The client is free of complaints of shortness of breath.

1. The client limits fluid intake. Rationale: The status of the client with a nursing diagnosis of impaired gas exchange would be evaluated against the standard outcome criteria for this nursing diagnosis. These would include that the client breathes easier, coughs up secretions effectively, and has clear breath sounds. The client should not limit fluid intake because fluids are needed to decrease the viscosity of secretions for expectoration.

89. When inspecting the stoma of a client following an ureterostomy 6 hours ago, the nurse notes that the stoma appears pale in color. Which interpretation does the nurse make based on this finding? 1.The vascular supply to the stoma is insufficient. 2.This is a normal appearance of the stoma postoperatively. 3.The client is experiencing a temporary fluid volume excess. 4.The rate of intravenous fluids requires an immediate increase

1. The vascular supply to the stoma is insufficient. Rationale: Following ureterostomy, the stoma should be red and moist. A pale stoma may indicate an inadequate vascular supply. This not a normal postoperative appearance. No data are available to determine whether the client is experiencing a fluid volume excess or a fluid volume deficit. A dry stoma may indicate body fluid deficit. Any sign of darkness or duskiness in the stoma may mean loss of vascular supply and must be corrected immediately or necrosis can occur.

33. The nurse reinforces instructions to the client about breast self-examination (BSE). The nurse instructs the client to lie down and examine the left breast. Which is the correct area for placing a pillow when examining the left breast? 1.Under the left shoulder 2.Under the right scapula 3.Under the right shoulder 4.Under the small of the back

1. Under the left shoulder Rationale: The nurse would instruct the client to lie down and place a towel or pillow under the shoulder on the side of the breast to be examined. If the left breast is to be examined, the pillow would be placed under the left shoulder. Options 2 and 4 are incorrect.

67. The nurse has reinforced discharge instructions regarding home care to a client following a prostatectomy for cancer of the prostate. He is being discharged with an indwelling urinary catheter. Which statement by the client indicates a need for further teaching? 1."I should keep the drainage bag lower than the bladder." 2."I should use the leg bag when I am in bed during the night." 3."The urologist will remove the catheter by deflating the balloon that is inside the bladder." 4."I should observe the urine and understand that the urine may contain some small blood clots."

2. " I should use the leg bag when I am in bed during the night." Rationale: The post prostatectomy client who is discharged with an indwelling urinary catheter needs to be instructed in maintaining the catheter at home. The nurse reviews the printed instructions with the client and caregiver. They need to understand and know how to empty the catheter and keep it aseptic. The client will attach the leg bag, which can be worn under pants, to drain urine while he is up and about. The drainage bag needs to be kept lower than the bladder to facilitate proper drainage. The urine may have some small blood clots but there should be no frank bleeding. The catheter will be removed by the urologist during a post-op office visit by deflating the balloon of the catheter.

113. The client arrives at the ambulatory care center complaining of flulike symptoms. On data collection, the client tells the nurse that he was bitten by a tick and is concerned that the bite is causing the sick feelings. The client requests a blood test to determine the presence of Lyme disease. Which question should the nurse ask next? 1."Was the tick small or large?" 2."When were you bitten by the tick?" 3."Did you save the tick for inspection?" 4."Did the tick bite anyone else in the family?"

2. "When were you bitten by the tick?" Rationale: There is a blood test available to detect Lyme disease; however, it is not a reliable test if performed before 4 to 6 weeks following the tick bite. The appropriate question by the nurse should elicit information related to when the tick bite occurred.

21. The client diagnosed with pemphigus is being seen in the clinic regularly. The nurse should plan care based on which description of this condition? 1.The presence of tiny red vesicles 2.An autoimmune disease that causes blistering in the epidermis 3.The presence of skin vesicles found along the nerve caused by a virus 4.The presence of red, raised papules and large plaques covered by silvery scales

2. An autoimmune disease that causes blistering in the epidermis. Rationale: Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. During the initial examination, clients may have crusting areas instead of intact blisters. Option 1 describes eczema, option 3 describes herpes zoster, and option 4 describes psoriasis.

75. The client calls the emergency department and tells the nurse that he received a bee sting to the arm. The client states that he has received bee stings in the past and is not allergic to bees but the site is painful and asks the nurse how to alleviate the pain. Which primary action should the nurse instruct the client to take? 1.Take two acetaminophen. 2.Apply ice and elevate the site. 3.Lie down and elevate the arm. 4.Place a heating pad on the site.

2. Apply ice and elevate the site. Rationale: When a bee sting occurs and is painful, it is best to treat the site locally rather than systemically. Pain may be alleviated by the application of an ice pack and elevating the site. A heating pad will increase discomfort at the site. Acetaminophen may be taken by the client to assist in alleviating discomfort, but this would not treat the injury at a local level. Lying down and elevating the arm may have some effect on reducing edema at the site but will not directly assist in alleviating the pain at the site of injury.

132. The nurse working in an obstetrical-gynecological primary health care provider's office is instructing a small group of premenopausal female clients about breast self-examination (BSE). Which instruction should the nurse reinforce as the first step to begin the BSE? 1.BSE begins with palpation of the axilla with arm slightly raised. 2.BSE begins with inspection of the breast standing before a mirror. 3.BSE begins with a vertical pattern palpation of the breasts and axillary area. 4.BSE begins in a lying position with palpation of the breasts and axillary area with the arm raised above the head.

2. BSE begins with inspection of the breast standing before a mirror. Rationale: BSE begins with inspection of the breasts while the woman is standing before a mirror. After this is completed the woman then palpates her axilla with her arm only slightly (not fully) raised. The second step of the BSE is vertical pattern palpation of the breasts and the axillary area. The ACS and women's health care experts recommend that the woman lie on her back with a folded towel under the shoulder of the breast to be examined. The arm on the same side is raised above her head.

143. A complete blood cell count is performed on the client with a diagnosis of systemic lupus erythematosus (SLE). The nurse should suspect that which finding will most likely be reported from this blood test? 1.Increased neutrophils 2.Decrease of all cell types 3.Increased red blood cell count 4.Increased white blood cell count

2. Decrease of all cell types. Rationale: In the client with SLE, a complete blood count commonly shows pancytopenia, a decrease of all cell types, probably caused by a direct attack of all blood cells or bone marrow by immune complexes. The other options are incorrect.

83. The nurse is assisting in developing a plan of care for the pregnant client diagnosed with acquired immunodeficiency syndrome (AIDS). The nurse should determine that which is the priority concern for this client? 1.Isolation 2.Development of an infection 3.Inability to care for herself at home 4.Lack of available support services

2. Development of infection. Rationale: Acquired immunodeficiency syndrome decreases the body's immune response, making the infected person susceptible to infections. AIDS affects helper T lymphocytes, which are vital to the body's defense system. Opportunistic infections are a primary cause of death in people affected with AIDS. Therefore, preventing infection is a priority of nursing care. Although the concerns in options 1, 3, and 4 may need to be addressed at some point in the care of the client, these are not priorities.

78. The client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking zidovudine 200 mg orally three times daily. The client reports to the health care clinic for follow-up blood studies, and the results indicate severe neutropenia. Which should the nurse next anticipate to be prescribed for the client? 1.Administration of epoetin alfa 2.Discontinuation of the medication 3.Reduction in the medication dosage 4.The administration of prednisone concurrent with the therapy

2. Discontinuation of the medication. Rationale: Hematological monitoring should be done every 2 weeks in the client taking zidovudine. If severe anemia or severe neutropenia develops, treatment should be discontinued until there is evidence of bone marrow recovery. If anemia or neutropenia is mild, a reduction in dosage may be sufficient. The administration of prednisone may further alter the immune function. Epoetin alfa is given to clients experiencing anemia.

52. A client is tentatively diagnosed with ovarian cancer. The nurse gathers data about which late symptom of this disease? 1.Mild digestive complaints 2.Pelvic pain, anemia, and ascites 3.Normal bowel and bladder function 4.Vague lower abdominal discomfort

2. Pelvic pain , anemia, and ascites. Rationale: Pelvic pain, anemia, and ascites are experienced late in the disease process for ovarian cancer. Vague lower abdominal discomfort and mild digestive complaints are early symptoms. Bowel and bladder functions are also affected early in this type of cancer.

105. The nurse reviews the care plan of a client with cancer undergoing chemotherapy. The nurse notes that the client has a concern about her appearance as a result of alopecia. The nurse plans to tell the client which information about hair loss and regrowth to assist the client in coping with this possible change? 1.Facial hair and body hair are generally not affected. 2.Regrown hair may have a different color and texture. 3.Hair loss is usually permanent for many older adult clients. 4.Hair loss usually begins within 5 days of the first treatment.

2. Regrown hair may have a different color and texture. Rationale: Hair loss is often temporary, and hair grows back once treatments are completed. Hair may have a different color and/or texture when it regrows. Hair loss often begins within 14 days of beginning treatment. Body hair and facial hair also are affected.

99. The nurse reads the chart of the client who has been diagnosed with stage III Lyme disease. The nurse should determine that which sign/symptom best supports this diagnosis? 1.A cardiac dysrhythmia 2.A generalized skin rash 3.Complaints of joint pain 4.Paralysis of a facial muscle

3. Complaints of joint pain. Rationale: Stage III develops within a month to several months after initial infection. It is characterized by arthritic symptoms, such as arthralgia and enlarged or inflamed joints, which can persist for several years after the initial infection. Cardiac and neurological dysfunction occurs in stage II. A rash occurs in stage I. Paralysis of the extremity where the tick bite occurred is not a characteristic of Lyme disease.

95. The nurse should interpret that the client prescribed zalcitabine is experiencing an adverse effect of this medication when which event is reported by the client? 1.Tinnitus 2.Diarrhea 3.Numbness in the legs 4.Burning with urination

3. Numbness in the legs. Rationale: Peripheral neuropathy is an adverse effect associated with the use of zalcitabine, which manifests initially as numbness and burning sensations in the extremities. They may progress to sharp shooting pains or severe continuous burning if the medication is not withdrawn. The other options are not associated with use of this medication.

68. The nurse is assisting in caring for a client receiving chemotherapy. On review of the morning laboratory results, the nurse notes that the white blood cell count is extremely low, and the client is immediately placed on neutropenic precautions. The client's breakfast tray arrives, and the nurse inspects the meal and prepares to bring the tray into the client's room. Which action should the nurse take before bringing the meal to the client? 1.Remove the coffee from the breakfast tray. 2.Ask the client if she feels like eating at this time. 3.Remove the fresh orange from the breakfast tray. 4.Call the dietary department and ask for disposable utensils.

3. Remove the fresh orange from the breakfast tray. Rationale: In the immunocompromised client, a low-bacteria diet is implemented. This includes avoiding fresh fruits and vegetables and implementing thorough cooking of all foods. Foods should be thoroughly cooked. Removing the coffee from the tray is not necessary. Disposable utensils are used for clients who are infectious and present a risk of transmitting an infection to others. It is best to encourage the client to eat because nutrition is very important in a client receiving chemotherapy who is immunocompromised.

3. The nurse is reviewing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory finding is indicative of the massive cell destruction that occurs with the chemotherapy? 1.Anemia 2.Decreased platelets 3.Increased uric acid level 4.Decreased leukocyte count

3.Increased uric acid level. Rationale: Hyperuricemia, elevated levels of uric acid, is especially common after treatment for leukemias and lymphomas, because the therapy results in massive cell destruction and the release of uric acid. Anemia (low red blood cell count), low platelet levels, and low white blood cell counts are associated with the bone marrow abnormalities that are a part of the leukemias and lymphoma disease process.

98. The client diagnosed with Lyme disease tells the nurse, "I heard this disease can affect the heart. Is this true?" The nurse should make which response to the client? 1."Where did you get your information?" 2."Yes, that's true but it rarely ever occurs." 3."It primarily affects the joints with the occasional facial paralysis." 4."It can, but you will be monitored closely for cardiac complications."

4. " It can, but you will be monitored closely for cardiac complications." Rationale: Stage II of Lyme disease develops within 1 to 6 months in the majority of untreated individuals. The serious problems that occur in this stage include cardiac conduction defects and neurological disorders, such as Bell's palsy and paralysis. The remaining options are either untrue or do not effectively address the client's concern.

142. The client reports to the health care clinic to obtain testing regarding human immunodeficiency virus (HIV) status after being exposed to an individual who is HIV positive. The test results are reported as negative and the client tells the nurse that he feels so much better knowing that he has not contracted HIV. The nurse should explain the test results to the client, including which information? 1.There is no further need for testing. 2.The test should be repeated in 1 week. 3.A negative HIV test is considered accurate. 4.A negative HIV test is not considered accurate during the first 6 months after exposure.

4. A negative HIV test is not considered accurate during the first 6 months exposure. Rationale: A test done for HIV should be repeated. There might be a lag period after the infection occurs and before antibodies appear in the blood. Therefore, a negative HIV test is not considered accurate during the first 6 months after exposure.

18. Which individual is least at risk for the development of Kaposi's sarcoma? 1.A kidney transplant client 2.A male with a history of same-sex partners 3.A client receiving antineoplastic medications 4.An individual working in an environment where exposure to asbestos exists

4. An individual working in an environment where exposure to asbestos exists. Rationale: Kaposi's sarcoma is a vascular malignancy that presents as a skin disorder and is a common acquired immunodeficiency syndrome indicator. It is seen frequently in men with a history of same-sex partners. Although the cause of Kaposi's sarcoma is not known, it is considered to be the result of an alteration or failure in the immune system. The renal transplant client and the client receiving antineoplastic medications are at risk for immunosuppression. Exposure to asbestos is not related to the development of Kaposi's sarcoma.

48. The home care nurse is prescribing dressing supplies for the client who has an allergy to latex. The nurse should ask the medical supply personnel to deliver which items? 1.Elastic bandages 2.Adhesive bandages 3.Brown Ace bandages 4.Cotton pads and silk tape

4. Cotton pads and silk tape. Rationale: Cotton pads and plastic or silk tape are latex-free products. The items identified in the incorrect options are products that contain latex.

139. The nurse is caring for a client who will have insertion of an internal cervical radiation implant. Which interventions should the nurse review with the client to prepare her for this procedure? Select all that apply. 1.The client's activity will be bed rest. 2.The client will have an indwelling urinary catheter placed. 3.Caregivers will wear lead shields while caring for the client. 4.Stool softeners will be administered to prevent constipation. 5.Active range-of-motion (ROM) exercises will be done at least twice daily.

Correct Answer: 1, 2, 3 Rationale: When a client has an internal cervical radioactive implant, precautions are planned to protect those around the client and to keep the implant in place and not harm the client. The client will be placed on bed rest, will have an indwelling urinary catheter in place, and caregivers will wear lead shields for protection. Clients are not normally administered stool softeners because of the risk of loose stools, which could potentially lead to dislodgement of the implant. Clients are log rolled so as not to move the implant. ROM exercises are not done.

90. The nurse is assisting in developing a postoperative plan of care for a client following a right mastectomy. Which interventions will be included in the plan of care? Select all that apply. 1.Place the right arm on a pillow. 2.Monitor the right arm for edema. 3.Check the incision for approximation. 4.Place a warm compress on the affected arm. 5.Monitor and measure drainage in the Jackson-Pratt drain. 6.Place a notation: "No intravenous (IVs), blood draws, or blood pressure readings in right arm."

Correct Answer: 1, 2, 3, 5, 6 Rationale: Following mastectomy, the arm should be elevated above the level of the heart. Specific arm exercises should be encouraged. No blood pressure readings, injections, IV lines, or blood draws should be performed on the affected arm, and a sign above the bed will alert all health care personnel. The nurse would also assess the incision for approximation (incision is pulled together or intact) during dressing changes and monitor and measure drainage in the Jackson-Pratt drain. Warm compresses are not used in the postoperative period because this will promote edema in the arm.

157. Which symptoms should the nurse anticipate and monitor for in clients diagnosed with stage 4 human immunodeficiency virus (HIV) infection? Select all that apply. 1.Lymphoma 2.Kaposi's sarcoma 3.Asymptomatic infection 4.Candidiasis of the esophagus 5.Recurrent upper respiratory infection 6.Unintentional weight loss less than 10% of body weight

Correct Answer: 1, 2, 4 Rationale: Lymphoma; Kaposi's sarcoma; and candidiasis of the esophagus, trachea, or lung are classified as clinical stage 4 HIV infection symptoms. Asymptomatic infection is a clinical stage 1 symptom. Recurrent upper respiratory infections are characteristic of stage 2 HIV infection as is the unintentional weight loss of less than 10%.

11. The client is admitted to the hospital with a diagnosis of suspected Hodgkin's disease. Which signs and symptoms of the client are associated with Hodgkin's disease? Select all that apply. 1.Fatigue 2.Weakness 3.Joint pain 4.Weight gain 5.Night sweats 6.Enlarged lymph nodes

Correct Answer: 1, 2, 5, 6 Rationale: Hodgkin's disease (lymphoma) is a chronic, progressive neoplastic disorder of the lymphoid tissue that is characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Other signs and symptoms include fatigue, weakness, weight loss, and night sweats. Weight gain and joint pain are not associated with Hodgkin's disease.

2. The nurse is assisting with conducting a health-promotion program to community members regarding testicular cancer. The nurse determines that further teaching is needed if a community member states that which is a sign/symptom of testicular cancer? Select all that apply. 1.Alopecia 2.Back pain 3.Painless testicular swelling 4.A heavy sensation in the scrotum 5.Elevation in prostate specific antigen (PSA) levels

Correct Answer: 1, 5 Rationale: Alopecia is not a sign/symptom of testicular cancer. However, it may occur as a result of radiation or chemotherapy. Elevated PSA levels are associated with prostate cancer. Testicular swelling without pain and a feeling of heaviness in the scrotum occur with testicular cancer as a result of the tumor growing. Back pain may indicate metastasis to the retroperitoneal lymph nodes.

58. A client with endometrial cancer is receiving doxorubicin, an antineoplastic agent. The nurse should specifically collect data about which criteria? Select all that apply. 1.Electrocardiogram 2.Level of orientation 3.Neuromuscular reflexes 4.Pupillary response to light 5.Hematological laboratory values

Correct Answer: 1, 5 Rationale: Doxorubicin has adverse/side effects affecting the red and white blood cell counts and platelets. In addition, it is known to be cardiotoxic, causing dysrhythmias and electrocardiogram changes. Because of bone marrow suppression during therapy with antineoplastic agents, hematological laboratory values should be monitored closely. The incorrect options reflect neurological symptoms, which are not the concern with this medication.

1. The nurse is assisting with developing a plan of care for the client with multiple myeloma. Which nursing intervention should be included to prevent renal failure for this client? Select all that apply. 1.Encouraging fluids 2.Providing frequent oral care 3.Coughing and deep breathing 4.Monitoring the red blood cell count 5.Monitoring serum calcium and uric acid levels

Correct Answer: 1, 5 Rationale: In order to prevent renal failure in the client with multiple myeloma, the nurse should encourage fluids and monitor serum calcium and uric acid levels. Hypercalcemia secondary to bone destruction is a priority concern in the client with multiple myeloma. The nurse should encourage fluids in adequate amounts to maintain an output of 1.5 L to 2 L a day. Clients require about 3 L of fluid per day. The fluid is needed not only to dilute the calcium and uric acid, but also to prevent protein from precipitating in the renal tubules. Oral care, encouraging coughing and deep breathing, and monitoring the red blood cell count are important for clients with cancer, but these interventions are not specific to prevention of renal failure.

154. The nurse is caring for the client diagnosed with systemic lupus erythematosus (SLE) that is affecting the hematopoietic system. Which data regarding signs and symptoms should the nurse anticipate collecting? Select all that apply. 1.Anemia 2.Alopecia 3.Splenomegaly 4.Discoid erythema 5.Lymphadenopathy 6.Raynaud's phenomenon

Correct Answer: 1,3, 5 Rationale: Hematology is the study of blood and blood-forming tissues, which include the bone marrow, blood, spleen, and lymph system. Therefore, anemia is a hematological system issue, and it often occurs with SLE. Lymphadenopathy, or enlarged lymph nodes, and splenomegaly, or an enlarged spleen, are also issues of the hematological system and occur with SLE. Alopecia is loss of hair, which is a dermatological condition, as is discoid erythema. Raynaud's phenomenon is cardiopulmonary in origin causing pallor and diminished blood flow to fingers.

37. The nurse is caring for a client after a mastectomy. Which nursing interventions should assist with preventing lymphedema of the affected arm? Select all that apply. 1.Placing cool compresses on the affected arm 2.Elevating the affected arm on a pillow above heart level 3.Taking no blood pressure measurements in the affected arm 4.Avoiding arm exercises during the immediate postoperative period 5.Maintaining an intravenous (IV) insertion site below the antecubital area on the affected side

Correct Answer: 2, 3 Rationale: Lymphedema is a potential complication of mastectomy, especially if the surgery included axillary node resection. After mastectomy, the primary health care provider's prescriptions regarding positioning are followed. No compression of the arm, as with a blood pressure measurement, should ever be done in the arm. The arm on the surgical side is usually elevated above the level of the heart, and simple arm exercises should be encouraged. No blood pressure readings, injections, IV line insertions, or blood draws should be performed on the affected arm. Cool compresses are not a recommended measure to prevent lymphedema from occurring.

38. The nurse is reinforcing instructions to a client on performing a testicular self-examination (TSE). Which instructions should the nurse provide to the client? Select all that apply. 1.Examine the testicles while lying down. 2.The best time for the examination is after a shower. 3.Gently touch the testicle with one finger to feel for a growth. 4.Testicular examinations should be done at least every 6 months. 5.Set up a schedule of performing TSE on the same day each month.

Correct Answer: 2, 5 Rationale: The TSE is recommended after a warm bath or shower when the scrotal skin is relaxed. The client should set up a schedule of performing TSE the same day each month in order not to forget. The client should stand to examine the testicles. Using both hands, with the fingers under the scrotum and the thumbs on top, the client should gently roll the testicles, feeling for any lumps. The TSE should be performed monthly.

69. he nurse is assisting in caring for a client with a diagnosis of bladder cancer who recently received chemotherapy. The nurse receives a telephone call from the laboratory who reports that the client's platelet count is 20,000 mm3. Based on this laboratory value, the nurse revises the plan of care and suggests including which interventions? Select all that apply. 1.Monitor for signs of infection in the client. 2.Monitor skin for the presence of petechiae. 3.Return delivered fresh flowers to the florist. 4.Instruct the client not to eat any fresh fruits. 5.Administer no intramuscular injections and limit venipunctures.

Correct Answer: 2, 5 Rationale: When the platelet count is decreased, the client is at risk for bleeding. A high risk of hemorrhage exists when the platelet count is less than 20,000 mm3. Fatal central nervous system hemorrhage or massive gastrointestinal hemorrhage can occur when the platelet count is less than 10,000 mm3. The client should be assessed for signs of bleeding. Petechiae are tiny red or purple dots noted on the skin due to ruptured capillaries. Many petechiae are noted with low platelet counts. Bleeding precautions are instituted and include no intramuscular injections and limited venipunctures, using small gauge needles only. Options 1, 3, and 4 are specific interventions related to the risk of infection: fresh flowers, fruits, and vegetables should be eliminated and signs of infection should be monitored.

158. Which findings should cause the nurse to postpone administration of an immunization and do further data collection? Select all that apply. 1.Over 60 years of age 2.Immune deficiency disease 3.Axillary temperature of 99° F 4.Negative tuberculin skin test at 48 hours 5.Type 1 diabetes mellitus requiring insulin 6.Familial history of severe allergic response to the immunization

Correct Answer: 2, 6 Rationale: Immune deficiency disease or immunosuppressive therapy require postponement of vaccination and checking with primary medical provider. Allergic responses to substances by the client or family members should be investigated. Being over 60 years of age is not a reason to postpone or cancel immunization. Axillary temperature of 99 is not febrile. A negative tuberculin skin test for tuberculosis is expected and normal. Having insulin-dependent diabetes mellitus places a person at risk for some conditions such as pneumonia and influenza, making immunizations more important.

4. The client is receiving external radiation to the neck for cancer of the larynx. The nurse monitors the client knowing that which are side/adverse effects of the external radiation? Select all that apply. 1.Dyspnea 2.Diarrhea 3.Sore throat 4.Constipation 5.Red and dry skin over neck

Correct Answer: 3, 5 Rationale: External radiation is used to treat cancer in a specific area by emission of ionizing radiation beams that destroy cancer cells and have minimal damage to the surrounding normal cells. The client receiving external radiation experiences both general side/adverse effects such as fatigue, nausea, anorexia and localized side/adverse effects in the specific area receiving radiation. A client who is receiving radiation to the larynx is most likely to experience a sore throat and dry, reddened skin in the throat area. Diarrhea or constipation occur with radiation to the gastrointestinal (GI) tract. Dyspnea may occur with lung involvement.

7. The nurse provides skin care instructions to the client who is receiving external radiation therapy. Which statement by the client indicates the need for further teaching? Select all that apply. 1."I will handle the area gently." 2."I will wear loose-fitting clothing." 3."I will avoid the use of deodorants." 4."I will limit sun exposure to 1 hour daily." 5."I will apply moisturizer with a cotton tipped applicator for itching. "

Correct Answer: 4, 5 Rationale: The client needs to be instructed to avoid exposure to the sun because of the risk of burns, resulting in altered tissue integrity. No lotions, ointments, or medications should be applied to the skin unless prescribed by the radiologist.

77. The nurse is reinforcing client education regarding symptoms of testicular cancer. The nurse encourages the client to report which symptoms as being associated with testicular cancer? Select all that apply. 1.Difficulty attaining an erection 2.Purulent discharge from the penis 3.Difficulty initiating the urine stream 4.A grainy mass palpated in a testicle 5.An enlargement of one of the testes

Correct Answer: 4, 5 Rationale: A grainy mass palpated in a testicle and enlargement of the testes are symptoms of testicular cancer and should be reported. Erectile dysfunction can occur from vascular disease as well as diabetes mellitus. Purulent drainage from the penis suggests an infection. Difficulty initiating the urine stream is often experience by men with benign prostatic hypertrophy (BPH).

5. The nurse is reinforcing instructions to a client receiving external radiation therapy. The nurse determines that the client needs further teaching if the client states an intention to take which action? Select all that apply. 1.Eat a high-protein diet. 2.Avoid exposure to sunlight. 3.Wash the skin with a mild soap and pat it dry. 4.Apply pressure on the radiated area to prevent bleeding. 5.Avoid standing within 6 feet of persons under the age of 18 years.

Correct Answer: 4, 5 Rationale: The client should avoid pressure on the radiated area and wear loose-fitting clothing to prevent a disruption in the skin integrity. A client receiving external radiation is not radioactive and does not need to avoid other persons, including young people. A diet high in protein assists in the healing process. Avoiding sunlight and washing the skin with gentle soap and patting dry will assist with preventing skin disruption.

156. Which medications should the nurse expect to be prescribed to effectively reduce nasal edema and rhinorrhea (thin watery discharge from the nose)? Select all that apply. 1.Isoniazid 2.Terbutaline 3.Corticotropin 4.Oxymetazoline 5.Phenazopyridine 6.Pseudoephedrine

Correct Answer: 4, 6 Rationale: Oxymetazoline and pseudoephedrine are decongestants that reduce nasal edema and rhinorrhea. Corticotropin is an anti-inflammatory agent. Isoniazid is used in the treatment of tuberculosis. Terbutaline causes bronchodilation. Phenazopyridine is a urinary analgesic.

39. The nurse is assisting with conducting a health-promotion program at a local school. The nurse determines that there is a need for further teaching if a student identifies which risk factors associated with cancer? Select all that apply. 1.Stress 2.Viral factors 3.Exposure to radiation 4.Low-fat and high-fiber diets 5.Maintaining a normal weight

Correct Answer: 4，5 Rationale: A healthy life style is one way to lower the risk of cancer. This includes maintaining a normal weight and following a low-fat, high-fiber diet. Viruses may be one of multiple agents that act to initiate carcinogenesis and that have been associated with several types of cancer. Increased stress has been associated with causing the growth and proliferation of cancer cells. Two forms of radiation, ultraviolet and ionizing, can lead to cancer. High-fiber diets may reduce the risk of colon cancer. A diet that is high in fat and obesity may increase the risk of the development of certain cancers.