NCLEX Review Quiz 3 Saunder's Questions (Ch. 36-38; 50-53)

544. The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor? 1. Age younger than 50 years 2. History of colorectal polyps 3. Family history of colorectal cancer 4. Chronic inflammatory bowel disease

1 Colorectal cancer risk factor include age older than 50 years, a family history of the diease, colorectal polyps and chronic inflammatory bowel disease.

560. A clinic nurse prepares a teaching plan for a client receiving an antineoplastic medication. When implementing the plan, the nurse should make which statement to the client? 1. "You can take aspirin as needed for headache" 2. "You can drink beverages containing alcohol in moderate amounts each evening" 3. "You need to consult with the HCP before receiving immunizations" 4. "It is fine to recive a flu cavvine at the local health fair without HCP approval because the flu is so contagious"

3 Because antineoplastic medications lower the resistance of the body, client must be informed not to receive immunizations without an HCP's approval. Clients also need to avoid contact with individual who have recently received a live virus vaccine. Clients need to avoid aspirin and aspirin-containing products to minimize the risk of bleeding, and they need to avoid alcohol to minimize the risk of toxicity and side/adverse effects.

375. The nurse is providing home care instructions to the parents of a 10-year-old child with hemophilia. Which sport activity should the nurse suggest for this child? 1. Soccer 2. Basketball 3. Swimming 4. Field hockey

3 Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Children with hemophilia need to avoid contact sports and to take precautions such as wearing elbow and knee pads and helmets with other sports. The safe activity for them is swimming.

567. The nurse is analyzing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory value would the nurse specifically note as a result of the massive cell destruction that occurred from the chemotherapy? 1. Anemia 2. decreased platelets 3. Increased uric acid level 4. Decreased leukocyte count

3 Hyperuremia is especially common following treatment of leukemias and lyphomas because chemotherapy results in massive cell kill. Although options 1, 2, and 4 also may be noted, an increased uric acid level is related specifically to cell destruction

392. A diagnosis of Hodgkin's disease is suspected in a 12 y/o child seen in a clinic. Several diagnostic studies are performed to determine the presence of this disease. Which diagnostic test result will confirm the diagnosis of Hodgkin's disease? 1. Elevated vanillylmandelic acid urinary levels 2. The presence of blast cells in the bone marrow 3. The presence of Epstein-Barr virus in the blood 4. The presence of Reed-Sternberg cells in the lymph nodes

4 Hodgkin's disease (a type of lymphoma) is a malignancy of the lymph nodes. The presence of giant, multinucleated cells (Reed-Sternberg cells) is the classic characteristic of this disease. Elevated levels of vanillylmandelic acid in the urine may be found in children with neuroblastoma. The presence of blast cells in the bone marrow indicates leukemia. Epstein-Barr virus is associated with infectious mononucleosis.

503. The clinic nurse assesses the skin of a client with a diagnosis of psoriasis. The nurse understands that which characteristic is associated with this skin disorder? 1. Oily skin 2. Clear, thin nail beds 3. Red-purplish scaly lesions 4. Silver-white scaly patched

Answer 4 Psoriatic patches are covered with silvery white scales. Affected areas include the scalp, elbows, knees, shins, sacral area, and trunk. Thickening, pitting, and discoloration of the nails occur. Pruritis may occur. The lesions in psoriasis are not red-purplish scaly lesions and the skin is dry.

506. When assessing a lesion diagnosed as malignant melanoma, the nurse most likely expects to note which finding? 1. An irregularly shaped lesion 2. A small papule with a dry, rough scale 3. A firm, nodular lesion topped with crust 4. A pearly papule with a central crater and a waxy border

Answer: 1 A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color. Actinic keratosis, a premalignant lesion, appears as a small scale. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration. Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border.

527. The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid (Azelex). Because of the medication prescription, the nurse would suspect that the client is being treated for which condition? 1. Acne 2. Eczema 3. Hair loss 4. Herpes simplex

Answer: 1 Azelaic acid is a topical medication used to treat mild to moderate acne. The acid appears to work by suppressing the growth of Propionibacterium acnes and by ddecreasing the proliferation of keratinocytes. Options 2, 3, and 4 are incorrect.

510. The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? 1. Return of distal pulses 2. Brisk bleeding from the site 3. Decreased edema formation 4. Formation of granulation tissue

Answer: 1 Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy

525. A client with severe acne is seen in the clinic and the health care provider prescribes isotretinoin (Amnesteem or Claravis). The nurse reviews the client's medication record and would contact the HCP if the client is taking which medication? 1. Vitamin A 2. Digoxin (Lanoxin) 3. Furosemide (Lasix) 4. Phenytoin (Dilantin)

Answer: 1 Isotretinoin is a metabolite of vitamin A and can produce generalized intensification of isotretinoin toxicity. Because of the potential for increased toxicity, vitamin A supplements should be discontinued before isotretinoin therapy. Options 2, 3, and 4 are not contraindicated with the use of isotretinoin.

519. The nurse is caring for a client who suffered inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on the level, the nurse would anticipate noting which sign in the client? 1. Coma 2. Flushing 3. Dizziness 4. Tachycardia

Answer: 2 Carbon monoxide levels between 11-20% result in flushing, headache, decreased visual acuity, decreased cerebral functioning, and slight breathlessness; levels of 21-40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, tachycardia; lvls of 41-60% result in seizure and coma; and levels higher than 60% result in death.

524. Isotretinoin (Amnesteem or Claravis) is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed? 1. Platelet count 2. Triglyceride level 3. Complete blood count 4. White blood cell count

Answer: 2 Isotretinoin can elevate triglyceride levels. Blood triglyceride levels hould be measured before treatment and periodically thereafter until the effect on the triglycerides has been evaluated. Options 1, 3, and 4 do not need to be monitored specifically during this treatment.

516. The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? 1. Vital signs 2. Urine output 3. Mental status 4. Peripheral pulses

Answer: 2 Successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. However, the most reliable indicator for determining adequacy of fluid resuscitation is the urine output. For an adult, the hourly urine volume should be 30-50 mL/hr.

528. Silver sulfadiazine (Silveadene, Thermazene, SSD cream) is prescribed for a client with a partial thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? 1. "The medication is an antibacterial" 2. "The medication will help heal the burn" 3. "The medication will permanently stain my skin" 4. "The medication should be applied directly to the wound"

Answer: 3 Silver sulfadiazine is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not stain the skin.

517. The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique? 1. Using sterile sheets and linens 2. Performing strict hand washing technique 3. Wearing gloves and a gown only when giving direct care to the client 4. Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron

Answer: 3 Thorough hand washing should be done before and after each contact with the burn-injured client. Sterile sheets and linens are used because of the client's high risk for infection. Protective garb, including gloves, cap, masks, show covers, gowns, and plastic apron, need to be worn when in the client's room and when directly caring for the client.

562. The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase (Elspar), an antineuoplastic agent. The nurse contacts theHCP before administering the medication if which disorder is documented in the client's history? 1. Pancreatitis 2. Diabetes mellitus 3. Myocardial infarction 4. Chronic obstructive pulmonary disease

1 Asparaginase is contraindicated if hypersensitivity exists, in pancreatitis, or if the client has a history of pancreatitis. The medication impairs pancreatic function and pancreatic function tests should be performed before therapy begins and when a week or more has elapsed between dose administrations. The client needs to be monitored for signs of pancreatitis, which include nausea, vomiting, and abdominal pain. The conditions noted in options 2, 3, and 4 are not contraindicated with this medication.

530. The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder? 1. Increased calcium level 2. Increased white blood cells 3. Decreased blood urea nitrogen level 4. Decreased number of plasma cells in the bone marrow

1 Findings indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue, and as elevated blood urea nitrogen level. An increased white blood cell count may or may not be present and is not related specifically to multiple myeloma.

546. The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function? 1. The passage of flatus 2. Absent bowel sounds 3. The client's ability to tolerate food 4. Bloody drainage from the colostomy

1 Following abdominal perineal resection, the nurse would expect the colostomy to begin to function within 72 hours after surgery, although it may take up to 5 days. The nurse should assess for a return of peristalsis, listen for bowel sounds, and check for the passage of flatus. Absent bowel sounds would not indicate the return of peristalsis. The client would remain NPO until bowel sounds return and the colostomy is functioning. Bloody drainage is not expected from a colostomy.

531. The nurse is developing a plan of care for the client with multiple myeloma and includes which priority intervention in the plan? 1. Encouraging fluids 2. Providing frequent oral care 3. Coughing and deep breathing 4. Monitoring the red blood cell count

1 Hypercalcemia caused by bone destruction is a priority concern in the client with multiple myeloma. The nurse should administer fluid in adequate amounts to maintain a urine output of 1.5 to 2 L/day; this requires about 3 L of fluid intake per day. The fluid needed not only to dilute the clacium overload but also to prevent protein from precipitating in the renal tubules. Options 2, 3, and 4 may be components of the plan of care but not the priority in this client.

385. A child undergoes surgical removal of a brain tumor. During the postoperative period, the nurse is monitoring the child and notes that the child is restless, the pulse rate is elevated, and the blood pressure has decreased significantly from the baseline value. The nurse suspects that the child is in shock. Which is the most appropriate nursing action? 1. Notify the HCP 2. Place the child in a supine position 3. Place the child in Trendelenburg's position 4. Increase the flow rate of the intravenous fluids

1 In the event of shock, the HCP is notified immediately before the nurse changes the child's position or increases intravenous fluids. After craniotomy, a child is never placed supine or Trendelenburg's position because it increases ICP and the risk for bleeding. The head of the bed should be elevated. Increasing intravenous fluids can cause an increase in ICP.

388. The nurse analyzed the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 19,500 cells/mm3. On the basis of this laboratory result, which intervention should the nurse include in the plan of care? 1. Initiate bleeding precautions 2. Monitor closely for signs of infection 3. Monitor the temperature every 4 hours 4. Initiate protective isolation precautions

1 Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. It affects the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production (thrombocytopenia). If a child is severely thrombocytopenic and has a platelet count less than 20,000 cells/mm3, bleeding precautions need to be initiated because of the increased risk of bleeding or hemorrhage. Precautions include limiting activity that could result in head injury, using soft toothbrushes, checking urine and stools for blood, and administering stool softners to prevent straining with constipation. In addition, suppositories, enemas, and rectal temperatures are avoided. Option 2, 3, and 4 are related to the prevention of infection rather than bleeding.

370. The clinic nurse is reviewing the health care provider's prescription for a child who has been diagnosed with scabies. Lindane has been prescribed for the child. The nurse questions the prescription if which is noted in the child's record? 1. The child is 18 months old 2. The child is being bottle-fed 3. A sibling is using lindane for the treatment of scabies 4. The child has a history of frequent respiratory infections

1 Lindane is a pediculicide product that may be prescribed to treat scabies. It is contraindicated for children younger than 2 years because they have more permeable skin, and high systemic absorption may occur, placing the child at risk for central nervous system toxicity and seizures. Lindane also is used with caution in children between the ages of 2 and 10 years. Siblings and other household members should be treated simultaneously. Options 2 and 4 are unrelated to the use of lindane. Lindane is not recommended for use by a breast-feeding woman because the medication is secreted into breast milk.

367. The mother of a 3-year-old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin? 1. Fine grayish red lines 2. Purple-colored lesions 3. Thick, honey colored crusts 4. Clusters of fluid-filled vesicles

1 Scabies is a parasitic skin disorder caused by an infestation of Sarcoptes scabiei (itch mite). Scabies appears as burrows or fine grayish red, threadlike lines. They may be difficult to see if they are obscured by excoriation and inflammation. Purple-colored lesions may indicate various disorders, including systemic conditions. Thick, honey-colored crusts are characteristic of impetigo or secondary infection in eczema. Clusters of fluid filled vesicles are seen in herpes virus infection.

389. The nurse is monitoring a 3 y/o child for signs and symptoms of increased intracranial pressure after a craniotomy. The nurse plans to monitor for which early sign or symptom of increased ICP? 1. vomiting 2. bulging anterior fontanel 3. increasing head circumference 4. complaints of a frontal headache

1 The brain, although well protected by the solid bony cranium, is highly susceptible to pressure that may accumulate within the enclosure. Volume and pressure must remain constant within the brain. A change in the size of the brain, such as occurs with edema or increased volume of intracranial blood or CSF without a compensatory change, leads to an increase in intracranial pressure, which may be life-threatening. Vomiting, an early sign of increased ICP, can become excessive as pressure builds up and stimulates the medulla in the brainstem, which houses the vomiting center. Children with open fontanels (posterior fontanels closes at 2 to 3 months; anterior fontanel closes at 12 to 18 months) compensate for ICP changes by skull expansion and subsequent bulging fontanels. When the fontanels have closed, nausea, excessive comiting, diplopia, and headaches become pronounced, with headaches becoming more prevalent in older children.

536. The nurse is caring for a client who is postoperative following a pelvic exenteration and the HCP changes the client's diet from NPO status to clear liquids. The nurse should check which priority item before administering the diet? 1. Bowel sounds 2. Ability to ambulate 3. Incision appearance 4. Urine specific gravity

1 The client is kept NPO until peristalsis returns, usually in 4 to 6 days. When signs of bowel function return, clear fluids are given to the client. If no distention occurs, the diet is advanced as tolerated. The most important assessment is to assess bowel sounds before feeding the client. Options 2, 3, and 4 are unrelated to the data in the question.

550. The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency? 1. Cyanosis 2. Arm edema 3, Periorbital edema 4. Mental status changes

3 Superior vena cava syndrome occurs when superior vena ccava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the monitoring 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. Cyanosis and mental status changes are late signs

535. The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment? 1. The client's pain rating 2. Nonverbal cues from the client 3. The nurse's impression of the client's pain 4. Pain relief after appropriate nursing intervention

1 The client's self-report is a critical component of pain assessment. The nurse should ask the client to describe the pain and listen carefully to the words the client uses to describe the pain. Nonverbal cues from the client are important but are not the most appropriate pain assessment measure. The nurse's impression of the client's pain is not appropriate in determining the client's level of pain. Assessing pain relief is an important measure, but this option is not related to the subject of the question.

386. The mother of a 4 y/o child tells the pediatric nurse that child's abdomen seems to be swollen. During further assessment of subjective data, the mother tells the nurse that the child is eating well and that the activity level of the child is unchanged. The nurse, suspecting the possibility of Wilms' tumor, should avoid which during the physical assessment? 1. Palpating the abdomen for a mass 2. Assessing the urine for the presence of hematuria 3. Monitoring the temperature for the presence of fever 4. Monitoring the blood pressure for the presence of hypertension

1 Wilm's tumor is the most common intraabdominal and kidney tumor of childhood. If Wilms' tumor is suspected, the tumor mass should not be palpated by the nurse. Excessive manipulation can cause seeding of the tumor and spread of the cancerous cells. Hematuria, fever, and hypertension are clinical manifestations associated with Wilms' tumor.

383. The nurse is conducting staff in-service training on von Willebrand's disease. Which should the nurse include as characteristics of von Willebrand's disease? Select all that apply. 1. Easy bruising occurs 2. Gum bleeding occurs 3. It is a hereditary bleeding disorder 4. Treatment and care are similar to that for hemophilia 5. It is characterized by extremely high creatinine levels 6. The disorder causes platelets to adhere to damaged endothelium

1, 2, 3, 4, 6 von Willebrand's disease is a hereditary bleeding disorder characterized by a deficiency of or a defect in a protein termed von Willebrand factor. The disorder causes platelets to adhere to damaged endothelium. It is characterized by an increased tendency to bleed from mucous membranes. Assessment findings include epistaxis, gum bleeding, easy bruising, and excessive menstrual bleeding. An elevated creatinine level is not associated with this disorder.

566. The nurse is monitoring the intravenous infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. On inspection of the site, the nurse notes redness and swelling and that the infusion of the medication has slowed in rate. The nurse suspects extravasation and should take which actions? Select all that apply. 1, Stop the infusion 2, Notify the HCP 3. Prepare to apply ice or heat to the site 4. Restart the IV at a distal part of the same vein 5. Prepare to administer a prescribed antidote into the site 6. Increase the flow rate of the solution to flush the skin and subcutaneous tissue

1, 2, 3, 5 Redness and swelling and a slowed infusion idicate signs of extravasation. If the nurse suspects extravasation during the intravenous administration of an antineoplastic medication, the infusion is stopped and the HCP is notified. Ice or heat may be prescribed for application to the site and an antidote may be prescribed to be administered into the site. Increasing the flow rate can increase damage to the tissues. Restarting an IV in the same vein can increase damage to the site and veins.

549. A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the health care provider will request which prescriptions? Select all that apply. 1. Radiation 2. Chemotherapy 3. Increased fluid intake 4. Decreased oral sodium intake 5. Serum sodium level determination 6. Medication that is antagonistic to antidiuretic

1, 2, 5, 6 Cancer is a common cause of SIADH. In SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium) and some degree of fluid retention. The syndrome is managed by treating the condition and cause and usually includes fluid retention, increased sodium intake, and medication with a mechanism of action that is antagonistic to antidiuretic hormone. Sodium levels are monitored closely because hypernatremia can develop suddenly as a result of treatment. The immediate institution of appropriate cancer therapy, usually radiation or chemotherapy, can cause tumor regression so that antidiuretic hormone synthesis and release processes return to normal.

539. The nurse is caring for a client with bladder cancer and bone metastasis. What signs/symptoms would the nurse recognize as indications of possible oncological emergency? Select all that apply. 1. Facial edema in the morning 2. Serum calcium level of 12 mg/dL 3. Weight loss of 20 lb in 1 month 4. Serum sodium level of 136 mg/dL 5. Serum potassium level of 3.4 mg/dL 6. Numbness and tingling of the lower extremities

1, 2, 6 Oncological emergengies include sepsis, disseminated intravascular coagulation, SIADH, spinal cord compression, hypercalcemia, superior vena cava syndrome, and tumor lysis syndrome. Blockage of blood flow to the venous system of the head resulting in facial edema is a sign of superior vena cava syndrome. A serum calcium level of 12 mg/dL indicates hypercalcemia. Numbness and tingling of the lower extremities could be a sign of spinal cord compression. Mild hypokalemia and weight loss are not oncological emergencies. A sodium level of 136 mg/dL is a normal level.

394. The nurse is performing an assessment on a 10 y/o child suspected to have Hodgkin's disease. The nurse understands that which assessment findings are specifically characteristics of this disease? Select all that apply. 1. Abdominal pain 2. Fever and malaise 3. Anorexia and weight loss 4. Painful, enlarged inguinal lymph nodes 5. Painless, firm, and movable adenopathy in the cervical area

1, 5 Hodgkin's disease (a type of lymphoma) is a malignancy of the lymph nodes. Specific clinical manifestations associated with Hodgkin's disease include painless, firm, and movable adenopathy in the cervical and supraclavicular areas and abdominal pain as a result of enlarged retroperitoneal nodes. Hepatosplenomegaly also is noted. Although fever, malaise, anorexia, and weight loss are associated with Hodgkin's disease, these manifestations are seen in many disorders.

382. The nurse is reviewing a health care provider's prescriptions for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? Select all that apply. 1. Restrict fluid intake 2. Position for comfort 3. Avoid strain on painful joints 4. Apply nasal oxygen at 2 L/min 5. Provide a high-calorie, high-protein diet 6. Give meperidine (Demerol) 25 mg intravenously every 4 hours for pain

1, 6 Sickle cell anemia is one of a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the RBC; insufficient oxygen causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstructing capillary blood flow. Oral and intravenous fluids are an important part of treatment. Meperidine (Demerol) is not recommended for a child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. The nurse would question the prescription for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain on painful joints, oxygen, and a high-calorie and high-protein diet are also important parts of the treatment plan.

540. 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 condition? 1. Rupture of the bladder 2. The development of a vesicovaginal fistula 3. Extreme stress caused by the diagnosis of cancer 4. Altered perineal sensation as a side effect of radiation therapy

2 A vesicovaginal fistula is a genital fistula that occurs between the bladder and vagina. The fistula is an abnormal opening between these two body parts and if thei occurs, the client may experience drainage of urine through the vagina. The client's complaint is not associated with options 1, 3, or 4.

376. The nursing student is presenting a clinical conference and discusses the cause of beta-thalassemia. The nursing student informs that a child at greatest risk of developing this disorder is which one? 1. A child of Mexican descent 2. A child of Mediterranean descent 3. A child whose intake of iron is extremely poor 4. A breast-fed child of a mother with chronic anemia

2 Beta-thalassemia is an autosomal recessive disorder characterized by the reduced production of one of the globin chains in the synthesis of hemoglobin (both parents must be carriers to produce a child with beta-thalassemia major), This disorder is found primarily in individuals of Mediterranean descent.

558. A client with acute myelocytic leukemia us being treated with busulfan (Mtleran, Bussulfex). Which laboratory value would the nurse specifically monitor during treatment with this medication? 1. Clotting time 2. uric acid level 3. potassium level 4. blood glucose level

2 Busulfan (Myleran, Busulfex) can cause an increase in the uric acid level. Hyperuricemia can produce uric acid nephropathy, renal stones, and acute kidney injury. Option 1, 3, and 4 are not specifically related to this medication

384. The nurse is monitoring a child for bleeding after surgery for removal of a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which intervention should the nurse perform immediately? 1. Reinforce the dressing 2. Notify the health care provider 3. Document the findings and continue to monitor 4. Circle the area of drainage and continue to monitor

2 Colorless drainage on the dressing in a child after craniotomy indicates the presence of cerebrospinal fluid and should be reported to the HCP immediately. Options 1, 3 and 4 are not immediate nursing interventions because they do not address the need for immediate interventions to prevent complications.

555. The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? 1. Placing cool compresses on the affected arm 2. Elevating the affected arm on a pillow above heart level 3. Avoiding arm exercises in the immediate postoperative period 4. Monitoring an intravenous site below the antecubital area on the affected side

2 Following mastectomy, the arm should be elevated above the level of the heart. Simple arm exercises should be encouraged. No blood pressure readings, injections, intravenous lines, or blood draws should be performed on the affected arm. Cool compresses are not a suggested measure to prevent lymphedema from occurring

568. The nurse is providing medication instructions to a client with breast cancer who is receiving cyclophosphamide. The nurse should tell the client to take which actions? 1. Take the medication with food 2. Increase fluid intake to 2000-3000 mL/day 3. Decrease sodium intake while taking the medication 4. Increase potassium intake while taking the medication

2 Hemorrhagic cystitis is an adverse effect that can occur with the use of cyclophosphamide. The client needs to be instructed to drink copious amounts of fluid during the administration of this medication. Clients also should monitor urine output for hematuria. The medication should be taken on an empty stomach, unless GI upset occurs. Hyperkalemia can result from the use of medications; therefore, the client would not be told to increase potassium intake. The client would not be instructed to alter sodium intake.

545. The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? 1. Clamp the Penrose drain 2. Change the dressing as prescribed 3. Notify the health care provider 4. Remove and replace the perineal packing

2 Immediately after surgery, profuse serosanguineous drainage from the perineal wound is expected. Therefore the nurse should change the dressing as prescribed. A Penrose drain should not be clamped because this action will cause the accumulation of drainage within the tissue. The nurse does not need to notify the HCP at this time. Penrose drains and packing are removed gradually over a period of 5-6 days as prescribed. The nurse should not remove the perineal packing.

380. The nurse is instructing the parents of a child with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction should the nurse tell the parents? 1. Administer the iron at mealtimes 2. Administer the iron through a straw 3. Mix the iron with cereal to administer 4. Add the iron to formula for easy administration

2 In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in RBCs. An oral iron supplement should be administered through a straw or medicine dropper placed at the back of the mouth because the iron stains the teeth. The parents should be instructed to brush or wipe the child's teeth of have the child brush the teeth after administration. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum. Iron is not added to formula or mised with cereal or other food items.

387. The pediatric nurse specialist provides a teaching session to the nursing staff regarding osteosarcoma. Which statement by a member of the nursing staff indicates a need for information? 1. "The femur is the most common site of this sarcoma" 2. "The child does not experience pain at the primary tumor site" 3. "Limping, if a weight-bearing limb is affected, is a clinical manifestation" 4. "The symptoms of the disease in the early stage are almost always attributed to normal growing pains"

2 Osteosarcoma is the most common bone cancer in children. Cancer usually is found in the metaphysis of long bones, especially in the lower extremities, with most tumors occurring in the femur. Osteosarcoma is manifested clinically by progressive insidious, and intermittent pain at the tumor site. By the time these children receive medical attention, they may be in considerable pain from the tumor. Options 1, 3, and 4 are accurate regarding osteosarcoma.

366. The nurse is monitoring a child with burns during treatment for burn shock. The nurse understands that which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation? 1. Skin turgor 2. Neurological assessment 3. Level of edema at burning 4. Quality of peripheral pulses

2 Sensorium is an accurate guide to determine the adequacy of fluid resuscitation. The burn injury itself does not affect the sensorium, so the child should be alert and oriented. Any alteration in sensorium should be evaluated further. A neurological assessment would determine the level of sensorium in the child. Option 1, 3, and 4 would not provide an accurate assessment of the adequacy of fluid resuscitation.

564. A client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which laboratory value while the client is taking this medication? 1. glucose level 2. calcium level 3. potassium level 4. prothrombin time

2 Tamoxifen may increase calcium, cholesterol, and triglyceride levels. Before the initiation of therapy, a complete blood count, platelet count, and serum calcium level should be assessed. These blood levels, along with cholesterol and triglyceride levels should be monitored periodically during therapy. The nurse should assess for hypercalcemia while the client is taking this medication. signs of hypercalcemia include increased urine volume, excessive thirst, nausea, vomiting, constipation, hypotonicity of muscles, and deep bone and flank pain.

547. The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common symptoms of this type of cancer? 1. Dyspnea 2. Hematuria 3. Urgency on urination 4. Frequency of urination

2 The most common symptom in clients with cancer of the bladder is hematuria. The client also may experience irritative voiding symptoms such as frequency, urgency, and dysuria, and these symptoms often are associated with carcinoma in situ. Dysuria, urgency, and frequency of urination are also signs of a bladder infection.

541. The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure? 1. To examine the testicles while lying down 2. That the best time for the examination is after a shower 3. To gently feel the testable with one finger to feel for growth 4. That testicular self-examination should be done at least every 6 months

2 The testicular-self examination is recommended monthly after a warm bath or shower when the scrotal skin is relaxed. The client should stand to examine the testicles. Using both hands, with fingers under the scrotum and thumbs on top, the client should gently roll the testicles, feeling for any lumps

502. A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg and asks the admitting nurse to explain what cellulitis means. The nurse bases the response on the understanding that cellulitis has which characteristics? 1. An inflammation of the epidermis only 2. A skin infection of the dermis and underlying hypodermis 3. An acute superficial infection of the dermis and lymphatics 4. An epidermal and lymphatic infection caused by Staphylococcus

2 Cellulitis is an infection of the dermis and underlying hypodermis that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and lymphatics.

393. Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk for infection? Select all that apply. 1. Maintain the child in a semiprivate room 2. reduce exposure to environmental organisms 3. Use strict aseptic technique for all procedures. 4. Ensure that anyone entering the child's room wears a mask 5. Apply firm pressure to a needle stick area for at least 10 minutes.

2, 3, 4 Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. It affects the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production (thrombocytopenia). A common complication of treatment for leukemia is overwhelming infection secondary to neutropenia. Measures to prevent infection include the use of a private room, strict hand-washing, ensuring that anyone entering the child's room wears a mask, and reducing exposure to environmental organisms by eliminating raw fruits and vegetables from the diet and fresh flowers from the child's room and by not leaving standing water in the child's room. Applying firm pressure to a needle stick area for at least 10 minutes is a measure to prevent bleeding.

532. When caring for a client with an internal radiation implant, the nurse should observe which principles? Select all that apply. 1. Limiting the time with the client to 1 hour per shift 2. Keeping pregnant women out of the client's room 3. Placing the client in a private room with a private bath 4. Wearing a lead shield when providing direct client care 5. Removing the dosimeter film badge when entering the client's room 6. Allowing individuals younger than 16 years old in the room as long as they are 6 feet away from the client

2, 3, 4 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 client must be placed in a private room with a private bath. The nurse should wear a lead shield to reduce the transmission of radiation. The dosimeter film badge must be worn when in the client's room. Children younger than 16 years of age and pregnant women are not allowed in the client's room.

554. A client is diagnosed as having a bowel tumor. The nurse should monitor the client for which complication of this type of tumor? Select all that apply. 1. Flatulence 2. Peritonitis 3. Hemorrhage 4. Fistula formation 5. Bowel perforation 6. Lactose intolerance

2, 3, 4, 5 Complications of bowel tumors include bowel perforation, which can result in hemorrage and peritonitis. Other complications include bowel obstruction, and fistula formation. Flatulence can occur bt is not a complication; lactose intolerance also is not a complication of intestinal tumor.

570. The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted? 1. A clotting time of 10 minutes 2. An ammonia level of 20 mg/dL 3. A platelet count of 50,000 cells/min 4. A white blood cell count of 5000 cells/mm3

3 Bleeding precautions need to be initiated when the platelet count decreases. The normal paltelet count is 150,000-450,000 cell/mm3. When the platelet count decreased, the client is at risk for bleeding. The normal white blood cell count is 4500-11,000 cellsm/mm3. When the white blood cell count drops, neutropenic precautions need to be implemented. The normal clotting time is 8-15 minutes. The normal ammonia value is 10-80 mcg/dL.

373. The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply. 1. Scarring is less severe in a child than in an adult 2. A delay in growth may occur after a burn injury 3. An immature immune system presents an increased risk of infection for infants and young children 4. The lower proportion of body fluid to mass in a child increases the risk of cardiovascular problems 5. Fluid resuscitation is unnecessary unless the burned area is more than 25% of the total body surface 6. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults

2, 3, 6 Pediatric considerations in the care of a burn victim include the following: Scarring is more severe in a child than in an adult. A delay in growth may occur after a burn injury. An immature immune system presents an increased risk of infection for infants and young children. The higher proportion of body fluid to mass in a child increases the risk of cardiovascular problems. Burns involving more than 10% of total body surface area require some form of fluid resuscitation. Infants and young children are at increased risk for protein and calorie deficiencies because they have smaller muscle mass and less body fat than adults.

552. As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement? 1. "I should avoid blowing my nose" 2. "I may need a platelet transfusion if my platelet count is too low." 3. "I'm going to take aspirin for my headache as soon as I get home" 4. "I will count the number of pads and tampons I use when menstruating"

3 During the period of greatest bone marrow suppression (the nadir), the platelet count may be low, less than 20,000 cells/mm3. The correct option describes an incorrect statement by the client. Aspirin and NSAIDs and products that contain aspirin should be avoided because of their antiplatelet activity. Options 1, 2, and 4 are correct statements by the client to prevent and monitoring bleeding.

543. A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloddy drainage from the nasogastric tube. The nurse should take which most appropriate action? 1. Measure abdominal girth 2. Irrigate the nasogastric tube 3. Continue to monitor the drainage 4. Notify the health care provider

3 Following gastrectomy, drainge fom the nasogastric tube is normally bloody for 24 hours postoperatively, changes to brown-tinged, and is then yellow or clear. Because bloody drainage is expected in the immediate postoperative period, the nurse should continue to monitor the drainage. The nurse does not need to notify the HCP at this time. Measuring abdominal girth is performed to detect the development of distention. Following gastrectomy, a nasogastric tube should not be irrigated unless there are specific HCP prescription to do so.

379. A 10 y/o child with hemophilia A has slipped on the ice and bumped his knee. The nurse should prepare to administer which prescription? 1. Injection of factor X 2. Intravenous infusion of iron 3. Intravenous infusion of factor VIII 4. Intramuscular injection of iron using the Z-track method

3 Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. The primary treatment is replacement of the missing clotting factor; additional medications, such as agents to relieve pain, may be prescribed depending on the source of bleeding from the disprder. A child with hemophilia A is at risk for joint bleeding after a fall. Factor VIII would be prescribed intravenously to replace the missing clotting factor and minimize the bleeding. Factor X and iron are not used to treat children with hemophilia A.

369. The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent indicates a need for further instruction? 1. "It is extremely contagious" 2. "It is most common in humid weather." 3. "Lesions most often are located on the arms and chest" 4. "It might show up in an area of broken skin, such as an insect bite."

3 Impetigo is a contagious bacterial infection of the skin caused by beta-hemolytic streptococci or staphylococci, or both. Impetigo is most common suring hot, humid summer months. Impetigo may begin in an area of broken skin, such as an insect bite or atopic dermatitis. Impetigo is extremely contagious. Lesions usually are located around the mouth and nose, but may be present on the hands and extremities.

534. The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy? 1. Restrict all visitors 2. Restrict fluid intake 3. Teach the client and family about the need for hand hygiene 4. Insert an indwelling urinary catheter to prevent skin breakdown

3 In the neutropenic client, meticulous hand hygiene education is implemented for the client, family, visitors, and staff. Not all visitors are restricted, but the client is protected from persons with known infections. Fluids should be encouraged. Invasive measures such as an indwelling urinary catheter should be avoided to prevent infections.

391. A 6 y/o child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden and asks the nurse for a vase for the flowers. Which response should the nurse provide to the grandmother? 1. "I have a vase in the utility room, and I will get it for you." 2. "I will get the vase and wash it well before you put the flowers in it." 3. "The flowers from your garden are beautiful, but should not be placed in the child's room at this time." 4. "When you bring flowers into the room, place them on the bedside stand as far away from the child as possible."

3 Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. It affects the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production (thrombocytopenia). For a hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas aeruginosa, to which the child is susceptible. In addition, fresh fruits and vegetables harbor molds and should be avoided until the white blood cell count increases.

390. A 4 y/o child is admitted to the hospital for abdominal pain. The mother reports that the child has been pale and excessively tired and is bruising easily. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are being performed on the child because acute lymphocytic leukemia is suspected. The nurse understands that which diagnostic study should confirm this diagnosis? 1. Platelet count 2. Lumbar puncture 3. Bone marrow biopsy 4. White blood cell count

3 Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. The confirmatory test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspirate and biopsy. A lumbar puncture may be done to look for blast cells in the spinal fluid that indicate CNS disease. The white blood cell count may be normal, high, or low in leukemia. An altered platelet count occurs as a result of the disease, but also may occur as a result of chemotherapy and does not confirm the diagnosis.

565. Megestrol acetate (Megace), an antineoplastic medication, is prescribed for a client with metastatic endometrial carcinoma. The nurse reviews the clients history and should contact the health care provider if which diagnosis is documented in the client's history? 1. Gout 2. Asthma 3. Thrombophlebitis 4. Myocardial infarction

3 Megestrol acetate (Megace) suppresses the release of luteinizing hormone from the anterior pituitary by inhibiting pituitary function and regressing tumor size. Megestrol is used with caution if the client has a history of thrombophlebitis. Options 1, 2, and 4 are not contraindications for the medication

548. The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care? 1. "I change my pouch every week" 2. "I change the appliance in the morning" 3. "I empty the urinary collection bag when it is two thirds full" 4. "When I'm in the shower I direct the flow of water away from my stoma"

3 The urinary collection bag should be changed when it is one-third full to prevent pulling of the appliance and leakage. The remaining options identify correct statements about the care of a urinary stoma.

501. A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response? 1. "Come to the emergency department" 2. "Apply calamine lotion immediately to the exposed skin areas" 3. "Take a shower immediately lathering and rinsing several times" 4. "It is not necessary to do anything if you cannot see anything on your skin"

3 When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the human skin. The client should be instructed to cleanse the area by showering immediately and to lather the skin several times and rinse each time in running water. Calamine lotion may be one product recommended for use if dermatitis develops. The client does not need to be seen in the emergency department at this time

559. A client with small cell lung cancer is being treated with etoposide (Topsar). The nurse monitors the client during administration, knowing that which adverse effect is specifically associated with this medication? 1. Alopecia 2. Chest pain 3. Pulmonary fibrosis 4. Orthostatic hypotension

4 An adverse effect specific to etoposife is orthostatic hypotension. Etoposide should be administered slowly over 30-60 minutes to avoid hypotension. The client's blood pressure is monitored during the infusion. Hair loss occurs with nearly all the antineoplastic medications. Chest pain and pulmonary fibrosis are unrelated to this medication

561. A client with ovarian cancer is being treated with vincristine (Vincasar). The nurse monitors the client, knowing that which manifestation indicates an adverse effect specific to this medication? 1. Diarrhea 2. Hair loss 3. Chest pain 4. Peripheral neutropathy

4 An adverse effect specific to vincristine is peripheral neuropathy, which occurs in almost every client. Peripheral neuropathy can be manifested as numbness and tingling in the fingers and toes. Depression of the Achilles tendon reflex may be the first clinical sign indicating peripheral neuropathy. Constipation rather than diarrhea is most likely to occyr with this medication, although diarrhea may occur occasionally. Hair loss occurs with nearly all the antineoplastic medications. Chest pain is unrelated to this medication

371. A topical corticosteroid is prescribed by a health care provider for a child with atopic dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream? 1. Apply the cream over the entire body 2. Apply a thick layer of cream to affected areas only 3. Avoid cleansing the area before application of the cream 4. Apply a thin layer of cream and rub it into the area thoroughly

4 Atopic dermatitis is a superficial inflammatory process involving primarily the epidermis. A topical corticosteroid may be prescribed and should be applied sparingly (thin layer) and rubbed into the area thoroughly. The affected area should be cleaned gently before application. A topical corticosteroid should not be applied over extensive areas. Systemic absorption is more likely to occur with extensive application.

377. A child with beta-thalassemia is receiving long-term blood transfusion therapy for the treatment of the disorder. Chelation therapy is prescribed as a result of too much iron from the transfusions. Which medication should the nurse anticipate to be prescribed? 1. Fragmin 2. Meropenem (Merrem) 3. Metoprolol (Toprol-XL) 4. Deferoxamine (Desferal)

4 Beta-thalassemia is an autosomal recessive disorder characterized by the reduced production of one of the globin chains in the synthesis of hemoglobin (both parents must be carriers to produce a child with beta-thalassemia major). The major complication of long-term transfusion therapy is hemosiderosis. to prevent organ damage from too much iron, chelation therapy with either Exhade of deferoxamine (Desferal) may be prescribed. Deferoxamine is classified as an antidote for acute iron toxicity. Fragmin is an anticoagulant used as prophylaxis for postop DV. Meropenem is an antibiotic. Metoprolol is a beta blocker used to treat hypertension

557. A client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed? 1. Echocardiography 2. Elecctrocardiography 3. Cervical radiography 4. Pulmonary function studies

4 Bleomycin is an antineoplastic medication that can cause interstitial pneumonia, which can progress to pulmonary fibrosis. Pulmonary function studies along with hematological, hepatic, and renal fucntion tests need to be monitored. The nurse needs to monitor lung sounds for dyspnea and crackles which indicate pulmonary toxicity. The medication need to be discontinued immediately if pulmonary toxicity occurs. Options 1, 2, and 3 are unrelated to the specific use of this medication.

569. A client with non-Hodgkin's lymphoma is receiving daunrubicin (DaunoXome). Which finding would indicate to the nurse that the client is experiencing an adverse effect related to the medication? 1. Fever 2. Sores in the mouth and throat 3. Complaints of nausea and vomiting 4. Crackles o auscultation of the lungs

4 Cardiotoxicity noted by abnormal electrocardipgraphic findings or cardiomyopathy manifested as heart failure (lung crackles) is an adverse effect of daunorubicin. Bone marrow depression is also an adverse effect. Fever is a freuqnt side effect and sores in the mouth and throat can occur occasionally. Nausea and comiting is a frequent side effect associated with the medication that beings a few hours after administration and last 24-48 hrs. Option 1, 2, and 3 are not adverse effects.

538. During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which symptom as typical of the disease? 1. Diarrhea 2. Hypermenorrhea 3. Abnormal bleeding 4. Abdominal distention

4 Clinical manifestations of ovarian cancer include abdominal distention, urinary frequently and urgency, pleural effusion, malnutrition, pain from pressure caused by the growing tumor and the effects of urinary or bowel obstruction, constipation, ascities with dyspnea, and ultimately general severe pain. Abnormal bleeding, often resulting in hypermenorrhea, is associated with uterine cancer.

374. The nurse analyzes the laboratory results of a child with hemophilia. The nurse understands that which result will most likely be abnormal in this child? 1. Platelet count 2. Hematocrit level 3. Hemoglobin level 4. Partial thromboplastin time

4 Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Results of tests that measure platelet function are normal; results of tests that measure clotting factor function may be abnormal. Abnormal laboratory results in hemophilia indicate a prolonged partial thromboplastin time. The platelet count, hemoglobin level, and hematocrit level are normal in hemophilia.

537. A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client? 1. Fatigue 2. Weakness 3. Weight gain 4. Enlarged lymph nodes

4 Hodgkin's disease is a chronic progressive neoplastic disorder of lyphoid tissue characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Weight loss is most likely to be noted. Fatigue and weakness may occur but are not related significantly to the disease.

551. The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which is a late sign of this oncological emergency? 1. Headache 2. Dysphagia 3. Constipation 4. Elecrocardiographic changes

4 Hypercalcemia is a manifestation of bone metastasis in late-stage cancer. Headache and dysphagia are not associated with hypercalcemia. Constipation may occur early in the process. Electrocardiogram changes include shorted ST segment and a widened T wave.

381. Laboratory studies are performed for a child suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia? 1. Elevated hemoglobin level 2. Decreased reticulocyte count 3. Elevated red blood cell count 4. Red blood cells that are microcytic and hypochromic

4 In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in RBCs. The results of a complete blood cell count in children with iron deficiency anemia show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated.

533. While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action? 1. Call the HCP 2. Reinsert the implant into the vagina 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 it in a lead container

4 In the event that a radiation source becomes dislodged, the nurse would first encourage the client to lie still until the radioactive source has been placed in a safe closed container. The nurse would use a long-handled forceps to place the source in the lead container that should be in the client's room. The nurse should then call the radiation oncologist and then document the event and the actions taken. It is not within the scope of nursing practice to insert a radiation implant.

542. A client is diagnosed with multiple myeloma and the client asks the nurse about the diagnosis. The nurse bases the response on which description of this 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 within the bone

4 Multiple myeloma is a B-cell neoplastic condition characterized by abnormal malignant proliferation of plasma cells and the accumulation of mature plasma cells in the bone marrow. Options 1 and 2 are not characteristics of multiple myeloma. Option 3 describes the leukemic process.

372. The school nurse is conducting pediculosis capitis (head lice) assessments. Which finding indicates a child has a "positive" head check? 1. Maculopapular lesions behind the ears 2. Lesions in the scalp that extend to the hairline or neck 3. White flaky particles throughout the entire scalp region 4. White sacs attached to the hair shafts in the occipital area

4 Pediculosis capitis is an infestation of the hair and scalp with live. The nits are visible and attached firmly to the hair shaft near the scalp. The occiput is an area in which nits can be seen. Maculopapular lesions behind the ears or lesions that extend to the hairline or neck are indicative of an infectious process, not pediculosis. White flaky particles are indicative of dandruff.

368. Permethrin (Elimite) is prescribed for a child with a diagnosis of scabies. The nurse should give which instruction to the parents regarding the use of this treatment? 1. Apply the lotion to areas of the rash only 2. Apply the lotion and leave it on for 6 hours 3. Avoid putting clothes on the child over the lotion 4. Apply the lotion to cool, dry skin at least 30 minutes after bathing

4 Permethrin is massaged thoroughly and gently into all skin surfaces (not just the areas that have the rash) from the head to the soles of the feet. Care should be taken to avoid contact with the eyes. The lotion should not be applied until at least 30 minutes after bathing and should be applied only to cool, dry skin. The lotion should be kept on for 8-14 hours, and then the child should be given a bath. The child should be clothed during the 8-14 hours of treatment contact time.

378. The clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instructions? 1. Stress 2. Trauma 3. Infection 4. Fluid overload

4 Sickle cell crises are acute exacerbations of the disease, which vary considerably in severity and frequency; these include vaso-occlusive crisis, splenic sequestration, hyperhemolytic crisis, and aplastic crisis. Sickle cell crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical/emotional stress. The mother of a child with sickle cell disease should encourage fluid intake of 1 1/2 to 2 times the daily requirement to prevent dehydration.

563. Tamoxifen citrate is prescribed for a client with metastatic breast carcinoma. The nurse administering the medication understands that which is the primary action of this medication? 1. It increased DNA and RNA synthesis 2. It promotes the biosynthesis of nucleic acids 3. It increases estrogen concentration and estrogen response 4. It competitively binds to estrogen receptors on tumors and other tissue targets

4 Tamoxifen is an antineoplastic medication tha competes with estradiol for binding to estrogen in tissues containing high concentrations of receptors. Uamoxifen is used to treat metastatic breast carcinoma in women and men. Tamoxifen is also effective in delaying the recurrence of cancer following mastectomy. Tamoxifen reduces DNA synthesis and estrogen response.

553. The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time? 1. At the onset of menstruation 2. Every month during ovulation 3. Weekly at the same time of day 4. 1 week after menstruation begins

4 The breast self-examination should be perfumed monthly, 7 days after the onset of the menstrual period. Performing the examination weekly is not recommended. t the onset of menstruation and during ovulation, hormonal changes occur that may alter breast changes

556. Chemotherapy dosage is frequently based on total body surface area; so it is important for the nurse to perform which assessment before administering chemotherapy? 1. Measure the client's abdominal girth 2. Calculate the client's body mass index 3. Ask the client about his or her weight and height 4. Measure the client's current weight and height

4 To ensure that the client receives optimal doses of chemotherapy, dosing is usually based on the total body surface area, which requires a current accurate height and weight for BSA calculations (before each administration). Asking the client about his or her height and weight may lead to inaccuracies in determining a true BSA and dosage. Calculating body mass index and abdominal girth will not provide the data needed.

500. The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first priority intervention in the event of this occurrence is which action? 1. Immobilize the affected extremity 2. Remove jewelry and constricting clothing from the victim 3. Place the extremity in a position so that it is below the level of the heart 4. Move the victim to a safe area away from the snake and encourage the victim to rest.

4 In the event of a snakebite, the first priority is to move the victim to a safe area from the snake and encourage the victim to rest to decrease venom circulation. Next, jewelry and constricting clothing are removed before swelling occurs. Immobilizing the extremity and maintaining the extremity below heart level would be done next; these actions limit the spread of the venom. The victim is kept warm and calm. Stimulants such as alcohol or caffeinated beverages are not given to the victim because these products may speed the absorption of the venom. The victim should be transported to an emergency facility as soon as is possible.

523. A burn client is receiving treatments of topical mafenide acetate (Sulfamylon) to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred? 1. Hyperventilation 2. Local rash at the burn site 3. Elevated blood pressure 4. Local pain at the burn site

Answer: 1 Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid base imbalance (hyperventilation). If this occurs, the medication will probably be discontinued for 1 to 2 days. Options 2 and 4 describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury.

520. Salicyclic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication? 1. Tinnitus 2. Diarrhea 3. Constipation 4. Decreased respirations

Answer: 1 Salicyclic acid is absorbed readily through the skin and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances. Constipation and diarrhea are not associated with salicylism.

514. The nurse manager is planning the clinical assignments for the day. Which staff members can be assigned to care for a client with herpes zoster? Select all that apply. 1. The nurse who never had roseola 2. The nurse who never had mumps 3. The nurse who never had chickenpox 4. The nurse who never had German measles 5. The nurse who never received the varicella-zoster vaccine

Answer: 1, 2, 4 Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the causative virus of chickenpox. Individuals who have not been exposed to the varicella-zoster virus or who did not receive the varicella-zoster vaccine are susceptible to chickenpox. Health care workers who are unsure of their immune status should have varicella titers done because exposure to a person with herpes zoster.

526. The nurse is applying a topical corticosteroid to a client with eczema. The nurse should monitor for the potential for increased systemic absorption if the medication were being applied to which body area? 1. Back 2. Axilla 3. Soles of the feet 4. Palms of the hands

Answer: 2 Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where permeability is poor (back, palms, soles).

521. The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply. 1. Sunscreen should be applied every 8 hours. 2. Use sunscreen when participating in outdoor activities 3. Wear a hat, opaque clothing, and sunglasses when in the sun 4. Avoid sun exposure in the late afternoon and early evening hours 5. Examine your body monthly for any lesions that may be suspicious

Answer: 2, 3, 5 The client should be instructed to avoid sun exposure between the hours of 10 am and 4 pm. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any possible cancerous or any precancerous lesions. Sunscreen should be reapplied every 2 to 3 hours and after swimming or sweating otherwise, the duration of protection is reduced.

512. A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. 1. Restrict fluids 2. Assess for airway patency 3. Administer oxygen as prescribed 4. Place a cooling blanket on the client 5. Elevate extremities if no fractures are present 6. Prepare to give oral pain medication as prescribed

Answer: 2, 3, 5 The primary goal for a burn injury is to maintain a patent airway, administer IV fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. AN IV line should be obtained and fluid resuscitation started. The extremities are elevated to assist in preventing shock. The client is kept warm and placed on NPO status because of the altered GU function that occurs as a result of a burn injury.

504. The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? 1. Patch test 2. Skin biopsy 3. Culture of the lesion 4. Wood's light examination

Answer: 3 With the classic presentation of herpes zoster, the clinical examination is diagnostic. However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide cytological examination of tissue. In a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.

509. An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? 1. 18% 2. 24% 3. 36% 4. 48%

Answer: 3 According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower half of both arms equals 9%. The subsequent burn included the posterior half of head, equaling 4.5%, and the upper half of posterior torso, equaling 9%. This totals 36%.

518. The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? 1. Out-of-bed activities 2. Bathroom privileges 3. Immobilization of the affected leg 4. Placing the affected leg in a dependent position

Answer: 3 Autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3-7 days. The period of immobilization allows the autograft time to adhere to the wound bed. Options 1, 2, and 4 are incorrect.

511. A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mmHg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the health care provider and anticipates which prescription? 1. Transfusing 1 unit of packed red blood cells 2. Administering a diuretic to increase urine output 3. Increasing the amount of intravenous lactated Ringer's solution administered per hour 4. Changing the IV lactated Ringer's solution to one that contains dextrose in water

Answer: 3 Fluid management during the first 24 hours following a burn injury generally includes the infusion of (usually) lactated Ringer's solution. Fluid resuscitation is determined by urine output and hourly urine output should be at least 30 mL/hr. The client's urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore the HCP would prescribe an increase in the amount of IV lactated Ringer's solution administered per hour. Blood replacement is not used for fluid therapy for burn injuries. Administering a diuretic would not correct the problem because it would not replace needed fluid. Diuretics promote the removal of the circulating volume, thereby further compromising the inadequate tissue perfusion. Dextrose in water is an isotonic solution, and an isotonic solution maintains fluid balance. This type of solution may be administered after the first 24 hours following the burn injury, depending on the client's physiological needs.

522. Mafenide acetate (Sulfamylon) is prescribed for a client with a burn injury. When applying the medication, the client complains of local discomfort and burning. The nurse should take which most appropriate action? 1. Discontinue the medication 2. Notify the health care provider 3. Inform the client that this is expected 4. Apply a thinner film than prescribed to the burn site

Answer: 3 Mafenide acetate is bacteriostatic for gram-negative and gram-positive organisms and is used to treat burns to reduce bacteria present in avascular tissues. The client should be informed that the medication will cause local discomfort and burning and that this is a normal reaction. Therefore, options 1, 2, and 4 are incorrect.

505. A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? 1. Metastasis is rare 2. It is encapsulated 3. It is highly metastatic 4. It is characteristic by local invasion

Answer: 3 Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. This skin cancer is highly metastatic, and a person's survival depends on early diagnosis and treatment. Options 1, 2, and 4 are not characteristics of melanoma.

507. A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? 1. A pink, edematous hand 2. A fiery red skin with edema in the nail beds 3. Black fingertips surrounded by an erythematous rash 4. A white color to the skin, which is insensitive to touch

Answer: 4 Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue edema appears. Options 1, 2, and 3 are incorrect.

515. A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? 1. 100% oxygen via an aerosol mask 2. Oxygen via nasal cannula at 6 L/min 3. Oxygen via nasal cannula at 15 L/min 4. 100% oxygen via a tight-fitting, nonrebreather face mask

Answer: 4 If an inhalation injury is suspected, administration of 100% oxygen via a tight-fitting nonrebreather face mask is prescribed until carboxyhemoglobin levels fall (usually below 15%). In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation also is assessed. Options 1, 2, and 3 are incorrect and would not provide the necessary oxygen supply needed for adequate tissue perfusion.

508. The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? 1. Intact skin 2. Full-thickness skin loss 3. Exposed bone, tendon, or muscle 4. Partial-thickness skin loss of the dermis

Answer: 4 In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact, open or ruptured, serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.

529. The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times? 1. Immediately before swimming 2. 5 minutes before exposure to the sun 3. Immediately before exposure to the sun 4. At least 30 minutes before exposure to the sun

Answer: 4 Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating.

513. The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? 1. Decreased heart rate 2. Increased urinary output 3. Increased blood pressure 4. Elevated hematocrit levels

Answer: 4 The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50-55% are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys, and renal perfusion and glomerular filtration are decreased, resulting in low urine output. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts