211 Exam I
While preforming a clinical breast exam, the nurse observes discharge from the nipple. What is MOST important to include in the documentation of this finding? A. Area of the "clock" that was compressed when the discharge was released B. Amount of pressure required for the discharge to be released C. Frequency and technique the patient uses for breast self-exam D. History of difficulty or pain when attempting to breast feed
A. Area of the clock that was compressed when the discharge was released
The client scheduled for a modified radical mastectomy asks specifically what tissue will be removed. The best response is: A. Breast and axillary nodes B. Breast, pectoral muscles, and axillary nodes C. Breast alone D. Only the portion of the breast involved
A. Breast and axillary nodes
The patient has just arrived from PACU after a mastectomy. How does the nurse position the patient? A. Head of the bed up at least 30 degrees with the affected arm elevated on a pillow B. Supine body position with the affected positioned straight by the side C. Any position that is most comfortable for the patient D. Side-lying position with the affected side down towards the mattress
A. Head of the bed up at least 30 degrees with the affected arm elevated on a pillow
The client newly diagnosed with cancer has been receiving chemotherapy. Which symptoms, if present, would indicate tumor lysis syndrome? (select all that apply) A. Hematuria B. Muscular weakness, twitching, or cramps C. Flank pain D. Cloudy oliguria
A. Hematuria B. Muscular weakness, twitching, or cramps C. Flank pain D. Cloudy oliguria
The healthcare provider ordered a sputum specimen. The nurse is aware that the preferable time to collect this specimen is which of the following? A. In the morning B. In the evening after forcing fluids all day C. After antibiotics have been started to loosen phlegm D. After the client has taken and expectorant
A. In the morning
The client with metastatic breast cancer is prescribed Tamoxifen. The nurse tells the client to do which of the following while taking the medication? (select all that apply) A. Report and unusual vaginal bleeding B. Schedule regular eye exams C. Stop the medication if increased pain occurs D. Extend the pap smear routine to evert 5 years E. Report lower leg swelling and redness as a side effect
A. Report and unusual vaginal bleeding B. Schedule regular eye exams E. Report lower leg swelling and redness as a side effect
The client has just returned to the unit after a right pneumonectomy. In which position should the nurse place the client? A. Right side B. Left side or back C. Back only D. Right side or left side
A. Right side
Which of the following patient statements regarding sickle cell anemia (SCA) indicates a need for FURTHER teaching? A. SCA is due to dominant, heterozygous inheritance of a gene responsible for production of abnormal hemoglobin B. SCA is most commonly found in African Americans and patients of Mediterranean descent C. Hemoglobin S sickles in conditions that involve hypoxia D. SCA is a chronic disease associated with painful episodes and poor prognosis
A. SCA is due to dominant, heterozygous inheritance of a gene responsible for production of abnormal hemoglobin
The nurse is providing care to the client with symptoms of advanced lung cancer. Which of the following diagnostic tests does the nurse anticipate may be ordered for the client? (select all that apply) A. Sputum cultures B. Pulmonary function tests C. Chest X-ray D. Bone scan E. Bronchoscopy
All of the above
The client with COPD and lung cancer needs dietary instruction. Which of the following instructions is most important for the nurse to give this client? A. Increase seasonings in food preparation in order to stimulate taste sensation B. Increase your intake of high quality, high calorie, carbohydrates and proteins C. Eat smaller portions of foods more often D. Drink cool, rather than warm, liquids to decrease feelings of fullness
B. Increase your intake of high quality, high calorie, carbohydrates and proteins
A patient with SCA crisis is experiencing severe abdominal and leg pain. His vital signs include BP 100/68, P 94, and RR 24. If ordered, which action(s) are appropriate? (select all that apply) A. Administer cold applications to leg to relieve pain B. Administer morphine sulfate for pain and monitor vital signs frequently C. Force fluids and monitor strict I/Os D. Bed rest and diversionary activities as tolerated
B. Administer morphine sulfate for pain and monitor vital signs frequently C. Force fluids and monitor strict I/Os D. Bed rest and diversionary activities as tolerated
The nurse is documenting a skin assessment. Using the ABCD rule, what does the A stand for? A. Actinic B. Asymmetry C. Assessment D. Arcus
B. Asymmetry
The nurse is reviewing laboratory results from the postmenopausal woman being evaluated for a breast mass. What type of metastasis does the increased serum calcium and alkaline phosphate levels suggest? A. Brain B. Bone C. Lung D. Liver
B. Bone
Which intervention is priority immediately after a modified radical mastectomy? A. Position the patient on the affected side to aid with the gravity flow of drainage from the incision site B. Immobilize the arm on the affected side for the first 24 hours postoperatively C. Assess the patient for anxiety because it can impede the healing process D. Teach the patient signs and symptoms of infection and how to monitor for altered wound healing
B. Immobilize the arm on the affected side for the first 24 hours postoperatively
The client had a right lobectomy yesterday and has a chest tube connected to suction at 20cm of water pressure. Upon assessment of the client this morning, the nurse notes that there is not fluctuation in the water-seal chamber. What would be the nurses immediate action? A. Increase the suction until fluctuation reappears B. Observe for kinks in the tubing C. Elevate the HOB to 80 degrees D. No action is necessary since the lung has likely re-expanded
B. Observe for kinks in the tubing
The nurse teaches the PRE-menopausal client that the best time to preform self-examination is: A. When her menstrual period begins B. One week after her menstrual period begins C. On the first day of the month D. On the 14th day of her menstrual cycle
B. One week after her menstrual period begins
The patient is one day post-mastectomy and is anxious to begin the prescribed exercises. Which exercise is appropriate for the patients FIRST efforts? A. Flex the fingers so that the hands slowly "walk" up the wall B. Squeeze the affected hand around a soft, round, object C. Swing the rope in small circles and gradually increase to larger circles D. Grab the ends of the rope and extend the arms until they are straight
B. Squeeze the affected hand around a soft, round, object
The nurse assesses the patients chest drainage system, and notices vigorous bubbling in the air leak monitor, and hears a hissing noise coming from the system. Which of the following nursing interventions is priority for the nurse to implement? A. Clamp the chest drainage tube immediately B. Reinforce the chest tube dressing C. Assess the patients respiratory status and VS D. Increase the wall suction from intermittent to continuous
C. Assess the patients respiratory status and VS
The nurse is caring for the patient who had a RIGHT-sided modified radical mastectomy. Which task does the nurse delegate to the UAP? A. Assess the drainage in the Jackson-Pratt drain B. Take the blood pressure on the right arm only C. Assist the patient to ambulate the day after surgery D. Teach the patient about arm care
C. Assist the patient to ambulate the day after surgery
The patient with lung cancer and paraneoplastic syndrome develops symptoms that include constipation, anorexia, nausea, and muscle twitching. Which lab is the priority for the nurse to evaluate for this client? A. Hgb and Hct B. BUN and Cr C. Calcium D. Potassium
C. Calcium
The spouse of a patient with a massive lung tumor develops tumor lysis syndrome. He asks the nurse to explain the syndrome. The best response from the nurse would be: (select all that apply) A. Massive destruction of red and white blood cells can cause endocrine failure B. I can see you are very concerned. Let me call the care provider for you C. Tumor cells breakdown, and the contents of the the tumor cells enter the circulatory system D. The syndrome can impact the heart and renal systems, and cause electrolyte disturbances
C. Tumor cells breakdown, and the contents of the the tumor cells enter the circulatory system D. The syndrome can impact the heart and renal systems, and cause electrolyte disturbances
The client is scheduled for radiation therapy. The nurse teaches to: A. Use talcum powder for comfort B. Apply a soothing ointment to the skin C. Wash the skin with water and pat dry D. Sunbathe as usual
C. Wash the skin with water and pat dry
Which of the following population groups are LEAST likely to develop breast cancer? A. Women over 50 years old B. Women whose mothers or sisters have breast cancer C. Women who had a child before the age of 30 D. Women who are overweight
C. Women who had a child before the age of 30
The patient with a right-sided chest tube connected to low-intermittent wall suction, complains of chest pain and dyspnea. The VS are BP 128/70, HR 100, and RR 32. Which of the following nursing interventions should the nurse implement FIRST? A. Administer morphine IV push over 4 mins B. Activate the rapid response team C. Notify the healthcare provider D. Assess the chest tube system for correct positioning, kinks, or clots
D. Assess the chest tube system for correct positioning, kinks, or clots
Patients with SCA have chronic anemia due to: A. poor dietary practices and decreased iron intake B. Decreased erythropoietin production and activity C. Blood loss due to sickle cell crisis D. Increased fragility and decreased life span of RBCs
D. Increased fragility and decreased life span of RBCs
The nurse preforms clinical breast exams on the following patients. Which patient has a symptom that suggests ADVANCED disease? A. Patient has gynecomastia B. Patient with an oval-shaped, mobile, rubbery mass C. Patient with a thin, milky discharge from the nipple D. Patient with a skin change of peau d'organge
D. Patient with a skin change of peau d'organge
Which activity is best for the 8 year old male recovering from sickle cell crisis who remains on bed rest? A. Television programs most of the day B. Phone calls from his friends at home and at school C. Reading books about African American people with sickle cell crisis D. Playing board games with his roommate
D. Playing board games with his roommate