Adult Health

A patient presents with signs and symptoms of anemia. A serum analysis reveals that the patient has decreased levels of folic acid, elevated iron, transferrin, ferritin, and increased mean corpuscular volume. The nurse should anticipate administering ____________ mg(s) as a usual daily dosage of folic acid replacement.

1 mg 1 mg per day is the recommended dose for folic acid replacement. 5mg is recommended for patients with malabsorption of folic acid.

Hypomagnesemia occurs when the serum magnesium concentration is below ___________________ mEq/L.

1.3 Normal serum magnesium levels are between 1.3 to 2.1 mEq/L.

Hypophosphatemia occurs when the serum phosphate concentration is below ________________ mEq/L.

1.7 Normal serum phosphate levels are between 1.7 and 2.6 mEq/L.

A serum calcium concentration greater than ________________ mg/dL is known as hypercalcemia.

10.5 Normal serum calcium levels are between 8.5 and 10.5 mg/dL

Hyponatremia is a condition with a serum sodium concentration below the normal range of less than _______________________ mEq/L.

135 Normal sodium levels are between 135 and 145 mEq/L.

Hypernatremia is a condition with a serum sodium concentration above the normal range of _______________________________mEq/L.

145 Normal sodium levels are between 135 and 145 mEq/L.

Hypermagnesemia occurs when the serum magnesium concentration is greater than __________________ mEq/L.

2.1 Normal serum magnesium levels are between 1.3 to 2.1 mEq/L.

When the serum phosphate concentration increases above ____________ mEq/L, it causes hyperphosphatemia.

2.6 Normal serum phosphate levels are between 1.7 and 2.6 mEq/L.

A serum potassium concentration of less than ____________________ mEq/L is considered to be hypokalemia.

3.5 Normal serum potassium levels are between 3.5 and 5 mEq/L.

A serum potassium concentration above _________________ mEq/L is considered hyperkalemia.

5 Normal serum potassium levels are between 3.5 and 5 mEq/L.

A serum calcium concentration less than __________________ mg/dL is referred to as hypocalcemia.

8.5 Normal serum calcium levels are between 8.5 and 10.5 mg/dL

Which patients will most likely undergo human chorionic gonadotropin testing prior to surgery? Select all that apply. A. A 42-year-old female undergoing a hysterectomy B. A 9-year-old male undergoing a tonsillectomy C. An 83-year-old female undergoing a hip fracture repair D. A 57- year-old male undergoing a hernia repair E. A 15-year-old female undergoing an appendectomy

A and E A 42-year-old female could be pregnant; therefore, human chorionic gonadotropin test, which tests for pregnancy, will very likely be performed before the patient undergoes hysterectomy surgery. A 15- year-old female could be pregnant; therefore, a human chorionic gonadotropin test, which tests for pregnancy, will very likely be performed before the patient undergoes an appendectomy. Options B and D are incorrect because the patients are male. Option C is incorrect because the female is 83 years old.

Which nursing statement is accurate when providing education to a post-menopausal patient who is at risk for hypercalcemia? A. "It is important for us to monitor your serum parathyroid levels." B. "It is important for you to increase your dietary intake of calcium." C. "It is important for us to monitor your serum magnesium levels." D. "It is important for you to increase your dietary intake of vitamin D."

A. A post-menopausal patient has an increased risk for hyperparathyroidism, which is the primary cause for hypercalcemia for this population. Option B is incorrect because A patient who is at risk for hypercalcemia should not be advised to increase dietary calcium. Option C is incorrect because Hypomagnesemia is associated with hypocalcemia, not hypercalcemia. Option D is incorrect because A patient who is at risk for hypercalcemia should not be advised to increase dietary vitamin D.

The nurse is providing care to a patient whose serum potassium level is 5.2 mEq/L. Which clinical manifestation should the nurse monitor the patient for during the assessment? A. Bradycardia B. Hyperactive deep tendon reflexes C. Lethargy D. Emesis

A. A serum potassium concentration of 5.2 mEq/L indicates hyperkalemia. The nurse should monitor for bradycardia, a clinical manifestation associated with this electrolyte imbalance. Option B is incorrect because A serum potassium concentration of 5.2 mEq/L indicates hyperkalemia. Hyperactive deep tendon reflexes are associated with hypocalcemia and hypomagnesemia, not hyperkalemia. Option C is incorrect because A serum potassium concentration of 5.2 mEq/L indicates hyperkalemia. Lethargy is a clinical manifestation associated with hyponatremia, hyponatremia, hypercalcemia, or hypermagnesemia, not hyperkalemia. Option D is incorrect because A serum potassium concentration of 5.2 mEq/L indicates hyperkalemia. Emesis is not a clinical manifestation associated with hyperkalemia.

Which nursing diagnosis would the nurse select for a postoperative patient experiencing decreased range of motion and increased fatigue? A. Activity intolerance B. Ineffective tissue perfusion C. Risk for activity intolerance D. Risk for ineffective tissue perfusion

A. Activity intolerance addresses patients who have actual decreased ambulation, range of motion, and increased fatigue. This patient has those clinical manifestations. This nursing diagnosis would be selected for the patient. Option B is incorrect because Ineffective tissue perfusion addresses patients who have decreased peripheral circulation as evidenced by altered skin color and temperature and diminished pulses. This patient does not have those manifestations. Option C is incorrect because Risk for activity intolerance addresses patients who have risk factors for decreased ambulation and other activities. This patient does not have risk factors. Option D is incorrect because Risk for ineffective tissue perfusion addresses patients who have risk factors for decreased peripheral circulation such as altered skin color and temperature and diminished pulses. This patient does not have those risk factors.

Which component is necessary for active transport of electrolytes to occur? A. Adenosine triphosphate B. Sodium-potassium pump C. High to low concentration gradient D. Open ion channel

A. Adenosine triphosphate, or ATP, is a necessary energy source for active transport of electrolytes to occur. Option B is incorrect because The sodium-potassium pump is an example of active transport of electrolytes. It is not a necessary component for the active transport of all electrolytes. Option C is incorrect because A concentration gradient of high to low is how solutes are moved by diffusion. This is not a necessary component for active transport. Option D is incorrect because An open ion channel is required for facilitated diffusion, not active transport.

The daughter of a patient in adult day care asks if she can care for her father's feeding tube. Which nursing response is most appropriate? A. "Have you considered an adult day health program for your father?" B. "That is not covered by Medicare." C. "You will need to place your father in a nursing home for that." D. "You will need home care now that your father needs more help."

A. Adult day cares are equipped to handle only social needs and supervision of the older adult. An adult day health program would meet those needs and also be able to provide for basic care needs associated with feeding and incontinence. Option B is incorrect because An adult day care does not provide medical services, and the provision of Medicare coverage is not relevant to the issue of increasing care needs. Option C is incorrect because There are several options to meet the needs of a patient with a feeding tube that do not require long-term placement. Option D is incorrect because Home care may be an option; however, a patient is not homebound because he or she has a feeding tube. Other more viable options, such as an adult day health program, should be presented.

Which nursing assessment data requires immediate intervention for the patient with cancer? A. Redness around the IV site following chemotherapy administration B. Reports of nausea following a meal C. Increased loss of hair following chemotherapy D. Decreased sensation in the lower extremities

A. Assess the site of intravenous administration carefully because prevention of extravasation is imperative. Extravasation occurs when a vesicant (chemical that damages tissue on contact) leaks into surrounding tissues. This can be very painful, and severe cases can require surgery. This requires immediate nursing intervention. Option B is incorrect because While the nurse should monitor the nausea and administer antiemetics as prescribed, this does not warrant immediate intervention. Option C is incorrect because Hair loss following chemotherapy is traumatic for the patient but is anticipated and does not require immediate nursing action. Option D is incorrect because Decreased sensation in the extremities is associated with chemotherapy-induced peripheral neuropathy. It should be monitored closely; however, it does not require immediate nursing intervention.

Which dietary suggestion will the nurse include when teaching about cancer risk reduction? A. Incorporate whole grain bread into your diet. B. Increase fat intake, including one serving of whole milk daily. C. Eat less salad to prevent infections. D. Do not drink any alcohol.

A. Avoid high fat, low fiber diets because they are associated with colon, breast, and ovarian cancer. Encourage eating of fruits, vegetables, and dietary whole grains. Whole grain bread is a good source of dietary whole grains. Option B is incorrect because Avoid high-fat, low-fiber diets because they are associated with colon, breast, and ovarian cancer. Encourage eating of fruits, vegetables, and dietary whole grains. Whole milk is high in fat and should be avoided. Option C is incorrect because Avoid high-fat, low-fiber diets as they are associated with colon, breast, and ovarian cancer. Encourage eating of fruits, vegetables, and dietary whole grains. Salad is a great source of vegetables and should be encouraged as part of a healthy diet. Option D is incorrect because Limit alcohol intake (two drinks per day for men and one drink per day for women) because alcohol is associated with a higher risk of certain cancers.

The nurse is providing care to a patient with decreased levels of serum potassium caused by excessive hormone action that shifts potassium into cells. Which hormone should the nurse expect to be elevated in the laboratory report? A. Insulin B. Parathyroid hormone C. Glucocorticoids D. Sodium

A. Insulin moves potassium into cells. Excessive insulin can decrease serum potassium levels. Option B is incorrect because Parathyroid hormone is an important regulator of calcium concentration, not potassium. Option C is incorrect because Glucocorticoids enhance the excretion of potassium, but they do not move it into cells. Option D is incorrect because Sodium will not move potassium into cells, and it is not a hormone.

The nurse is preparing to provide patient and family education to a patient with multiple myeloma who will be discharged the following day. Which is the most appropriate teaching to ensure patient safety after discharge? A. "Ensure adequate support when walking." B. "Make sure you take the prescribed analgesics." C. "Drink plenty of water every day." D. "Have electrolytes monitored frequently."

A. Because of the risk for pathological fractures, the patient must have adequate physical support, with assistance from a caregiver or use of a cane, when walking. Option B is incorrect because Taking prescribed analgesics is important for relief of pain, but this is not the most appropriate teaching to ensure patient safety after discharge. Option C is incorrect because Hydration is an important aspect of nursing management for the patient with multiple myeloma, but it is not the most appropriate teaching to ensure patient safety after discharge. Option D is incorrect because Although the patient with multiple myeloma is at risk for renal dysfunction and should have electrolytes monitored for fluid balance, this is not the most appropriate teaching to ensure patient safety after discharge.

A woman with Hodgkin's lymphoma is receiving patient education from the nurse. Which recommendation for follow-up care is important to prevent future malignancies? A. "Make sure you have routine mammograms." B. "Continue to have yearly positron emission tomography (PET) scans." C. "A bone marrow examination should be performed routinely." D. "A complete blood count (CBC) should be done at every follow-up appointment."

A. Because one of the most common secondary malignancies is breast cancer, having routine mammograms is important for early detection. Option B is incorrect because PET scans are used to stage and assess response to therapy for Hodgkin's lymphoma, not as routine screening for secondary malignancies. Option C is incorrect because A bone marrow examination is used to diagnose Hodgkin's lymphoma, not to screen for secondary malignancies. Option D is incorrect because A CBC may indicate changes in blood cells but would not necessarily identify secondary malignancies.

Which surgical procedure is classified as minor surgery? A. Breast biopsy B. Colon resection C. Cleft palate repair D. Finger amputation

A. Biopsies often require little to no anesthesia or respiratory assistance. There is minimal risk to the patient, making this type of procedure a minor surgery. Options B, C and D are incorrect because they require anesthesia and respiratory assistance.

What interaction can occur between targeted anticancer drugs and CYP3A4 inhibiting drugs? A. Drugs that inhibit CYP3A4 can reduce metabolism of targeted drugs. B. Drugs that inhibit CYP3A4 may reduce the plasma level of targeted drugs. C. Combining targeted drugs with CYP3A4-inhibiting drugs can cause a severe anaphylactic reaction. D. Combining targeted drugs with CYP3A4-inhibiting drugs can inhibit the renal excretion of targeted drugs.

A. CYP3A4-inhibiting drugs can reduce metabolism of targeted drugs and increase their plasma levels. Option B is incorrect because CYP3A4-inhibiting drugs may reduce metabolism of targeted drugs and increase their levels in the blood. Option C is incorrect because Concurrent administration of targeted drugs and CYP3A4-inhibiting drugs is not associated with anaphylactic reactions. Option D is incorrect because Combining targeted drugs and CYP3A4-inhibiting drugs is not associated with renal impairment or inhibited renal function.

Which statement is true about the regulation of electrolytes? A. Calcium is regulated by the parathyroid hormone. B. Magnesium is regulated by the atrial natriuretic peptide (ANP). C. Phosphate is regulated by aldosterone. D. Sodium is regulated by vitamin D.

A. Calcitonin moves calcium out of bone, when needed, and decreases calcium excretion. Option B is incorrect because ANP regulates the sodium content in the body, not the magnesium content. Option C is incorrect because Phosphate is regulated by the parathyroid gland and other factors that influence renal excretion. Option D is incorrect because Sodium is regulated by secretion of aldosterone and atrial natriuretic peptide (ANP). Vitamin D plays a role in the regulation of calcium.

A patient is diagnosed with drug-related hyperphosphatemia. Which type of drug should the nurse include in the teaching session as the cause of the current diagnosis? A. Cathartics B. Phosphate-binding antacids C. Loop diuretics D. Thiazide diuretics

A. Cathartics, a classification of laxatives, is a cause for hyperphosphatemia. Option B is incorrect because Phosphate-binding antacids are a cause for hypophosphatemia, not hyperphosphatemia. Option C is incorrect because Loop diuretics are a cause for hypophosphatemia, not hyperphosphatemia. Option D is incorrect because Thiazide diuretics are a cause for hypophosphatemia, not hyperphosphatemia.

Which patient assessment is consistent with delirium in the hospitalized older adult? A. Sudden onset of confusion B. Trying to climb out of bed since admission C. Unable to remember the President of the United States D. Withdrawn behavior

A. Delirium is an acute presentation of altered cognition, as opposed to dementia, which is a gradual decline. Option B is incorrect because Because the patient was admitted with this behavior, there is no acute change, indicating this is associated with dementia. Option C is incorrect because Being unable to remember items associated with long-term memory and components of person, place, and time is associated with dementia versus an acute onset of delirium. Option D is incorrect because Withdrawn behavior often accompanies depression in the older adult versus delirium.

The nursing student is presenting information related to the movement of electrolytes to fellow classmates. Which process should the nursing student state as moving electrolytes within a body compartment by random movements? A. Diffusion B. Facilitated diffusion C. Active transport D. Sodium-potassium pump

A. Diffusion moves electrolytes within a body compartment by random movements. Option B is incorrect because Facilitated diffusion requires a carrier, such as protein, to carry the solute across a membrane from an area of higher concentration to an area of lower concentration. Option C is incorrect because Active transport is the transport of a solute from areas of lower to higher concentration. Option D is incorrect because The sodium-potassium pump is an example of active transport. This pump moves sodium out of the cells and potassium into the cells.

Which nursing documentation reflects the cellular aspect of cancer? A. Grade 2 B. Breast cancer C. Aneuploidy D. Stage III

A. Grading is based on the cellular aspect of cancer. Grade 2 indicates that the cells are moderately differentiated. Option B is incorrect because Anatomic origin is the site of the original cancer. Option C is incorrect because Ploidy classifies the tumor chromosomes. When chromosomes are altered or missing, aneuploidy exists. The degree of aneuploidy often increases with the degree of malignancy. Option D is incorrect because Staging is based on the clinical aspect of cancer, or the extent of disease. Stage III cancer is consistent with local and regional spread.

Which goal did the nurse develop for a patient with a nursing diagnosis of Anxiety related to fear of surgery? A. Patient will exhibit vital signs within normal limits during the preoperative period. B. Patient will sleep for 8 hours the night before the surgery. C. Patient will verbalize the need for the scheduled surgical procedure. D. Patient will avoid discussing factors that are creating fear of surgery.

A. Elevated blood pressure, heart rate, and respiratory rate are indicators of increased anxiety due to sympathetic nervous system response to fear. The goal of vital signs within normal limits was developed from the nursing diagnosis of Anxiety related to fear of surgery. Option B is incorrect because This goal relates to the nursing diagnosis of Insomnia, not Anxiety related to fear of surgery. Addressing insomnia does not result in normal vital signs. Option C is incorrect because This goal relates to the patient's understanding of the reason for surgery, which may be related to the nursing diagnosis of Knowledge Deficit. Teaching the patient does not result in normal vital signs. Option D is incorrect because This goal does relate to the patient's fear of surgery. However, avoiding discussing fears increases anxiety and does not result in normal vital signs.

Which surgical procedure is classified as minor surgery? A. Facial mole removal B. Exploratory laparotomy C. Mastectomy (breast removal) D. Cholecystectomy (gallbladder removal)

A. Facial mole removal requires little to no anesthesia or respiratory assistance. There is minimal risk to the patient, which makes this type of procedure a minor surgery. Option B is incorrect because An exploratory laparotomy involves opening the abdomen or using a laparoscope to look inside the abdomen. It requires anesthesia and respiratory assistance. There is high risk to the patient, making this a major, not minor, surgery. Option C is incorrect because A mastectomy requires anesthesia and respiratory assistance. There is high risk to the patient, making this a major, not minor, surgery. Option D is incorrect because A cholecystectomy requires anesthesia and respiratory assistance. There is high risk to the patient, making this a major, not minor, surgery.

Which older adult patient statement requires additional nursing teaching for fall prevention? A. "I keep flip flops beside the door to take my dog out at night." B. "My daughter bought non-skid rug pads for the large area rug in the living room." C. "I just got new glasses with a non-glare coating." D. "I plan to go to physical therapy after discharge."

A. Flip flops are not appropriate footwear. While it is appropriate to keep footwear by the door to use at night, wearing flip flops, especially at night, can be a significant risk and requires further teaching. Option B is incorrect because Non-skid pads can be used under large area rugs to prevent the rug from slipping while walking on it. This does not require further teaching. Option C is incorrect because New glasses indicate that the patient is receiving regular eye care and has corrected vision. This does not require additional teaching. Option D is incorrect because Physical therapy can be very beneficial to restore strength and mobility following hospitalization. This does not require additional teaching.

A patient with sickle cell disease is admitted to the hospital for the second time in 4 months, has an oral temperature of 100.9° F, and is experiencing severe pain. Hydroxyurea is being added to the patient's medication regimen. Which patient outcome shows this medication is effective? A. The patient experiences a reduced number of sickle cell crises. B. The patient's temperature returns to normal. C. The patient's heart rate increases. D. The patient's oxygen level stays between 85% and 90%.

A. Hydroxyurea is the only drug shown to be clinically beneficial for antisickling. This drug increases the production of hemoglobin F (fetal hemoglobin), which is accompanied by a reduction in hemolysis, an increase in hemoglobin concentration, and a decrease in sickled cells and painful crises. The number of hospital admissions will be reduced if hydroxyurea is effective. Option B is incorrect because Hydroxyurea is not administered in order to reduce a fever, and therefore, reduction in body temperature would not indicate a positive patient outcome. Option C is incorrect because Hydroxyurea is not administered to stabilize a patient's heart rate. Therefore the increased heart rate does not indicate a positive patient outcome. Option D is incorrect because Normal oxygen saturation should be maintained above 90% to maintain adequate tissue oxygenation. Less than 90% would cause hypoxia.

The nurse identifies the nursing diagnosis of Imbalanced nutrition: less than body requirements related to anorexia, nausea, and vomiting. Which electrolyte imbalance should the nurse use as the "as evidenced by" portion for this nursing diagnostic statement? A. Hypercalcemia B. Hypernatremia C. Hyperkalemia D. Hypermagnesemia

A. Hypercalcemia (high levels of calcium in the blood) is often the cause of anorexia, nausea, and vomiting. Therefore, this is an appropriate term to use as the "as evidenced by" portion of the nursing diagnostic statement. Option B is incorrect because Hyponatremia, not hypernatremia, causes the clinical manifestations of anorexia, nausea, and vomiting. Therefore, this is not an appropriate term to use as the "as evidenced by" portion of the nursing diagnostic statement. Option C is incorrect because Hypokalemia, not hyperkalemia, causes the clinical manifestations of anorexia, nausea, and vomiting. Therefore, this is not an appropriate term to use as the "as evidenced by" portion of the nursing diagnostic statement. Option D is incorrect because Hypermagnesemia is often associated with nausea and vomiting; however, it is not associated with anorexia. Therefore, this is not an appropriate term to use in the "as evidenced by" portion of the nursing diagnostic statement.

Which serum sodium concentration should the nurse identify as hyponatremia? A. 130 mEq/L B. 135 mEq/L C. 140 mEq/L D. 145 mEq/L

A. Hyponatremia is a serum sodium concentration that is less than 135 mEq/L. Normal serum sodium levels are between 135 and 145.

The daughter of an older adult patient admitted with a urinary tract infection asks the nurse, "Why is my mom acting different and trying to climb out of bed? She has never done this before." Which nursing teaching is most appropriate? A. "Infection can cause delirium in the older adult." B. "These symptoms are consistent with the onset of dementia." C. "Delirium can progress to dementia." D. "Restraints are the best option until the infection is controlled."

A. Infection can cause delirium in the older adult, which is an acute change in cognition that often resolves with treatment of the cause. Option B is incorrect because This presentation is not consistent with dementia. Dementia is a steady decline in cognitive function, not an acute change. Option C is incorrect because Delirium does not progress to dementia. Delirium often resolves with treatment of the cause. Option D is incorrect because Restraints are not the best option. Other alternatives should be explored to protect the patient, reserving restraints as a last resort.

Which nursing action is most appropriate to address chemotherapy-induced nausea and vomiting? A. Administer antiemetics before nausea or vomiting starts. B. Encourage the patient to hold ice chips in the mouth during chemotherapy treatments. C. Eat only moist or soft foods. D. Assess the oral cavity.

A. Most chemotherapy drugs cause nausea and vomiting. As such, it is important to be proactive in preventing the unwanted effects by administering antiemetics before nausea and vomiting starts. Option B is incorrect because Ice chips in the mouth during chemotherapy is known as oral cryotherapy and is used to prevent mucositis, not chemotherapy-induced nausea and vomiting. Option C is incorrect because Eating only moist or soft foods is an intervention to treat mucositis. Patients with chemotherapy-induced nausea and vomiting should be treated with an antiemetic before the nausea and vomiting starts. Option D is incorrect because Assessment of the oral cavity is a standard nursing assessment for all patients and does not specifically address or treat chemotherapy-induced nausea and vomiting. The most appropriate nursing action is to administer an antiemetic before the nausea and vomiting begins.

A patient is admitted with thrombocytopenia and states that he was born with it. The nurse suspects the patient has which type of thrombocytopenia? A. Pancytopenia B. Neonatal alloimmune C. Immune thrombocytopenic purpura (ITP) D. Thrombotic thrombocytopenic purpura (TTP)

A. Pancytopenia, or Fanconi anemia, is an inherited (congenital) thrombocytopenia. Option B is incorrect because While neonatal alloimmune thrombocytopenia may be present at birth, it is an acquired immune thrombocytopenia and is not inherited (congenital). Option C is incorrect because Immune or idiopathic thrombocytopenic purpura (ITP) is an acquired immune thrombocytopenia and is not congenital. Option D is incorrect because Thrombotic thrombocytopenic purpura (TTP) is an acquired nonimmune thrombocytopenia and is not congenital.

Which preoperative interventions reduce the risk for surgical infection? A. Bathing with antimicrobial soap B. Withholding food and fluids C. Removing hair from the surgical site D. Placing an indwelling urinary catheter

A. Patients are instructed to shower or bathe with an antimicrobial soap the evening prior to surgery, or the day prior to ambulatory surgery. Antimicrobial soap reduces the risk for introduction of pathogens when incisions are made through the skin. Option B is incorrect because Withholding food or fluids prevents aspiration of stomach contents during or after intubation for anesthesia. It does not prevent infection. Option C is incorrect because Hair is no longer removed from the surgical site as a method for decreasing surgical risk. Hair removal is now according to surgeon preference. Option D is incorrect because Placing an indwelling catheter, unless there is a specific reason for doing so, is not required. Not only do catheters fail to protect against infection, they contribute to infection.

The nurse has just administered gefitinib to a cancer patient orally. When will the patient have maximum levels of the medication in the blood? A. 3-7 hours after administration B. 8-12 hours after administration C. 13-17 hours after administration D. 18-22 hours after administration

A. Plasma levels of oral gefitinib peak between 3 and 7 hours after administration. Plasma levels of the drug may fall after 7 hours.

Which should the nurse include in a patient-teaching session as the most common cause for hyperphosphatemia? A. Poor kidney function B. Decreased phosphate intake C. Excessive parathyroid hormone D. Decreased vitamin D intake

A. Poor kidney function is a cause of hyperphosphatemia. Option B is incorrect because Decreased intake of phosphate causes hypophosphatemia, not hyperphosphatemia. Option C is incorrect because Excessive parathyroid hormone causes hypophosphatemia, not hyperphosphatemia. Option D is incorrect because Decreased vitamin D intake causes hypophosphatemia, not hyperphosphatemia.

The nurse is caring for a patient newly diagnosed with Hodgkin's lymphoma. Which statement by the patient indicates to the nurse that further education on the disease's etiology is needed? A. "I've gotten a lot of viruses." B. "I work around a lot of toxins at work." C. "I once had an Epstein-Barr infection." D. "My aunt and grandmother had Hodgkin's too."

A. Possible risk factors for Hodgkin's lymphoma do not include viral infections. Viral infections are associated with causing multiple myeloma. Option B is incorrect because Possible risk factors for Hodgkin's lymphoma include exposure to occupational toxins. The nurse would not need to provide further education if the patient acknowledges that working with toxins can cause Hodgkin's lymphoma. Option C is incorrect because Possible risk factors for Hodgkin's lymphoma include a previous Epstein-Barr virus infection. The nurse would not need to provide further education if the patient acknowledges Epstein-Barr infection as a cause of Hodgkin's lymphoma. Option D is incorrect because Possible risk factors for Hodgkin's lymphoma include a genetic predisposition. The nurse would not need to provide further education if the patient acknowledges family history of Hodgkin's lymphoma as a cause of the disease.

A patient is in the operating room for spinal surgery. The nurse will place the patient in which position for this type of surgery? A. Prone B. Supine C. Lithotomy D. Dorsal Recumbent

A. Prone positioning is used for posterior thorax and spinal surgeries. Option B is incorrect because Supine positioning is used for thoracic, heart, and abdominal surgeries. Option C is incorrect because Lithotomy positioning is used for gynecologic, rectal, perineal, and genitourinary surgeries. Option D is incorrect because Dorsal recumbent positioning is used for thoracic, heart, and vaginal surgeries.

Which should the nurse identify as a primary cause of hypocalcemia? A. Protein depletion B. Breast cancer C. Immobilization D. Excessive intake of vitamin D

A. Protein depletion is a primary cause of hypocalcemia. Incorrect Option B is incorrect because Breast cancer is a primary cause of hypercalcemia, not hypocalcemia. Option C is incorrect because Immobilization is a primary cause of hypercalcemia, not hypocalcemia. Option D is incorrect because Excessive intake of vitamin D is a primary cause for hypercalcemia, not hypocalcemia.

Which is the most common cause of hypercalcemia? A. Hyperparathyroidism B. Inadequate dietary intake of calcium C. Inadequate dietary intake of vitamin D D. Hyperphosphatemia

A. Hyperparathyroidism is the most common cause of hypercalcemia. Option B is incorrect because An inadequate dietary intake of calcium is a cause for hypocalcemia, not hypercalcemia. Option C is incorrect because An inadequate dietary intake of vitamin D is a cause for hypocalcemia, not hypercalcemia. Option D is incorrect because Hyperphosphatemia is a cause for hypocalcemia, not hypercalcemia.

Which strategy would be most effective to promote wellness for an older adult in a rural area? A. Provide transportation to the health care clinic. B. Discuss health care quality. C. Describe Medicare options. D. Air commercials that advertise care options.

A. Providing transportation identifies and addresses a known need associated with care of older adults within a rural population. Option B is incorrect because While lack of health care quality is a barrier to access, discussing quality does not provide an actionable approach to reduction of the barrier. Option C is incorrect because While Medicare can help alleviate financial limitation, discussing Medicare does not provide an actionable approach to reduction of the barrier. Option D is incorrect because While commercials that advertise care options may address the perception of health care quality and access, patients in rural areas may not see these commercials, and this is not an actionable approach to reduction of the barrier.

Documentation reveals a patient's lymph nodes are abnormal and indicative of Reed-Sternberg cells. When the nurse is reviewing the patient's medical history, which finding is likely? A. Mononucleosis infection 10 years ago B. Repeated radiation exposure C. Hip fracture from a fall and osteoporosis D. Presence of the Philadelphia chromosome

A. Reed-Sternberg cells are indicative of Hodgkin's lymphoma. Risk factors for Hodgkin's lymphoma include a history of Epstein-Barr virus infection, so a previous mononucleosis infection is a likely finding. Option B is incorrect because Radiation exposure is associated with multiple myeloma. Reed-Sternberg cells are indicative of Hodgkin's lymphoma. Past radiation exposure would not be a likely finding in a patient with Reed-Sternberg cells. Option C is incorrect because Skeletal fractures and osteoporosis are associated with multiple myeloma. Reed-Sternberg cells are associated with Hodgkin's lymphoma. A previous hip fracture and osteoporosis would not be likely findings in a patient with Reed-Sternberg cells. Option D is incorrect because The Philadelphia chromosome is associated with acute lymphocytic leukemia, while Reed-Sternberg cells are indicative of Hodgkin's lymphoma. The presence of the Philadelphia chromosome would not be a likely finding in a patient with Reed-Sternberg cells.

When conducting patient education related to the causes of hypermagnesemia, which cause should the nurse include in the teaching session? A. Renal failure B. Laxative abuse C. Loop diuretics usage D. Gastric suctioning

A. Renal failure is a primary cause of hypermagnesemia. Option B is incorrect because Laxative abuse is a cause for hypomagnesemia, not hypermagnesemia. Option C is incorrect because Loop diuretics is a cause of hypomagnesemia, not hypermagnesemia. Option D is incorrect because Gastric suctioning is a cause of hypomagnesemia, not hypermagnesemia.

Which nursing diagnosis would the nurse individualize for a patient recovering from left jaw surgery? A. Risk for Pain related to left jaw surgery B. Risk for Eating Inability as evidenced by jaw pain C. Inability to Eat associated with pain from jaw surgery D. Pain related to jaw surgery as evidenced by complaints

A. Risk for Pain related to left jaw surgery is a correctly stated NANDA nursing diagnosis. There is data to support individualizing this nursing diagnosis. The patient is at risk for pain because the risk factor of left surgery exists. All other options are incorrect because they are not correctly stated nursing diagnoses. There is no data to support individualizing these nursing diagnoses.

A patient diagnosed with metastasizing cancer has a history of immune thrombocytopenic purpura (ITP) controlled with prednisone. Which information will need to be covered in the education plan for this patient? A. Information on chemotherapy since some drugs will cause thrombocytopenia B. The interaction between steroids and chemotherapy since there is a synergistic effect C. The interaction between steroids and radiation since this is known to cause bleeding in patients D. Information on radiation therapy since radiation has been associated with hypercoagulable states

A. Some chemotherapy drugs can lead to thrombocytopenia, and therefore, the patient will need education on this therapy. Option B is incorrect because Steroids and chemo do not have a synergistic effect; therefore, they will not be a part of the patient education plan. Option C is incorrect because The interaction between steroids and radiation is not known to cause bleeding in patients. Option D is incorrect because Radiation is not associated with hypercoagulable states; therefore, this will not be covered in the patient education plan.

The nurse would collaborate with which team member about dietary modifications prior to discharging a postoperative patient? A. Dietician B. Home care nurse C. Physical therapist D. Health care provider

A. The dietician would be responsible for preparing a diet plan that meets the postoperative patient's caloric needs. The dietician would also teach the patient about the diet prior to discharge. Option B is incorrect because A home care nurse would assist a non-independent patient to follow his or her diet, but would not be responsible for the preparation of the dietary treatment plan. Option C is incorrect because The physical therapist would be involved in the patient's physical rehabilitation, but not in preparation of a dietary plan. Option D is incorrect because The health care provider might prescribe a specialized diet for the postoperative patient but is not involved in the patient's postoperative dietary planning.

A patient has the goal of, "Patient will verbalize understanding of scheduled surgical procedure." Which nursing diagnosis does this goal address? A. Deficient Knowledge B. Readiness for Enhanced Knowledge C. Teaching Deficiency D. Health Promotion

A. The goal addresses the nursing diagnosis of Deficient Knowledge because it indicates the patient has no previous knowledge or experience with the surgical procedure. Option B is incorrect because Readiness for Enhanced Knowledge implies the patient is asking questions about the surgical procedure, not verbalizing the understanding of such. Option C is incorrect because Teaching deficiency is not a NANDA nursing diagnostic label. A teaching deficiency is the condition in which patient's need teaching. Option D is incorrect because health promotion is a nursing diagnostic category, not a nursing diagnosis.

The nurse is providing discharge teaching to a patient who will be taking tyrosine (gefitinib) at home. Which adverse response to this medication should the nurse instruct the patient to report to the prescriber immediately? A. Dyspnea B. Skin rash C. Conjunctivitis D. Nausea and vomiting

A. If a patient taking gefitinib develops respiratory symptoms, the prescriber should be informed and the patient should be evaluated for severe adverse reactions. All other options are common experiences from taking gefitnib. These symptoms should be self monitored and reported to the nurse if changes occur.

Which nursing diagnosis will the preoperative nurse select for a patient who is asking questions about a scheduled surgery? A. Deficient Knowledge B. Risk for Deficient Knowledge C. Self-Care Deficit D. Risk for Self-Care Deficit

A. The nurse will select the nursing diagnosis Deficient Knowledge for the preoperative patient who asks questions because it indicates a lack of knowledge or understanding about the preoperative care or the surgery. Option B is incorrect because A NANDA nursing diagnosis of Risk for Deficient Knowledge does not exist; therefore, this cannot be selected. Option C is incorrect because There is no indication that the patient cannot perform self-care based on the patient asking questions. This is not an appropriate nursing diagnosis for this patient. Option D is incorrect because There is no indication that the patient has risk factors for inability to perform self-care based on asking questions. This is not an appropriate nursing diagnosis for this patient.

A patient presents to the emergency department with severe bilateral lower extremity weakness and shallow respirations. Heart rate and rhythm are normal and the patient is alert. Which laboratory test should the nurse anticipate based on the current data? A. Serum potassium B. Urine specific gravity C. Serum sodium D. Serum calcium

A. The nurse would anticipate a serum potassium concentration test for this patient. Hypokalemia causes bilateral quadriceps muscle weakness that may ascend to weaken the respiratory muscles. Option B is incorrect because A urine specific gravity is used to assess sodium imbalances. Option C is incorrect because Serum sodium imbalances cause decreased level of consciousness. Option D is incorrect because Calcium imbalances alter neuromuscular excitability and do not cause respiratory muscle weakness.

Which nursing diagnosis will the nurse select for a patient who reports difficulty sleeping prior to surgery? A. Anxiety B. Risk for Fear C. Ineffective Coping D. Risk for Insomnia

A. The patient is exhibiting a sign of anxiety, which is difficulty sleeping related to anxiety over impending surgery. The preoperative nurse will select this nursing diagnosis for the patient, which is an actual nursing diagnosis. Option B is incorrect because The patient is demonstrating signs of fear. This means Risk for Fear is not the correct nursing diagnosis based on this patient's data. Option C is incorrect because The patient shows no manifestations of ineffective coping, such as confusion or inability to make decisions. The nurse will not select this nursing diagnosis for the patient. Option D is incorrect because The patient is reporting difficulty sleeping. This means risk for insomnia is not the correct nursing diagnosis based on this patient's data. The patient is experiencing insomnia.

A newlywed couple is undergoing family planning counseling. The wife mentions that she has the sickle cell trait, while her husband does not. Which statement by the couple demonstrates that they have an understanding of how sickle cell disease is inherited? A. "Our children have a 50% chance of inheriting the sickle cell trait." B. "Our children have a 100% chance of inheriting the sickle cell trait." C. "Our children have a 25% chance of inheriting the sickle cell disease." D. "Our children have a 50% chance of inheriting sickle cell disease."

A. The patient who has the sickle cell trait is heterozygous for hemoglobin S (Hgb S). The patient who does not have the sickle cell trait is homozygous for normal hemoglobin. Therefore 50% of the couple's offspring will be homozygous for normal hemoglobin and 50% will be heterozygous for Hgb S and have the sickle cell trait. Option B is incorrect because The sickle cell trait requires one Hgb S and one normal hemoglobin gene. Because the wife has the sickle cell trait and is therefore heterozygous for Hgb S (having one Hgb S gene and one normal gene), and the husband is homozygous for normal hemoglobin, there is no chance that 100% of the couple's offspring will inherit the Hgb S gene. Option C is incorrect because The sickle cell disease occurs when a person is homozygous for Hgb S. Because the wife has the sickle cell trait and is therefore heterozygous for Hgb (having one Hgb S gene and one normal gene), and the husband is homozygous for normal hemoglobin, there is no chance that 25% of the couple's offspring will inherit two copies of the Hgb S gene. Option D is incorrect becauseSickle cell disease occurs when a person is homozygous for Hgb S. Because the wife has the sickle cell trait and is therefore heterozygous for Hgb (having one Hgb S gene and one normal gene), and the husband is homozygous for normal hemoglobin, there is no chance that 50% of the couple's offspring will inherit two copies of the Hgb S gene.

Which intraoperative patient goal, beginning with "The patient will" and addressing body temperature, is measurable? A. Maintain intraoperative temperature in range for patient B. Have temperature continually assessed throughout surgery C. Show minor temperature variations prior to surgical procedure D. Achieve normal temperature within two hours following surgery

A. The patient will maintain intraoperative temperature in range for patient is a correctly stated and measurable patient goal. Option B is incorrect because The patient will have temperature continually assessed throughout surgery is a nursing action, not a measurable patient goal. Option C is incorrect because The patient will show minor temperature variations prior to surgical procedure is not measurable because it does not delineate the meaning of minor variations in temperature and it pertains to the preoperative, not the intraoperative, temperature. Option D is incorrect because The patient will achieve normal temperature within two hours following surgery addresses the patient's postoperative, not intraoperative, body temperature.

Which collaborative care treatment modality should the nurse include in the plan of care to prevent complications for the patient with multiple myeloma? A. Prescribe weight-bearing exercises with physical therapy B. Have the nuclear medicine department perform routine positron emission tomography (PET) scans C. Arrange for radiation treatments D. Have the pharmacist explain the chemotherapy drugs to the patient

A. The patient with multiple myeloma is at risk for osteoporosis. Weight-bearing exercises with physical therapy will help the bones reabsorb calcium. Option B is incorrect because PET scans are used to diagnose cancer metastasis and will not improve patient outcomes. Option C is incorrect because The patient with multiple myeloma does not require radiation. Radiation can only be used with solid tumors, and multiple myeloma is a cancer of the B lymphocytes. Radiation will not improve the outcome for this patient. Option D is incorrect because The nurse will be administering the chemotherapy drugs; therefore the nurse, not the pharmacist, will educate the patient about medications.

Which nursing diagnosis will the preoperative nurse select for a patient requesting information about preventing skin cancer after surgery to remove a skin lesion? A. Readiness for Enhanced Knowledge B. Self-Care Deficit C. Risk for Skin Cancer D. Ineffective Health Maintenance

A. The patient's questions about preventive measures support the preoperative nurse's selection of Readiness for Enhanced Knowledge nursing diagnosis. The patient displayed interest and readiness for learning by asking questions. Option B is incorrect because This diagnosis implies the patient is unable to care for himself, which is not supported in this scenario. Option C is incorrect because The patient may have risk factors for skin cancer based on the surgery being performed, but this diagnosis does not address the patient's situation. Option D is incorrect because This diagnosis implies the patient is unable to provide his own health maintenance, which is not supported in this scenario.

What is the rationale for informing patients about their pain management plan during the preoperative phase of surgery? A. Minimizes patient fears B. Enables use of patient pain scale C. Eliminates post-recovery teaching D. Prepares patient for surgical pain

A. The rationale for including patients in pain management plans during the preoperative phase of surgery is to minimize any fears they have about postoperative pain. Fear is common, but knowledge of pain management alleviates fear. Option B is incorrect because Use of a patient pain scale, such as rating pain on a scale from one to ten, is part of the pain management plan. It is a way to quantify a patient's pain, not the rationale for teaching pain management. Option C is incorrect because Including patients in pain management plans during the preoperative phase of surgery does not eliminate the need for post-recovery teaching. Preoperative teaching about pain needs to be reinforced during the recovery phase of surgery. Option D is incorrect because Including patients in pain management plans during the preoperative phase of surgery does prepare patients for expected postoperative pain. However, that is not the rationale for including patients in pain management plans.

The nurse identifies the nursing diagnosis Risk for electrolyte imbalance for an older adult patient experiencing nausea, vomiting, and diarrhea. Which is an accurate goal statement for the nurse to include in the patient's plan of care? A. Patient's serum potassium level will be within the normal range of 3.5-5.0 mEq/L during the hospitalization. B. Patient's serum sodium level will be within the normal range of 1.5-2.0 mEq/L during the hospitalization. C. Patient's serum calcium level will be within the normal range of 135-145 mEq/L during the hospitalization. D. Patient's serum magnesium level will be within the normal range of 8.4-10.2 mg/dL during the hospitalization.

A. This is an accurate goal for the patient as the normal range for potassium is 3.5-5.0 mEq/L. All other levels of electrolytes are incorrectly stated.

On day five post-op, a patient's laboratory blood results reveal a platelet count of 95,000/μL. The patient has been prophylactically treated with heparin for the past five days for deep vein thrombosis. Which treatment orders should the health care team anticipate to manage this patient? A. Discontinue the heparin B. Increase heparin dosage slightly C. Add aspirin to the heparin treatment D. Switch patient to low-molecular-weight heparin

A. This patient has developed heparin-induced thrombocytopenia (HIT) and heparin will need to be discontinued. If not already indicated in the patient's electronic health record, it should be noted that this patient should never receive heparin in the future. Option B is incorrect because This patient may be at risk for developing a clot, but increasing heparin is not the appropriate management as it may lower the patient's platelet count even more. Option C is incorrect because Adding aspirin to heparin is not the best step in management. This may act to lower the patient's platelet count even more. Option D is incorrect because This patient has developed heparin-induced thrombocytopenia (HIT). Patients who have had HIT should never be given heparin or low-molecular-weight heparin (LMWH) as HIT is often caused by an immune reaction to heparin.

Which assessment finding would support the diagnosis of hypocalcemia? A. Trousseau sign B. Lethargy C. Shallow respirations D. Stupor

A. Trousseau sign is a neurologic symptom of spasm of the muscles in the hand and wrist that occurs when the blood supply to the hand is occluded with a blood pressure cuff. It indicates increased neuromuscular excitability and is associated with hypocalcemia or hypomagnesemia. Option B is incorrect because Lethargy is a clinical manifestation associated with hypercalcemia, not hypocalcemia. Option C is incorrect because Shallow respirations from muscle weakness are associated with severe hypokalemia, not hypocalcemia. Option D is incorrect because Stupor is a clinical manifestation associated with hypercalcemia, not hypocalcemia.

Which patient assessment data is consistent with delirium according to the Confusion Assessment Method (CAM)? A. Difficult to arouse B. History of dementia C. Frustrated with noise D. Walks slowly

A. Using the Confusion Assessment Method, an altered level of consciousness, such as difficulty to arouse, is consistent with a diagnosis of delirium. Option B is incorrect because A history of dementia is not consistent with delirium according to the CAM. Option C is incorrect because Frustration with noise is not consistent with delirium according to the CAM. Option D is incorrect because Walking slowly is not consistent with delirium according to the CAM.

Which statement made by the patient on chemotherapy with a low platelet count requires further nursing education? A. "Playing football with my kids makes me feel normal." B. "I will use a soft toothbrush to brush with." C. "I am taking a stool softener every day." D. "I have stopped taking a daily baby aspirin."

A. While physical activity is good, any sports that could cause contact should be avoided. The patient with low platelets is at risk for bleeding, and football is a contact sport. This statement requires further education. Option B is incorrect because Using a soft toothbrush is appropriate to prevent bleeding in the oral cavity that can occur easily with low platelets. This statement does not require further education. Option C is incorrect because Taking a stool softener daily is appropriate to decrease straining associated with bowel movements to reduce the risk of rectal bleeding. This statement does not require further education. Option D is incorrect because Aspirin should be avoided due to the increased risk of bleeding. This statement does not require further education.

What is the priority nursing action for an older adult patient who reports xerostomia? A. Assess the oral cavity. B. Brush the patient's teeth. C. Provide an assistive device to hold the patient's toothbrush. D. Order a diet with soft foods.

A. Xerostomia is dry mouth and can be caused by conditions as well as medications. The priority nursing action is to assess the oral cavity following the patient's report. Option B is incorrect because The patient may be able to brush his or her own teeth; the priority nursing action is to assess the oral cavity following the patient's report. Option C is incorrect because The patient may not need an assistive device to brush his or her teeth; the priority nursing action is to assess the oral cavity following the patient's report. Option D is incorrect because Soft foods are often ordered for the older adult who has problems with dentition or swallowing. This is not the priority action for a patient who reports xerostomia.

After receiving three chemotherapy treatments, the patient asks the nurse if the cancer staging has improved. Which nursing response would be appropriate? A. "Once your cancer staging has been determined, it does not change even though your condition may be improving." B. "The cancer staging is reevaluated every 3 months." C. "The cancer staging should improve with each chemotherapy treatment." D. "The cancer staging is only revised following a body scan to evaluate potential metastasis."

A. After a complete diagnostic workup, the staging of a particular cancer is determined. Once determined, the staging does not change and is used to evaluate the effectiveness of treatment and evolution of the disease. Option B is incorrect because Once the initial staging and diagnosis is made, the staging does not change. The patient is evaluated frequently to determine the effectiveness of treatment. Option C is incorrect because While the cancer may respond effectively to the chemotherapy treatment, the staging does not change. Option D is incorrect because Cancer staging is not revised following a body scan. While a body scan may reveal metastasis, this does not change the initial staging of the cancer.

A patient receiving imatinib asks the nurse why it is recommended to avoid alcohol intake while taking the medication. Which response by the nurse is most appropriate? A. "Alcohol intake can impair liver metabolism of imatinib." B. "Alcohol can increase the risk of adverse drug reactions." C. "Alcohol can increase imatinib's elimination from the blood." D. "Alcohol intake can cause impaired judgment and dosing mistakes."

A. Alcohol can impair liver function and reduce metabolism of imatinib. Option B is incorrect because Alcohol intake does not cause adverse drug reactions with imatinib. Option C is incorrect because Impaired liver function reduces drug metabolism and may increase drug levels in the blood. Option D is incorrect because Alcohol intake may influence wrong dosing of medication, but that is not the specific reason for its restriction in patients taking imatinib.

Which nursing student statement regarding carcinogens requires further education from the nurse? A. "Carcinogens are associated with genetic predisposition." B. "Carcinogens are agents that can cause cancer." C. "Age and long-term exposure to carcinogens can decrease immunity." D. "Carcinogens can be viruses that cause cellular change."

A. Carcinogens are cancer-causing agents that are capable of altering normal cellular function. Carcinogens and/or exposure to are not associated with genetic predisposition, which is related to an inherited genetic mutation. As such, this statement by the nursing student requires further education. Option B is incorrect because Carcinogens are cancer-causing agents that are capable of altering normal cellular function. These carcinogens can be chemical, viral, or related to radiation. Option C is incorrect because As age increases, immunity decreases, and a longer potential exposure to carcinogens exists. Option D is incorrect because Viral carcinogens are known as oncoviruses and can begin when a virus infects the cells of the body.

During which stage of cancer development are oncogenes activated? A. Initiation B. Promotion C. Progression D. Exposure

A. During initiation, a mutation in the cell's genetic structure is the first stage in the development of cancer. These changes can activate oncogenes and damage suppressor genes, leading to excessive cell division. Option B is incorrect because Oncogenes are activated during the initiation phase, not the promotion phase of cancer development, which is the reversible proliferation of the altered cells. Option C is incorrect because Oncogenes are activated during the initiation phase, not the progression phase of cancer development, which is characterized by increased growth, invasiveness, and metastasis. Option D is incorrect because Exposure is not a stage of cancer development. Exposure to cancer-causing agents (carcinogens) may or may not lead to cancer development.

Which nutrient will the nurse recommend that the older adult increase? Select all that apply. A. Vitamin C B. Glucose C. Vitamin D D. Niacin E. Calcium F. Vitamin A

A., C., E., F. Most older adults need an increased dietary intake of vitamins D, C, and A and an increase in calcium intake. Options B and D are incorrect because Glucose and niacin are not commonly decreased with aging.

Which cancer treatment strategy uses the body's own immune system to fight cancer? A. Biological response modifiers B. Chemotherapy C. Hematopoietic stem cell transplantation D. Brachytherapy

A. Immunotherapy includes biological response modifiers (BRMs) and targeted therapies. Some BRMs can boost the immune system, and others have direct antitumor activity. Option B is incorrect because Chemotherapy is the use of chemical agents to kill cancer cells, not the body's immune system. Option C is incorrect because Hematopoietic stem cell transplantation (HSCT), formerly referred to as bone marrow transplantation, is an effective yet complex treatment for a number of malignant and nonmalignant diseases. Option D is incorrect because Brachytherapy is radiation delivered by an internal device or seed.

How is skin thickening associated with some types of cancer? A. The skin thickens due to the changes in the cell growth. B. Skin thickening is the immune response to cellular invasion. C. Tissues bleed with cancer development, causing thickening of the skin. D. Hormones are released that cause the skin to dimple and thicken.

A. In some types of cancer, most often skin or breast, the cellular growth causes the skin to appear thicker creating a warning sign for cancer development. Option B is incorrect because Skin thickening is not an immune response. It is a result of altered cellular growth. Option C is incorrect because Bleeding can occur with cancer; however, this creates bruising or petechiae, not skin thickening. Option D is incorrect because Hormones can fuel cancer development; however, they do not cause the skin to thicken. This is the result of altered cellular growth.

Which nursing student statement regarding cancer risk requires further education? A. "Infections are not related to cancer development." B. "The risk of cancer is decreased with an increase in mobility." C. "Eliminating or decreasing alcohol intake can decrease the risk of cancer." D. "Using sunscreen can reduce the risk of cancer associated with ultraviolet radiation."

A. Infections can be related to cancer development. For example, certain sexual viruses can increase the risk for cervical cancer. This student statement requires further education. Option B is incorrect because Regular exercise and increased mobility are associated with a decreased cancer risk. This statement is correct and does not require further education. Option C is incorrect because Limiting alcohol intake can decrease the risk of certain cancers. This statement is correct and does not require further education. Option D is incorrect because Applying sunscreen is a primary prevention strategy for skin cancer. This statement is correct and does not require further education.

A nurse recently assigned to work in the oncology unit asks the charge nurse what her job description is. Which response by the charge nurse is most appropriate? A. "You need to have orientation and unit training before your first patient care assignment." B. "Your oncology nursing certification confirms your knowledge and ability to work in this unit." C. "You have adequate medical surgical nursing experience and can start working as soon as possible." D. "You need to complete the general new hire orientation and report to me for your unit assignment."

A. Nurses working with cancer patients and administering anticancer medications require special training to be able to give safe and effective patient care. Option B is incorrect because It is standard practice to train and orient nurses newly assigned to a specialized nursing unit regardless of their backgrounds. Option C is incorrect because Nursing experience that does not directly involve caring for cancer patients is inadequate; specialized training is needed for the nurse to provide safe administration of anticancer drugs. Option D is incorrect because General new hire orientations usually do not involve teaching of the specific skills and safety measures needed to provide safe administration of anticancer drugs.

A patient is diagnosed with thalassemia minor and the caregiver asks the nurse, "What symptoms should I be expecting with this disease?" What is the best response from the nurse? A. "Although the patient may have mild anemia, you should not expect any symptoms." B. "You should monitor for any delays in physical growth and cognitive development." C. "The patient may experience urinary symptoms, indicating damage to the kidneys." D. "You can expect to see flu-like symptoms associated with widespread pain."

A. Patients with thalassemia minor frequently have no symptoms, despite a slight anemia. Option B is incorrect because Patients with thalassemia major, not thalassemia minor, often experience delayed physical and mental development. Option C is incorrect because Acute kidney injury is a symptom of sickle cell disease, not thalassemia minor. Option D is incorrect because Fever, tenderness, nausea and vomiting, and pain are symptoms of sickle cell disease, not thalassemia minor.

Which statement defines perioperative nursing? A. The provision of nursing care during the three phases of surgery B. The ability of nurses to care for patients while undergoing surgery C. The planning and coordination of surgical care for a variety of patients D. The preparation of and care for patients before and after surgical procedures

A. Perioperative nursing is the care that nurses provide to patients before, during, and after surgery. Option B is incorrect because Caring for patients while they are undergoing surgery is part of perioperative nursing, but this action does not completely define the term. Option C is incorrect because Planning and coordinating surgical care for a variety of patients is part of perioperative nursing, but these actions do not address all aspects of the term. Option D is incorrect because The preparation of and care for patients before and after surgical procedures are part of perioperative nursing, but these actions do not completely define the term.

Which term reflects the chromosomal number and appearance of cells? A. Ploidy B. Histology C. Staging D. TNM system

A. Ploidy describes cancer cells by their chromosomal number and appearance. Option B is incorrect because Histology is the pathological appearance of cancer cells. Option C is incorrect because Staging is the clinical aspect of cancer, or the extent of the disease. Option D is incorrect because The TNM system is used to describe the anatomic extent of the cancer using three parameters. The T category describes the primary tumor site. The N category describes the extent of lymph node involvement. The M category describes the degree of metastasis.

Which action should the nurse initially take when a supine postoperative patient complains of breathing difficulty? A. Reposition the patient B. Reintubate the patient C. Suction the patient's airway D. Encourage the Valsalva maneuver

A. Repositioning the patient is the initial action the nurse should take when a patient complains of breathing difficulty. Placing the patient in the Fowler or semi-Fowler position facilitates breathing, promotes comfort, and places minimal strain on abdominal incisions. Option B is incorrect because The anesthesiologist, not the nurse, reintubates the patient in an emergency situation. It is not necessary to reintubate a conscious patient who is able to complain of difficulty breathing. Option C is incorrect because Suction might be necessary to clear a patient's airway if it is obstructed with vomit, blood, or secretions, but is not the initial nursing action taken for a conscious patient who is able to speak. Option D is incorrect because The Valsalva maneuver should be avoided, especially if the cause of breathing difficulty is unknown. The maneuver is associated with increased intrathoracic pressure and could trigger complications such as pulmonary embolism.

Which nursing statement describes Stage 0 cancer? A. "Stage 0 cancer is known as carcinoma in situ." B. "Stage 0 cancer only has a limited spread." C. "Stage 0 cancer is localized but can easily spread." D. "Stage 0 cancer indicates distant metastasis."

A. Stage 0 cancer is carcinoma in situ; cancer that is localized and shows no tendency to invade or spread to other tissues. Option B is incorrect because Stage 0 cancer does not have any spread. Option C is incorrect because Stage 0 cancer is localized and shows no tendency to spread. Option D is incorrect because Stage 0 cancer is localized and does not indicate distant metastasis.

Which teaching will the nurse provide to a patient receiving teletherapy who is concerned about exposing his children to radiation? A. Teletherapy poses no risk of exposure to others. B. Children are more sensitive to radiation and should stay at arm's length for 24 hours following the teletherapy treatment. C. Teletherapy is internal radiation that will emit low dose radiation for up to 3 days following the treatment. D. If you are concerned about exposure to others, it would be good to discuss with your provider switching from teletherapy to brachytherapy.

A. Teletherapy is external beam radiation and places no exposure risk to others. Option B is incorrect because While it is true that children should avoid sources of radiation, there is no risk of exposure following teletherapy treatment. Option C is incorrect because Teletherapy is an external beam radiation. It is not an internal method and does not emit radiation following the treatment. Option D is incorrect because Switching types of radiation is not a viable option because the type of radiation is determined by the type and location of the cancer.

Which nursing diagnosis will the preoperative nurse select for a patient with diabetes? A. Risk for Unstable Blood Glucose B. Risk for Hypothermia C. Ineffective Tissue Perfusion D. Fluid Volume Deficit

A. The preoperative nurse will select Risk for Unstable Blood Glucose for the patient with diabetes because the patient is NPO prior to surgery and will remain without food for a prolonged time. Glucose is infused intravenously to provide for the patient's needs during surgery, and insulin or oral hypoglycemic medications are adjusted accordingly. Option B is incorrect because there is no need for the perioperative nurse to select this nursing diagnosis. Patients with diabetes are at no greater risk for hypothermia than other patients, unless they have severe diabetic neuropathy. All patients are protected from hypothermia during surgery. Option C is incorrect because There is no need for the perioperative nurse to select this nursing diagnosis. Patients with diabetes are at no greater risk for ineffective peripheral tissue perfusion than other patients during surgery. Option D is incorrect because There is no need for the perioperative nurse to select this nursing diagnosis. Patients with diabetes are at no greater risk for fluid volume deficit than other patients, unless they experience hyperglycemia. They are monitored very closely for hyperglycemia and treated with insulin should it occur.

What is the rationale for collecting data about the patient's past experiences with anesthesia during the preoperative interview? A. Determining the patient's anesthesia risk B. Establishing the patient's understanding of anesthesia C. Eliminating some aspects of anesthesia teaching D. Creating a baseline for post-anesthesia comparison

A. The rationale for the preoperative nurse and anesthesiologist or anesthetist collecting data pertaining to the patient's previous experience with anesthesia is to determine the patient's risk for reactions to anesthetics, such as malignant hyperthermia. Option B is incorrect because Collecting this information does allow an opportunity for the preoperative nurse and anesthetist to answer patient questions and correct misunderstandings about anesthesia. However, this is not the rationale for collecting this important data. Option C is incorrect because Collecting this information does not eliminate the need for teaching patients about anesthesia, answering questions, or correcting misunderstandings about anesthesia. Option D is incorrect because This data is important for creating a history for the patient, but it does not create a baseline for comparison. This is not the rationale for collecting this important data.

Which dietary selection is most appropriate for the patient with cancer? A. An omelet with bacon, ham, and spinach B. Chips and salsa with avocado C. Spaghetti with marinara sauce D. Grilled cheese with French fries

A. This dietary selection is most appropriate, because it has the most protein and caloric density to provide optimal nutritional support. This item provides approximately 30 grams of protein. Option B is incorrect because This dietary selection provides no protein and is therefore not the best nutritional option for the patient with cancer. Option C is incorrect because While spaghetti does contain calories and carbohydrates, there is no protein source. Thus, this is not the best nutritional option for the patient with cancer. Option D is incorrect because Cheese is a source of protein; however, it is much lower in protein than the optimal choice of eggs, bacon, and ham.

When a patient's condition is serious but not life-threatening, which type of procedure will be scheduled? A. Urgent B. Elective C. Palliative D. Emergency

A. Urgent surgery is required when the health condition is not immediately life-threatening. However, the surgery must be performed within 24 hours or the condition can become life-threatening. Option B is incorrect because Elective surgery can be planned in advance by the patient and surgeon and performed when it is convenient for both as long as the patient's condition is not serious. Option C is incorrect because Palliative surgery is conducted to improve comfort and/or alleviate pain, but can be scheduled at the convenience of the patient and surgeon, as long as the patient's condition is not critical. Option D is incorrect because Emergency surgery is an immediate surgery required for a life-threatening medical condition. The surgery cannot be delayed.

Which patient statement about cancer treatment requires further education? A. "Pain is just a part of having cancer." B. "Small, frequent meals help keep my caloric intake up." C. "I will look in my mouth daily to make sure it looks normal." D. "I have to swallow the oral chemotherapy drug whole."

A. With proper assessment, cancer pain can be controlled. This patient requires further education. Option B is incorrect because Provide small, frequent, high-calorie, high-protein foods because small meals may be tolerated better than a large meal. This statement is correct and does not require further education. Option C is incorrect because Mucositis (sores in the mouth) is a common side effect of chemotherapy and radiation of the head and neck. This statement is correct and does not require further teaching. Option D is incorrect because Oral chemotherapy drugs may be administered in the home or by non-oncology nurses. Oral agents cannot be crushed, split, broken, or chewed. This statement is correct and does not require further teaching.

Which actions will the preoperative nurse perform when a patient is scheduled for admission to the nursing unit following surgery? Select all that apply. A. Verify patient information in electronic record B. Confirm arrangements were made with dietary services C. Establish postoperative teaching protocols D. Collaborate with facility discharge planner E. Escort family to unit for brief orientation

A. and B. For patients admitted to the hospital, the preoperative nurse verifies that all patient information is present in the electronic health record to facilitate a smooth transition to the nursing unit from the post recovery unit. The surgeon will arrange dietary and other ancillary services when patients are admitted to the unit, but the preoperative nurse confirms those arrangements to facilitate the patent's admission process following recovery from surgery. Option C is incorrect because The preoperative nurse is not responsible for establishing postoperative teaching protocols. However, the preoperative nurse does begin postoperative teaching, such as deep breathing and leg exercises while the patient is prepared for surgery. Option D is incorrect because The preoperative nurse is not responsible for collaborating with the facility discharge planner. The unit nurse is responsible for coordinating the patient's discharge. Option E is incorrect because The preoperative nurse is not responsible for orienting the patient's family to the nursing unit. The unit nurse is responsible for that activity.

Which initial assessments would the nurse perform on a patient admitted to the PACU following a lengthy surgery? Select all that apply. A. Respiratory status B. Neurological status C. Estimated blood loss D. Dressings and drains E. Skin color and temperature

A. and B. The initial assessment of patients admitted to the PACU includes assessment of the patient's respiratory system, including breath sounds, rate rhythm, depth, use of accessory muscles, and gag reflex. Neurological statusThe initial assessment of patients admitted to the PACU includes assessment of the patient's neurological status, including the level of consciousness, orientation, speech pattern, and motor and sensory ability. Option C is incorrect because The PACU nurse is not expected to assess the patient's estimated blood loss. This information is received from the OR staff (circulating nurse and anesthetist). It is also included on the intraoperative patient record. Option D is incorrect because Assessment of the patient's dressings and drains follows the initial admission assessment. Once the patient is deemed stable, other assessments such as this one are conducted. Option E is incorrect because Assessment of the patient's skin color and temperature follows the initial admission assessment. Once the patient is deemed stable, other assessments such as these are conducted.

Which actions would the PACU nurse implement for a patient going into hypovolemic shock? Select all that apply. A. Establish a patent airway B. Elevate the head of the bed C. Administer prescribed IV fluids D. Administer 2% oxygen by mask E. Initiate cardiopulmonary resuscitation

A. and C. Shock is an emergency situation. The nurse's goal is to improve and maintain tissue perfusion. Nursing interventions for a patient going into hypovolemic shock include establishing and maintaining a patent airway to support oxygenation. Shock is an emergency situation. The nurse's goal is to improve and maintain tissue perfusion. Nursing interventions for a patient going into hypovolemic shock include administering prescribed IV fluids and blood to support circulation and perfusion. Option B is incorrect because Shock is an emergency situation. The head of the bed should be flat with the legs elevated to increase venous return for a patient going into hypovolemic shock. Elevating the patient's head could worsen the shock. Option D is incorrect because Shock is an emergency situation. 100% oxygen should be administered by mask to facilitate oxygenation and maintain tissue perfusion and prevent the patient from developing further shock. Oxygen should be administered until shock is corrected. Option E is incorrect because Shock is an emergency situation. However, a patient going into hypovolemic shock is conscious and able to respond, although some patients may be disoriented. Initiating CPR is detrimental to the patient until the patient goes into cardiopulmonary arrest.

Which goals are appropriate for a PACU patient with the nursing diagnosis "Risk for deficient fluid volume related to surgical blood loss and NPO status"? Select all that apply. A. The patient will remain free from hypovolemia B. The patient will exhibit reduced wound drainage C. The patient will maintain hemodynamic stability D. The patient will receive fluid therapy via IV route E. The patient will exhibit minimal nausea and vomiting

A. and C. The goal of remaining free from hypovolemia is appropriate for a patient with this nursing diagnosis. The goal is to prevent further fluid losses. The goal of maintaining hemodynamic stability is appropriate for a patient with this nursing diagnosis. The goal is to prevent further fluid losses. Option B is incorrect because The goal of reduced wound drainage is directed at wound care and does not address this nursing diagnosis Option D is incorrect because This is not a patient goal. It is a nursing intervention. The nurse will treat the patient's fluid deficit, if it occurs, with fluid therapy. Option E is incorrect because The goal of minimal nausea and vomiting does not address this nursing diagnosis. It addresses the patient's comfort and the potential for fluid loss if the patient vomits.

It is important for the nurse to assess for sleep apnea preoperatively because of its association with which postoperative complication Select all that apply. A. Oxygen desaturation B. Delayed healing C. Electrolyte imbalance D. Airway obstruction E. Fluid imbalance

A. and D. Sleep apnea increases the risk for oxygen desaturation as evidenced on pulse oximetry during recovery from prolonged periods of non-breathing. It's very important the preoperative nurse assess for, and record, this condition prior to the patient's surgery. Sleep apnea increases the risk for airway obstruction when opioids are administered for pain control following surgery. It is very important the preoperative nurse assess for, and record, this condition prior to the patient's surgery. Option B is incorrect because Sleep apnea does not influence postoperative healing following surgery or anesthesia. Option C is incorrect because Sleep apnea does not influence electrolyte balance following surgery or anesthesia. Option E is incorrect because Sleep apnea does not influence fluid balance following surgery or anesthesia.

Which nursing interventions reduce patient preoperative stress and anxiety? Select all that apply. A. Acknowledge the patient's fears as real B. Assure the patient there is no need for fear C. Agree that surgery can be frightening D. Minimize fears to create sense of security E. Address the patient's fears by being supportive

A. and E. It is important for preoperative nurses to acknowledge a patient's fears. Once acknowledged and known, fears are reduced by explaining to the patient what can be expected during surgery and recovery. Reducing fears reduces anxiety and stress. Perioperative nurses reduce the patient's stress and anxiety when they address the patient's fears by being caring and supportive. When patients feel they are being supported and know what to expect, they can relax and feel less stressed. Option B is incorrect because Assuring a patient there is no need for fear sends the message that the nurse does not recognize the patient's feelings and fears. Lack of recognition of fears can add to a patient's stress and anxiety. Option C is incorrect because Agreeing that surgery can be frightening can easily add to the patient's stress rather than relieve it. This should only be used if it is followed with recognition of the patient's fears. Option D is incorrect because Minimizing the patient's fears fails to recognize the extent of the patient's fears, which can add to the patient's stress rather than relieve it.

One of Mr. Johnson's nursing diagnoses is Risk for electrolyte imbalance. Which indicators should the nurse monitor to determine if the NOC of Electrolyte and acid-base balance has been achieved? Select all that apply. A. Apical heart rate and rhythm B. Serum potassium C. Food intake D. Pain rating E. Blood pressure

A., B. Apical heart rate and rhythm are NOC indicators for Electrolyte and acid-base balance. Serum potassium is an NOC indicator for Electrolyte and acid-base balance. Option C is incorrect because Food intake is an NOC indicator for Nutritional status: nutrient intake, not electrolyte and acid-base balance. Option D is incorrect because Pain rating is an NOC indicator for Comfort level, pain control, pain level, not for electrolyte and acid-base balance. Option E is incorrect because Blood pressure is an NOC indicator for Cardiac pump effectiveness, not for electrolyte and acid-base balance.

Which assessment data should the nurse use in the "related to" portion of the nursing diagnostic statement for Risk for electrolyte imbalance? Choose all that apply. Select all that apply. A. Diarrhea B. Emesis C. Diuretic use D. Muscle cramps E. Cardiac arrhythmia

A., B., C. Diarrhea is a "related to" factor that supports the nursing diagnosis of Risk for electrolyte imbalance. Emesis, or vomiting, is a "related to" factor that supports the nursing diagnoses of Risk for electrolyte imbalance. Diuretic use is a "related to" factor that supports the nursing diagnosis of Risk for electrolyte imbalance. Option D is incorrect because Muscle cramping is a manifestation of an electrolyte imbalance, but is not a "related to" factor for this nursing diagnosis. Option E is incorrect because Cardiac arrhythmias is a manifestation of an electrolyte imbalance, but is not a "related to" factor for this nursing diagnosis.

Which factors should the nurse identify as increasing a patient's risk for hypovolemic hyponatremia? Select all that apply. A. Diuretics B. Emesis C. Diarrhea D. Dehydration E. Fever

A., B., C. Diuretic administration is one factor that increases a patient's risk for hypovolemic hyponatremia. Emesis is one factor that increases a patient's risk for hypovolemic hyponatremia. Diarrhea is one factor that increases a patient's risk for hypovolemic hyponatremia. Option D is incorrect because Dehydration increases a patient's risk for water depletion hypernatremia, not hypovolemic hyponatremia. Option E is incorrect because Insensible loss of water due to fever increases a patient's risk for water depletion, not hypovolemic hyponatremia.

What stages are part of the cancer development process? Select all that apply. A. Initiation B. Promotion C. Progression D. Exposure E. Contact F. Metastasis

A., B., C. Initiation is the first stage of cancer development. Promotion is the second stage of cancer development. Progression is the third stage of cancer development. Option D is incorrect because Exposure to a carcinogen may occur during the stage of initiation, but it is not a stage of cancer development. Option E is incorrect because Contact with a carcinogen may occur during the stage of initiation, but it is not a stage of cancer development. Option F is incorrect because Metastasis often occurs in the progression stage of cancer development, but it is not a stage of cancer development.

Which patient teaching does the preoperative nurse complete immediately prior to surgery? Select all that apply. A. Preoperative procedures B. Intraoperative routines C. Postoperative expectations D. Anesthesia precautions E. Discharge Medications

A., B., C. The preoperative nurse teaches patients about all preoperative procedures, such as IV access, as the patient is being prepared for surgery to decrease patient anxiety. The preoperative nurse teaches patients about what to expect once transferred into the surgical suite, such as transfer to the operating room bed. These simple explanations prevent fear and prepare the patient for transfer to the operating room. The preoperative nurse teaches patients about what to expect when waking from anesthesia after transfer to the PACU. This prevents the patient from being afraid when waking in an unfamiliar environment. Option D is incorrect because Anesthesia precautions are not part of preoperative teaching. However assessment of the patient for factors that might affect the anesthetic administered to the patient is important. Option E is incorrect because Anesthesia precautions are not part of preoperative teaching. However, assessment of the patient for factors that might affect the anesthetic administered to the patient is important.

Which are the causes of hypokalemia? Select all that apply. A. Laxative abuse B. Anorexia C. Emesis D. Chemotherapeutic agents E. Aldosterone blockers

A., B., C., D. Laxative abuse, anorexia, emesis, and chemotherapy drugs can cause hypokalemia. Option E is incorrect because Aldosterone blockers cause hyperkalemia, not hypokalemia.

Which factors does the anesthesia team consider when deciding on the type of anesthetic agent to use? Select all that apply. A. Surgical site B. Type of surgery C. Length of surgery D. Patient's condition E. Surgeon's preference

A., B., C., D. Location of surgery is a factor considered by the anesthesia team when deciding on the type of anesthetic agent. If the surgery involves a limb, regional anesthesia may be selected over general anesthesia. The type of surgery is a factor considered by the anesthesia team when they decide on the type of anesthetic agent. Major surgery requires general anesthesia, while minor surgeries may only require local anesthesia. The length of surgery is a factor considered by the anesthesia team when they decide on the type of anesthetic agent. Some anesthetics are more quickly metabolized than others. The patient's condition is a factor considered by the anesthesia team when they decide on the type of anesthetic agent. Regional anesthesia is preferred for hemodynamically unstable patients. Option E is incorrect because Surgeon preference is not a factor considered by the anesthesia team when they decide on the type of anesthetic agent because the anesthesia team has the expertise to make decisions that best protect patient safety.

Which patient assessments are completed by the PACU nurse on an ongoing basis? Select all that apply. A. IV infusion rate B. Patency of drains C. Dressing drainage D. Extremity movement E. Anesthesia emergence

A., B., C., D. The PACU nurse assesses IV fluid infusion rate on an ongoing basis while the patient is in the PACU. This prevents fluid volume overload or fluid volume deficiency following surgery. The PACU nurse assesses patency of drains on an ongoing basis throughout the patient's stay in the PACU. Non-patent drains can be a reason for returning the patient to the OR because they can result in abscess formation or infection. The PACU nurse assesses dressing drainage amount, consistency, odor, and color on an ongoing basis while the patient is in the PACU. The PACU nurse assesses the patient's ability to move all extremities on an ongoing basis while the patient is in the PACU. Inability to move an extremity can indicate stroke or another serious complication. Option E is incorrect because The PACU nurse assesses for gradual emergence from anesthesia when a patient is first admitted to the PACU and is not yet fully conscious. Once the patient is conscious, this assessment is no longer performed on an ongoing basis unless a complication occurs.

The nurse identifies "Related to hypokalemia" as a priority nursing diagnosis. During the nursing assessment, which clinical manifestation would the nurse identify as part of the "as evidenced by" segment of the nursing diagnostic statement. Select all that apply. A. Tachycardia B. Hypotension C. Poor muscle tone D. Poor skin turgor E. Poor appetite

A., B., C., D. The heart is affected with hypokalemia. Tachycardia is a clinical manifestation the nurse can use to formulate the "as evidenced by" portion of the nursing diagnostic statement for the patient's plan of care. The cardiovascular system is affected with hypokalemia. Hypotension is a clinical manifestation the nurse can use to formulate the "as evidenced by" portion of the nursing diagnostic statement for the patient's plan of care. The neuromuscular system is affected with hypokalemia. Poor muscle tone is a clinical manifestation the nurse can use to formulate the "as evidenced by" portion of the nursing diagnostic statement for the patient's plan of care. Nausea and vomiting occur with hypokalemia, which leads to dehydration. Poor skin turgor is a clinical manifestation the nurse can use to formulate the "as evidenced by" portion of the nursing diagnostic statement for the patient's plan of care. Option E is incorrect because impaired cardiac output is not manifested by a poor appetite; therefore, the nurse should not use this to formulate the "as evidenced by" portion of the nursing diagnostic statement for the patient's plan of care.

Which elements should the nurse include when providing patient teaching regarding the primary functions of electrolytes within the body? Select all that apply. A. Transmitting nerve impulses B. Regulating acid-base balance C. Altering the action potential of nerve fibers D. Maintaining fluid osmolality E. Secreting insulin and epinephrine

A., B., C., D. Transmitting nerve impulses is a primary function of electrolytes within the body. Regulating acid-base balance is a primary function of electrolytes within the body. Altering the action potential of nerve fibers is a primary function of electrolytes within the body. Maintaining fluid osmolality is a primary function of electrolytes within the body. Option E is incorrect because Secreting insulin and epinephrine is not a primary function of electrolytes. These hormones help to regulate the concentration of electrolytes in body fluids.

What are the characteristics of targeted cancer therapy? Select all that apply. A. It suppresses tumor growth. B. It disrupts synthesis of DNA or DNA's precursors. C. It is deliberately designed to interact with target cells. D. It acts on specific molecular targets associated with cancer. E. It is deliberately designed to suppress the actions of specific hormones.

A., C., and D., Targeted drugs suppress tumor growth. Targeted drugs only interact with cells they are designed to act on. Targeted drugs are designed to target and destroy specific cancer cells. Option B is incorrect because Disruption of synthesis of DNA or DNA's precursors is a non-specific action of cytotoxic drugs, which interfere with cell replication. Option E is incorrect because Targeted drugs primarily act on the cells whose proliferation they are designed to block; they are not designed to directly influence hormone activity.

Which topics will the preoperative nurse include in patient teaching? Select all that apply. A. Deep breathing B. Leg exercises C. Pain management D. Incentive spirometer E. Lifestyle changes

A., B., C., D. Teaching deep breathing preoperatively facilitates patient compliance and ability with deep breathing and coughing postoperatively. Deep breathing and coughing increases lung expansion, facilitates secretion removal, and enhances oxygenation. Teaching leg exercises preoperatively facilitates patient compliance and ability to perform exercises postoperatively. Leg exercises prevent thrombophlebitis. Teaching pain management preoperatively facilitates patient ability to understand what to expect after surgery, and decreases fear and anxiety. Teaching use of an incentive spirometer preoperatively facilitates patient compliance and ability to use the spirometer postoperatively. Use of the spirometer increases lung expansion, facilitates secretion removal, and enhances oxygenation. Option E is incorrect because Lifestyle changes are not part of preoperative teaching. However, lifestyle changes are often included in postoperative teaching.

Ms. Lewis is a 29-year-old African-American woman who comes to the emergency department seeking treatment for an acute episode of sickling. She complains of severe pain in her arms, legs, joints, and abdomen and in her chest when she takes a deep breath. Ms. Lewis was diagnosed with sickle cell anemia when she was 4 months old but has only had a few episodes of sickling in the last 4 to 5 years. Her last episode was 6 months ago. Ms. Lewis has had a cold for the last several days and also complains of a sore throat and cough. Ms. Lewis rates her pain as a 9 on a scale of 0 to 10. She is not currently taking any medications. Ms. Lewis does not smoke but occasionally drinks alcohol when out with friends. On assessment, her lips and oral mucous membranes are found to be dry and pale and her skin turgor is fair. Her vital signs are as follows: blood pressure (BP) 108/68 mm Hg, heart rate (HR) 94 beats/min and regular, respiratory rate (RR) 22 breaths/min and unlabored, and temperature 102° F (38.9° C). She has crackles in her left and right lower lobes. Heart sounds are normal. Her abdomen is soft and nondistended but painful on palpation. Bowel sounds are active in all quadrants. Her ankles, knees, wrists, and elbows are swollen, warm to touch, and very painful. Which information is important for the nurse to include in a patient education plan for Ms. Lewis? Select all that apply. A. Medication adherence B. Avoiding high altitudes C. Hydration recommendations D. Smoking and alcohol cessation E. Signs and symptoms of sickle cell crisis

A., B., C., E. Medication adherence is important for adequate pain control and reducing the frequency of sickle cell crises. Avoiding high altitudes helps to reduce hypoxia. Adequate hydration is necessary to prevent dehydration. Teaching the patient signs and symptoms in order to determine when to seek medical attention quickly is important. This will help counteract potential causes of sickle cell crises, such as upper respiratory tract infections. Option D is incorrect because The patient is not a smoker and consumes alcohol only occasionally, so this information does not need to be provided.

The nurse is educating a patient on the appropriate treatment for Hodgkin's lymphoma. Which statement by the patient indicates the need for further teaching? Select all that apply. A. "I will be able to stop my treatment once the cancer is in remission." B. "We can start with a conservative treatment of corticosteroids and see how I respond." C. "The treatment for the disease is safe and without serious side effects." D. "The treatment for my cancer will depend on the stage at which I am diagnosed." E. "Chemotherapy is the only treatment for Hodgkin's lymphoma."

A., B., C., E. Once in remission, intensive chemotherapy may be needed to achieve a cure. Therapy should not be discontinued. Corticosteroid treatment is the initial treatment for multiple myeloma. Hodgkin's lymphoma is treated more aggressively at the outset. The treatment for Hodgkin's lymphoma is aggressive and may result in life-threatening side effects. Irradiation may be used as a supplement to chemotherapy, depending on site of disease and the presence of resistant disease after chemotherapy. Option D is incorrect because The treatment for Hodgkin's lymphoma depends on the stage and prognosis.

What characteristics are associated with normal cell function? Select all that apply. A. Tight adherence B. Contact inhibition C. Apoptosis D. Aneuploidy E. Migration F. Differentiated function

A., B., C., F. Normal cells have tight adherence due to proteins that help the cells stick closely together. Normal cells have contact inhibition in that they respect the boundaries of other cells surrounding them. Normal cells demonstrate apoptosis by dying at an appropriate time to ensure body function. Normal cells have differentiated function, demonstrating at least one specific function that helps the body work. Options C and E are characteristics associated with cancer cells.

What teaching will the nurse include when providing a class on medication safety to older adults? Select all that apply. A. "It is important to use the same pharmacy for all your medications." B. "Keep a list of current medications with you." C. "A pill planner may help you remember to take your medications." D. "If your spouse takes the same medication, you may be able to get a larger quantity for less expense." E. "Over-the-counter medications generally do not affect prescription medications." F. "The pharmacist can be very helpful if you have questions about medications."

A., B., C., F. Using the same pharmacy is important because the pharmacist can often detect potential drug interactions. Older adults should be encouraged to keep a list of current medications that includes the name, dose, and timing. A pill planner can be a helpful strategy for some older adults to remind them to take their medications. The pharmacist can be a very valuable resource in understanding medications. Using one pharmacy with a trusted pharmacist can be a key component of medication safety for older adults. Option D is incorrect because Medications should never be borrowed or shared. If the spouse takes the same medication, it is a separate prescription. Option E is incorrect because The older adult should check with the health care provider before adding any over-the-counter medications because they can affect prescription medications.

A patient presents to the emergency department (ED) with a serum phosphate concentration of 3.1 mEq/L. Which should the nurse assess this patient for based on this laboratory value? Select all that apply. A. Tetany B. Hyperreflexia C. Decreased deep tendon reflexes D. Muscle cramps E. Shallow respirations

A., B., D. A serum phosphate concentration greater than 2.6 mEq/L indicates hyperphosphatemia. The nurse should assess for tetany, a clinical manifestation of hypocalcemia caused by hyperphosphatemia. A serum phosphate concentration greater than 2.6 mEq/L indicates hyperphosphatemia. The nurse should assess for hyperreflexia, a clinical manifestation of hypocalcemia caused by hyperphosphatemia. A serum phosphate concentration greater than 2.6 mEq/L indicates hyperphosphatemia. The nurse should assess for muscle cramps, a clinical manifestation of hypocalcemia caused by hyperphosphatemia. Option C is incorrect because A serum phosphate concentration greater than 2.6 mEq/L indicates hyperphosphatemia. Decreased deep tendon reflexes occur with hypercalcemia or hypermagnesemia; therefore, the nurse would not assess for this clinical manifestation. Option E is incorrect because A serum phosphate concentration greater than 2.6 mEq/L indicates hyperphosphatemia. Shallow respirations occur with hypophosphatemia or hypermagnesemia; therefore, the nurse would not assess for this clinical manifestation.

A patient is diagnosed with thrombocytopenia. Which symptoms would the nurse expect to observe in a patient with thrombocytopenia? Select all that apply. A. Petechiae B. Vomiting C. Numbness D. Tachycardia E. Hypotension F. Abdominal pain

A., D., E., F. Cutaneous bleeding is a symptom of thrombocytopenia that can manifest as petechiae. Tachycardia is a clinical manifestation of thrombocytopenia that can occur due to internal bleeding. Hypotension is a clinical manifestation of thrombocytopenia that can occur due to internal bleeding. Abdominal pain can be a symptom of internal bleeding and a clinical manifestation of thrombocytopenia. Options B and C are not clinical manifestations of thrombocytopenia.

A nurse is educating a patient who has recently been diagnosed with Hodgkin's lymphoma. The nurse explains which signs/symptoms may be experienced if the disease is in the advanced stage? Select all that apply. A. Urinary symptoms B. Loss of motor function C. Increased intracranial pressure D. Decreased red blood cell levels E. Painless cervical node swelling

A., B., D. Advanced stages of Hodgkin's lymphoma may be marked by enlarged retroperitoneal nodes, interfering with renal function and causing urinary symptoms. Loss of motor functionThe advanced stages of Hodgkin's lymphoma may result in paraplegia and loss of motor function as a result of spinal cord compression. Anemia can result from increased destruction and decreased production of erythrocytes in the advanced stage of Hodgkin's lymphoma. Option C is incorrect because Increased intracranial pressure is a manifestation of leukemia, not late-stage Hodgkin's lymphoma. Option E is incorrect because Enlargement of the cervical, axillary, or inguinal lymph nodes is a symptom of the early, not late, stages of Hodgkin's lymphoma and is typically not painful unless pressure is exerted on adjacent nerves.

Which patient assessments are completed by the PACU nurse following the initial admission assessment? Select all that apply. A. Dressings B. Pain level C. Vital signs D. Oxygen saturation E. Level of consciousness

A., B., D. Dressings are assessed once the initial admission assessment is completed. Dressings are assessed for drainage and the presence of drains. Pain level is assessed once the initial assessment is completed. When the patient is determined to be stable, the patient's pain is treated. Oxygen saturation is assessed once the initial assessment is completed. Oxygen saturation is automatically and continually monitored along with the patient's electrocardiogram. Option C is incorrect because Vital signs are part of the initial admission assessment. Once vital signs are assessed and evaluated as within normal parameters for the patient, other assessments are completed. Option E is incorrect because Level of consciousness (LOC) is part of the initial admission assessment. Once LOC is established, other assessments are completed.

Ms. Lewis is a 29-year-old African-American woman who comes to the emergency department seeking treatment for an acute episode of sickling. She complains of severe pain in her arms, legs, joints, and abdomen and in her chest when she takes a deep breath. Ms. Lewis was diagnosed with sickle cell anemia when she was 4 months old but has only had a few episodes of sickling in the last 4 to 5 years. Her last episode was 6 months ago. Ms. Lewis has had a cold for the last several days and also complains of a sore throat and cough. Ms. Lewis rates her pain as a 9 on a scale of 0 to 10. She is not currently taking any medications. Ms. Lewis does not smoke but occasionally drinks alcohol when out with friends. On assessment, her lips and oral mucous membranes are found to be dry and pale and her skin turgor is fair. Her vital signs are as follows: blood pressure (BP) 108/68 mm Hg, heart rate (HR) 94 beats/min and regular, respiratory rate (RR) 22 breaths/min and unlabored, and temperature 102° F (38.9° C). She has crackles in her left and right lower lobes. Heart sounds are normal. Her abdomen is soft and nondistended but painful on palpation. Bowel sounds are active in all quadrants. Her ankles, knees, wrists, and elbows are swollen, warm to touch, and very painful. Which nursing interventions should be implemented for Ms. Lewis, given her current symptoms? Select all that apply. A. Administer intravenous fluids. B. Administer antipyretics as needed. C. Start rehydration therapy with clear liquid diet. D. Start a patient-controlled analgesia (PCA) regimen. E. Allow her to ambulate independently to use the bathroom only.

A., B., D. Ms. Lewis's dry lips and mucosa indicate she is dehydrated in need of rapid rehydration therapy. Ms. Lewis has a fever, and antipyretics are necessary to reduce her temperature. Because of the initial state of the crisis, the patient needs continuous pain medication through a PCA device. As pain is reduced and relief is sustained, the patient can rely on oral and as-needed analgesic regimens. Option C is incorrect because Ms. Lewis's dry lips and mucosa indicate dehydration and a need for intravenous fluids. Oral fluids are insufficient. Option E is incorrect because Because of her current status of severe pain and swollen ankles and knees, Ms. Lewis should be ambulating with assistance at all times.

Which interventions should the nurse initiate to prevent a patient from developing postoperative pneumonia? Select all that apply. A. Place patient in Fowler's position B. Promote fluid intake every 2 hours C. Monitor pulse oximetry every shift D. Encourage incentive spirometer use E. Enforce frequent leg and arm exercises

A., B., D. Placing the patient in a semi-Fowler's or Fowler's position facilitates lung expansion, which prevents stasis of secretions and development of postoperative pneumonia. Fluid hydration orally or with IV fluids helps liquefy secretions and facilitates patient ability to expectorate them. Secretion removal helps prevent postoperative pneumonia. Encouraging the use of an incentive spirometer is an effective intervention for preventing pneumonia. It assists patients with deep breathing, which prevents stasis of secretions and facilitates lung expansion. Option C is incorrect because Pulse oximetry should be assessed on postoperative patients to determine adequacy of oxygenation; however, assessing pulse oximetry does not prevent pneumonia. Option E is incorrect because Leg and arm exercises are very effective for preventing thrombophlebitis, but they do not prevent pneumonia.

During surgery, which patient parameters are continually assessed? Select all that apply. A. Heart rate B. Temperature C. Urinary output D. Respiratory rate E. Patient position

A., B., D. The patient's heart rate is continually assessed during all surgeries except minor surgeries performed on an outpatient basis, such as removal of skin lesions. For those patients, heart rate is assessed prior to and following surgery. The patient's temperature is continually assessed during all surgeries except minor surgeries performed on an outpatient basis, such as removal of skin lesions. For those patients, temperature is assessed prior to and following surgery. The patient's respiratory rate is continually assessed during all surgeries except minor surgeries performed on an outpatient basis, such as removal of skin lesions. For those patients, respiratory rate is assessed prior to and following surgery. Option C is incorrect because Urinary output is not continually assessed unless the patient has an indwelling urinary catheter in place. Only patients undergoing surgeries such as cardiac or open abdominal surgeries typically have indwelling catheters in place for urinary output assessment. Option E is incorrect because The patient's position is important and is thoroughly assessed prior to surgery. It is frequently assessed during surgery, but it is not continually assessed during surgery.

Which activities are performed by the nurse during the preoperative phase of ambulatory surgery? Select all that apply. A. Identification of expected outcomes B. Collaboration with patient and family C. Coordination of diagnostic testing D. Verification of patient identification E. Scheduling of follow-up appointments

A., B., D. The preoperative nurse plans for the entire perioperative period, including the identification of expected outcomes, which help establish interventions that address nursing diagnoses. The preoperative nurse collaborates with patients and families during the preoperative phase of ambulatory surgery to ensure identified outcomes are met. The preoperative nurse verifies patient identification during the preoperative phase of ambulatory surgery to ensure surgery is performed on the correct patient. Option C is incorrect because Diagnostic testing is performed prior to the patient reporting to the ambulatory surgery center. This is not an activity performed by the preoperative nurse. Option E is incorrect because The patient or family members take responsibility for making follow-up appointments after the patient is discharged from the ambulatory surgery center. This is not an activity performed by the preoperative nurse.

Which activities take place after patient admission to the presurgical care unit? Select all that apply. A. Preoperative forms are completed. B. Anesthesia performs a risk assessment. C. Diagnostic procedures are initiated. D. Potential health problems are identified. E. Surgeon confirms surgery will take place.

A., B., D. After patient admission to the presurgical care unit, the preoperative nurse ensures that all preoperative forms are completed and the surgeon's orders are carried out. After patient admission to the presurgical care unit, anesthesia performs a risk assessment on the patient prior to administering pre-anesthesia medications. After patient admission to the presurgical care unit, the preoperative nurse assesses the patient to identify any potential health problems that could be risk factors for anesthesia or surgery. Option C is incorrect because The patient has diagnostic testing and other procedures, such as an ECG, in preparation for surgery. This occurs after agreement between the patient and surgeon about the surgery and before, not after, the patient is admitted to the presurgical care unit. Option E is incorrect because Agreement between the patient and surgeon that the surgery will take place occurs before the surgery is scheduled and before the patient is admitted to the presurgical care unit.

Which action(s) would the nurse take to maintain a patient's body temperature during surgery? Select all that apply. A. Cover patient in thermal drapes. B. Warm any required saline irrigations. C. Increase temperature of the OR suite. D. Warm IV fluids prior to administration. E. Place patient on a warm water mattress.

A., B., D., E. Covering the patient in thermal drapes is an effective means of maintaining patient body temperature during surgery. The drapes trap the patient's body heat beneath the drapes, preventing heat loss. Warm saline irrigation is an effective means of maintaining patient body temperature during surgery. It is especially effective during open abdominal surgeries. Warming IV fluids before administering them helps maintain patient body temperature because the warmed fluid is circulated by the cardiovascular system. Warm water mattresses circulate warm water beneath the patient, preventing heat loss. They are an effective means of maintaining patient body temperature during surgery. Option C is incorrect because Increasing the OR suite temperature does not increase the patient's body temperature and places the patient at risk for infection. The cool OR environment prevents pathogenic growth.

Which anesthetics provide regional anesthesia? Select all that apply. A. Spinal B. Epidural C. Balanced D. Bier block E. Nerve block

A., B., D., E. Spinal anesthesia is a type of regional anesthesia. It involves injecting an anesthetic into the subarachnoid space to block sensations to the lower body. Epidural anesthesia is a type of regional anesthesia. It involves injecting an anesthetic agent into the epidural space in the lumbar or thoracic region to block sensations. Bier block is a type of regional anesthesia. It involves injecting anesthetic agents into venous circulation and using tourniquets to prevent blood from entering systemic circulation. The anesthetic disrupts nerve impulses to specific areas of the body. A nerve block is a type of regional anesthesia. It involves injecting an anesthetic into tissues surrounding nerves to disrupt nerve impulses to specific areas of the body. Option C is incorrect because Balanced anesthesia is a type of general anesthesia, not a type of regional anesthesia.

Which information should the nurse provide to the postoperative patient prior to discharge to home? Select all that apply. A. Wound care B. Medications C. Follow-up tests D. Diet instructions E. Allowed activities

A., B., D., E. The nurse should provide information about wound care if applicable prior to discharge. These instructions should also be provided in writing. The nurse should provide information about any prescribed or OTC medications the patient must take prior to discharge. These instructions should also be provided in writing. The nurse should provide information about diet and any dietary restrictions prior to discharge. These instructions should also be provided in writing. The nurse should provide information about allowed activities and any activity restrictions prior to discharge. These instructions should also be provided in writing. Option C is incorrect because The nurse would not provide information about follow-up tests. The nurse should provide information about the need to contact the surgeon's office to schedule a follow-up appointment. Sometimes the surgeon leaves information about the specific date or week in which the patient should schedule the appointment.

Which interventions will the nurse include in the plan of care for a patient admitted for hematopoietic stem cell transplantation (HSCT) to treat acute lymphocytic leukemia (ALL)? Select all that apply. A. Bring a DVD player in to the patient's room so the patient can watch movies B. Educate the patient regarding graft-versus-host disease (GVHD) C. Provide information and brochures about hospice care D. Ask the patient about religious preferences and whether the patient would like the chaplain to visit E. Have the patient turn, take a deep breath, and use an incentive spirometer every 1 to 2 hours

A., B., D., E. The patient hospitalized for HSCT will be hospitalized for long periods in isolation, and a DVD player will allow the patient to watch movies as an activity. Because GVHD is a primary complication of HSCT, the nurse will educate the patient about the signs of GVHD to report. Patients undergoing HSCT are undergoing life-threatening treatment for cancer, and the nurse will help meet the patient's spiritual needs. A primary complication of HSCT is interstitial pneumonia. The nurse will instruct the patient in ways to prevent this from occurring and to facilitate lung expansion. Option C is incorrect because The goal of HSCT is to achieve remission and eradicate the cancer. The nurse should not provide information about end-of-life care to this patient.

Which serum calcium concentrations should the nurse identify as abnormal? Select all that apply. A. 7.9 mg/dL B. 8.4 mg/dL C. 9.0 mg/dL D. 10.0 mg/dL E. 10.6 mg/dL

A., B., E. A serum calcium concentration of 7.9 mg/dL indicates hypocalcemia. 8.4 mg/dLA serum calcium concentration of 8.4 mg/dL indicates hypocalcemia. A serum calcium concentration of 10.6 mg/dL indicates hypercalcemia. Options C and D is incorrect because they are within normal limits. Normal calcium concentrations are between 8.5 and 10.5

The student nurse is preparing a presentation regarding the sodium-potassium pump. Which statement should the student include in the presentation? Select all that apply. A. "ATP is required for the sodium-potassium pump to move sodium and potassium ions." B. "This pump moves sodium out of the cell and potassium into the cell." C. "The sodium-potassium pump is an example of facilitated diffusion." D. "This pump is an example of diffusion, which evenly exchanges sodium and potassium ions." E. "This pump moves three sodium ions for every two potassium ions."

A., B., E. ATP is required for the active transport process. The sodium-potassium pump is a type of active transport process and requires ATP to move sodium and potassium ions. The sodium-potassium pump moves sodium out of the cell and potassium into the cell. The sodium-potassium pump is an example of active transport, which moves three sodium ions for every two potassium ions. Option C is incorrect because The sodium-potassium pump is not an example of facilitated diffusion. Option D is incorrect because The sodium-potassium pump is not an example of diffusion and there is not an even exchange between these ions.

A patient is diagnosed with iron deficiency anemia. Which laboratory values would the nurse expect to see in the patient's electronic health record? Select all that apply. A. Decreased MCV level B. Increased TIBC Level C. Decreased folate level D. Increased ferritin level E. Decreased serum iron level

A., B., E. MCV levels are decreased in iron deficiency anemia. TIBC levels are increased in iron deficiency anemia. Serum iron levels are decreased in iron deficiency anemia. Option C is incorrect because Folate levels are normal in iron deficiency anemia. A decreased folate level would not indicate iron deficiency anemia. Option D is incorrect because Ferritin levels are decreased in iron deficiency anemia. An increased ferritin level would not indicate iron deficiency anemia.

Which postoperative conditions require immediate intervention by the PACU nurse? Select all that apply. A. Shock B. Hemorrhage C. Incisional pain D. Disorientation E. Pulmonary embolism

A., B., E. Shock is a postoperative emergency condition requiring immediate nursing interventions to correct the cause of shock and thereby improve and maintain tissue perfusion. Hemorrhage is a postoperative emergency. It requires immediate nursing interventions to control bleeding and maintain the patient's circulatory volume. When bleeding is severe, the PACU nurse contacts the surgeon, because the patient may need to return to the OR for the cause of bleeding to be corrected. Pulmonary embolism is a postoperative emergency. It requires immediate nursing interventions to stabilize the respiratory and cardiovascular systems and prevent the development of additional emboli. Option C is incorrect because Incisional pain is a common and expected postoperative condition. It is not considered an emergency or a complication. It is treated by administering pain medication, which facilitates patient comfort. Option D is incorrect because Disorientation is a common postoperative condition related to anesthesia and does not constitute an emergency. Nursing interventions include conducting frequent neurologic assessments until the patient is responsive and oriented.

Which assessments are made upon the patient's arrival to the post-anesthesia care unit (PACU) following surgery? Select all that apply. A. Airway B. Breathing C. Dressing D. IV site E. Vital signs

A., B., E. The PACU nurse immediately assesses the arriving patient's airway to ensure patency. The PACU nurse immediately assesses the arriving patient for breathing to determine rate and depth. The PACU nurse immediately assesses the arriving patient's vital signs and compares them with preoperative vital signs to determine deviations from normal. Option C is incorrect because The PACU nurse does not assess the patient's dressing until the patient is deemed stable. Option D is incorrect because The PACU nurse does not assess the patient's IV site and IV flow rate until the patient is deemed stable.

The nurse is monitoring serum electrolyte levels for a patient who was admitted to the emergency department with dehydration. Which data should the nurse report to the primary care provider as abnormal? Select all that apply. A. Serum Na+ of 150 mEq/L B. Serum K+ of 5.2 mEq/L C. Serum Ca2+ of 9 mg/dL D. Serum Mg2+ of 2 mEq/L E. Serum PO4 3- 2.9 mEq/L

A., B., E. The normal range for a serum Na+ is 135-145 mEq/L. This finding should be reported to the primary care provider. Serum K+ of 5.2 mEq/LThe normal range of serum K+ is 3.5-5 mEq/L. This finding should be reported to the primary care provider. The normal range for a serum PO4 3- is 1.7-2.6 mEq/L. This finding should be reported to the primary care provider. Options C and D are within normal limits.

Which activities should the preoperative nurse perform after admitting the patient for ambulatory surgery? Select all that apply. A. Review the surgical procedure with the patient. B. Initiate the patient's prescribed intravenous fluids. C. Arrange for the patient's overnight stay. D. Have the patient provide surgical consent. E. Answer any questions the patient may have.

A., B., E. The preoperative nurse should review the surgical procedure with the patient to verify patient understanding of the scheduled procedure. The preoperative nurse should initiate the patient's prescribed intravenous fluids in preparation for the anesthetist to administer pre-anesthesia medications and any needed medications during surgery. The preoperative nurse should answer any of the patient's questions about the surgery or anesthesia. The surgeon should be summoned in the event the nurse cannot answer all of the patient's questions. Option C is incorrect because The preoperative nurse does not need to make arrangements for the patient's overnight stay because ambulatory surgery does not require an overnight stay, unless serious complications develop during surgery. Option D is incorrect because The preoperative nurse does not have the patient provide surgical consent. This is the responsibility of the surgeon. The nurse can witness the patient's consent, however.

Which patient assessment findings would the PACU nurse receive from the circulating nurse during report? Select all that apply. A. Vital signs B. Length of surgery C. Oxygen saturation D. Anesthetic received E. Estimated blood loss

A., C., E. Vital signs are assessment findings the PACU nurse would receive from the circulating nurse during report. They reflect the patient's hemodynamic status. Oxygen saturation is an assessment finding the PACU nurse would receive from the circulating nurse during report. It reflects the patient's respiratory and circulatory status. Blood loss is an assessment finding the PACU nurse would receive from the circulating nurse during report. Blood loss reflects the patient's hemodynamic and circulatory status. Option B is incorrect because The length of surgery would be reported to the PACU nurse because prolonged surgeries can affect a patient's recovery; however, length of surgery is not a patient assessment finding. Option D is incorrect because The PACU nurse would receive information about the anesthetic received by the patient because it affects the patient's wake time; however, anesthetic information is not a patient assessment finding.

The nurse is conducting a health history assessment for a patient who is diagnosed with hypermagnesemia. Which questions should the nurse in the assessment interview? Select all that apply. A. "What type of laxatives do you use?" B. "Have you had diarrhea recently?" C. "Do you use over the counter antacids?" D. "Do you have lactose intolerance?" E. "Do you take a prescribed diuretic?"

A., C. Some laxatives are high in magnesium; therefore, this question is appropriate for the nurse to include when conducting a health history interview assessment for a patient with hypermagnesemia. Some over the counter antacids are high in magnesium; therefore, this question is appropriate for the nurse to include when conducting a health history interview assessment for a patient with hypermagnesemia Option B is incorrect because Diarrhea increases potassium excretion and, if chronic, also increases calcium and magnesium excretion; asking about diarrhea is not an appropriate assessment question during the health history interview for a patient who presents with hypermagnesemia Option D is incorrect because Asking the patient about lactose intolerance is not an appropriate assessment question during the health history interview for a patient who presents with hypermagnesemia. Option E is incorrect because Loop diuretics cause hypokalemia and sometimes hypomagnesemia, not hypermagnesemia; therefore, this is not an appropriate assessment question during the health history interview for a patient who presents with hypermagnesemia.

Which conditions undergo surgery in inpatient settings rather than ambulatory settings? Select all that apply. A. Acute medical conditions B. Fractured bones C. Chronic diseases D. Breast biopsy E. Organ transplantations

A., C. E. Patients with acute medical conditions, such as unstable angina or acute appendicitis, undergo surgery in inpatient surgical settings. This enables patient admission for testing prior to surgery and admission to critical care or the nursing unit following surgery for further assessment to ensure positive patient outcomes. Patients with chronic diseases, such as diabetes mellitus, undergo surgery in inpatient surgical settings unless the surgery is very minor. This enables patient admission for testing prior to surgery and admission to nursing unit following surgery for further assessment to ensure positive patient outcomes. This very specialized surgery is always performed in the inpatient setting. Specialized equipment and staff are required. The patient is admitted to critical care following surgery and is immune-suppressed, which requires vigilance in preventing postoperative infection. Option B is incorrect because Setting or pinning of fractured bones can be treated in ambulatory surgery settings when surgery is needed. The inpatient surgical setting is not required for this type of surgery. Option D is incorrect because Breast biopsies can be performed in ambulatory surgery settings. The inpatient surgical setting is not required for this type of surgery.

Which advantages are afforded to patients who elect to have their surgeries at ambulatory surgery centers? Select all that apply. A. Decreased costs B. Flexible scheduling C. Home recoveries D. Reduced risk for infections E. No pretest requirements

A., C., D. Decreased cost is an advantage of ambulatory surgery over inpatient surgery because the surgical stay is shorter. Home recovery is an advantage for patients who undergo ambulatory surgery. Recovery time is shorter and faster when patients return to their home environment. Patients undergoing surgery at ambulatory care centers are exposed to fewer health care-associated infections. They are not exposed to ill patients and are there for a short period of time. Option B is incorrect because Flexible scheduling may or may not be available at all ambulatory surgical centers. Scheduling is dependent on how many surgeries are performed at the center each day. Option E is incorrect because This is not an advantage. Ambulatory surgery patients require similar tests for anesthesia and surgery as other patients. However, they require fewer pre- and postoperative tests.

Which statements regarding the sodium-potassium pump are true? Select all that apply. A. The pump moves sodium out of the cells and potassium into the cells. B. This pump is an example of facilitated diffusion. C. This pump is an example of active transport. D. The pump moves three sodium ions for every two potassium ions. E. The pump keeps the ECF lower in sodium and higher in potassium than the ICF.

A., C., D. The sodium-potassium pump moves sodium out of the cells and potassium into the cells. This is a true statement. The sodium-potassium pump is an example of active transport. This is a true statement. The sodium-potassium pump moves three sodium ions for every two potassium ions. This is a true statement. Option B is incorrect because The sodium-potassium pump is not an example of facilitated diffusion. This statement is false. Option E is incorrect because The sodium-potassium pump keeps the ICF lower in sodium and higher in potassium than the ECF. This statement is false.

When changing the patient's dressing, the nurse should assess the surgical site for which characteristics? Select all that apply. A. Signs of infection B. Type of tape closure C. Placement of drains D. Condition of dressing E. Approximation of edges

A., C., E Signs of infection at the surgical site should be assessed during any dressing change. Purulent drainage, foul smell, and erythema need to be reported to the surgeon. Placement of drains and amount and type of drainage is an important assessment during any dressing change. If there is excessive drainage or bleeding the nurse must notify the surgeon. Approximation of surgical site edges is an important assessment during any dressing change. Separated edges indicate potential dehiscence or evisceration. The nurse must notify the surgeon. Option B is incorrect because The type of tape closure is not a characteristic of the surgical site. However, the tape closure should be assessed to determine if it is a specialized closure for repeated use, such as a Montgomery strap. Option D is incorrect because The condition of the dressing is not a characteristic of the surgical site. However, the dressing should be assessed for the degree of saturation related to drainage.

Which items found during the review of a medical history should the nurse identify as risk factors for hypocalcemia? Select all that apply. A. Inadequate dietary intake B. Overproduction of parathyroid hormone C. Hypomagnesemia D. Extended immobilization E. Hypoparathyroidism

A., C., E. Inadequate dietary intake will lower the levels of calcium. This can cause hypocalcemia. Hypomagnesemia may cause hypocalcemia due to the passive reabsorption of electrolytes caused by renal disease. Hypoparathyroidism causes a decrease in parathyroid hormone production, which causes hypocalcemia. Option B is incorrect because Overproduction of parathyroid hormone (PTH) is not a cause of hypocalcemia. Option D is incorrect because Extended immobilization is associated with hypercalcemia, not hypocalcemia.

A patient is diagnosed with iron deficiency anemia and is prescribed oral iron replacement therapy. Several weeks into the therapy the patient's iron levels are not increasing. Which questions should the nurse ask the patient to ensure the oral supplements are being taken in a way that maximizes absorption? Select all that apply. A. "Are you taking your iron before meals?" B. "Are you taking your prescribed laxative?" C. "Are you ingesting the iron through a straw?" D. "Are you pairing your iron with a vitamin C supplement?" E. "Are you taking two-300-mg tablets of ferrous sulfate three times a day?"

A., D. Iron should be taken before meals to prevent the medication binding with food and decreasing its absorption. Taking iron with meals can decrease absorption. Vitamin C can increase iron absorption and should accompany iron for maximum absorption. Vitamin C can be consumed through supplements or orange juice. Option B is incorrect because A laxative may be taken to avoid gastrointestinal side effects but does not enhance absorption of the iron. Option C is incorrect because Iron may be taken through a straw to avoid staining the patient's teeth, not to enhance absorption. Option E is incorrect because The typical prescribed dose should be 150-200 mg of elemental iron per day. This would equate to one-300-mg ferrous sulfate tablet, not two, three times per day.

Which surgical settings are preferred sites for a patient who needs cataract surgery? Select all that apply. A. Specialty clinic B. Inpatient surgery C. Surgeon's office D. Same-day surgery E. Outpatient surgery

A., D., E. A specialty clinic, such as a freestanding surgery center, whose surgeons specialize in cataract surgery, is a preferred site for performing this patient's cataract surgery. A same-day surgery center is a preferred site for performing outpatient surgery, such as cataract removal and lens transplant. Same-day surgery is also known as ambulatory surgery. An outpatient surgery center is a preferred site for performing outpatient surgery, such as cataract removal and lens transplant. Outpatient surgery is also known as ambulatory surgery. Option B is incorrect because Cataract surgery can be performed in an inpatient surgical suite, but because it is ambulatory surgery, this is not a preferred site. Option C is incorrect because the surgeon's office is not a preferred site for cataract surgery. Specialized equipment for the surgery is required, which limits the surgeon's ability to perform this surgery in the office. Also, surgical guidelines prohibit most surgeries from being performed outside accredited surgical centers.

Which special precautions do intraoperative nurses take when positioning intraoperative patients? Select all that apply. A. Padding any pressure points B. Using supine patient position C. Removing OR table attachments D. Ensuring correct body alignment E. Placing grounding pad under patient

A., D., E. Padding of all pressure points is a special precaution taken by the intraoperative nurse during positioning to ensure patient safety and freedom from positioning injuries. Ensuring correct body alignment is a special precaution taken by the intraoperative nurse during positioning to prevent postoperative discomfort or injury from incorrect body alignment. Placing an electrical grounding pad beneath the patient is a special precaution taken by the intraoperative nurse to prevent burns from the use of cautery devices during surgery. The pad must be placed so that it does not cause pressure, but remains beneath the patient. Option B is incorrect because The supine position is one of several positions used for surgeries. The patient is usually placed supine initially, but for some surgeries patients are placed in positions other than the supine position. Option C is incorrect because Removing OR table attachments is not a special precaution. Attachments that facilitate positioning such as straps, pillows, and wedges are added to the OR table by the intraoperative nurse.

Which causes, related to poor intake of phosphate, should the nurse include in a teaching session for a patient who is diagnosed with hypophosphatemia? Select all that apply. A. Phosphate-binding antacids B. Loop diuretics C. Diabetic ketoacidosis D. Alcoholism E. Malabsorption syndrome

A., D., E. Phosphate-binding antacids is one cause for hypophosphatemia related to poor intake of phosphate. Alcoholism is one cause for hypophosphatemia related to poor intake of phosphate. Malabsorption is one cause for hypophosphatemia related to poor intake of phosphate. Option B is incorrect because Loop diuretics is a cause for hypophosphatemia related to increased excretion, not poor intake of phosphate. Option C is incorrect because Diabetic ketoacidosis is a cause for hypophosphatemia related to increased excretion, not poor intake of phosphate.

Which actions would the nurse implement for a patient with postoperative pneumonia? Select all that apply. A. Hydrate with oral or IV fluids B. Discourage frequent coughing C. Maintain in supine flat position D. Administer prescribed antibiotics E. Promote use of incentive spirometer

A., D., E. The nurse should encourage oral fluids or administer prescribed IV fluids to keep the patient well hydrated. Fluids help liquefy secretions and facilitate expectoration in patients with pneumonia. The nurse should administer prescribed antibiotics to treat postoperative pneumonia because it is inflammation of the lung caused by an infectious organism. Promote use of incentive spirometerThe nurse should encourage the use of incentive spirometry and deep breathing exercises to promote lung expansion in patients with pneumonia. Option B is incorrect because The nurse should encourage, not discourage frequent coughing. Coughing promotes expectoration of secretions. Retained secretions promote bacterial growth. Option C is incorrect because The nurse should place the patient in the Fowler or semi-Fowler position, not the flat supine position. An elevated head and chest position facilities chest expansion and oxygenation.

Which information will the nurse include in discharge teaching for a patient with cancer? Select all that apply. A. Avoid large crowds. B. Take aspirin to prevent blood clots. C. You may continue to play soccer. D. Protein shakes can be used to increase protein intake. E. Inspect your mouth daily. F. Do not reuse cups or dishes without washing them.

A., D., E., F. Avoiding large crowds is appropriate to decrease the patient's risk of infection. Using protein shakes is encouraged to increase the intake of protein. The patient with cancer should assess the oral cavity daily for signs of bleeding and/or mucositis. The patient with cancer should wash all cups and dishes in between uses to decrease the risk of infection. Option B is incorrect because

Which patient assessment data corresponds with the clinical syndrome of frailty? Select all that apply. A. Unintentional weight loss of 18 pounds B. Confusion that starts at sundown C. Slow reaction time D. Generalized weakness E. Walking slowly F. Reports of feeling exhausted

A., D., E., F. Unintentional weight loss is one of the manifestations associated with a diagnosis of frailty. eakness is one of the manifestations associated with a diagnosis of frailty. Slow walking and slowed physical activity are manifestations associated with a diagnosis of frailty. Exhaustion is one of the manifestations associated with a diagnosis of frailty. Option B is incorrect because Confusion or cognitive changes are not associated with the diagnosis of frailty. Option C is incorrect because Reaction time decreases normally with age. This is not a manifestation associated with the diagnosis of frailty.

A patient presents with symptoms of thrombocytopenia and a platelet count of 50,000/µL. To differentiate thrombocytopenia from a myeloproliferative disorder, which diagnostic study would the nurse anticipate being prescribed for this patient? A. Urinalysis B. Bone marrow biopsy C. Platelet activation assay D. Complete blood count (CBC)

B. A bone marrow biopsy may be necessary to rule out leukemia, aplastic anemia, and other myeloproliferative disorders and can be used to differentiate thrombocytopenia from other myeloproliferative disorders. Option A is incorrect because A urinalysis is not used to diagnose or differentiate thrombocytopenia types. Option C is incorrect because The platelet activation assay is used to differentiate types of thrombocytopenia not to confirm diagnosis. Option D is incorrect because A CBC is appropriate to measure and confirm the platelet count, which is already known for this patient.

Which surgical procedure is classified as major surgery? A. Breast biopsy B. Colon resection C. Lesion removal D. Cataract removal

B. A colon resection requires anesthesia and respiratory assistance. There is high risk to the patient, making this a major, not minor, surgery. Options A, C and D do not require anesthesia or respiratory assistance therefore they are minor surgeries.

A patient with a history of chronic immune thrombocytopenic purpura (ITP) comes to the nurse for dietary advice. As a health care provider, you understand that an important goal for this patient is to reduce mouth soreness and irritation. Which intervention would be helpful for this patient? A. Citrus fruits B. Soft, bland food C. Raw vegetables D. Curry-flavored food

B. A diet of soft, bland foods will be most helpful to patients and help prevent mouth discomfort and irritation. Option A is incorrect because Though citrus foods are high in vitamin C and good for collagen formation, citrus foods will need to be avoided since they are acidic and can cause mouth discomfort for patients with thrombocytopenia. Option C is incorrect because Raw vegetables will be slightly stiff and cause mouth discomfort. It will be better if the vegetables are cooked and softer. Option D is incorrect because though turmeric can have a healing effect, foods that contain curry should be avoided since they are generally spicy and will cause mouth discomfort.

Which surgical procedure is reconstructive? A. Liposuction B. Facial skin graft C. Cleft palate repair D. Abdominal laparoscopy

B. A facial skin graft is a reconstructive surgery that restores function or appearance of traumatized or malnourished tissues, e.g., following the removal of a cancerous lesion. Option A is incorrect because Liposuction is a cosmetic surgery used to improve personal appearance, not a reconstructive surgery. Option C is incorrect because A cleft palate repair is a constructive surgery used to restore function lost due to a congenital defect, not a reconstructive surgery. Option D is incorrect because Laparoscopy of the abdomen is a type of diagnostic surgery used to confirm a diagnosis.

The nurse is reviewing the laboratory results of a patient who received chemotherapy for acute myelogenous leukemia (AML). Which laboratory finding would compel the nurse take the grapes off the patient's lunch tray? A. Red blood cell count (RBC) of 3.2 cells/μL B. White blood cell count (WBC) of 1.6 cells/μL C. Platelet count of 100,000 cells/μL D. Blood urea nitrogen (BUN) of 30

B. A low WBC count places the patient at risk for infection. When a patient's WBC count is this low, neutropenia precautions are implanted, and fresh fruits or vegetables are not allowed. Option A is incorrect because A low RBC count does not require the nurse to remove the grapes from the patient's lunch tray. A low RBC would compel the nurse to plan rest periods because of anemia. Option C is incorrect because A low platelet count would place the patient at risk for bleeding and the nurse would avoid administering aspirin, but it would not require the nurse to remove the grapes from the patient's tray. Option D is incorrect because An elevated BUN may indicate dehydration but would not compel the nurse to remove grapes from the patient's lunch tray.

A risk intraoperative nursing diagnosis would be selected for a patient with which finding? A. Abnormal blood gas results B. Protruding bony prominences C. Acute surgical site pain after a procedure D. Nausea and vomiting following anesthesia

B. A risk intraoperative nursing diagnosis would be selected for a patient with protruding body prominences. The patient is at risk for postoperative injury from positioning but does not yet have an injury. Option A is incorrect because abnormal blood gas results reflect an actual intraoperative nursing diagnosis, not a risk nursing diagnosis. Option C is incorrect because An actual postoperative, not intraoperative, nursing diagnosis would be selected for this patient. Pain occurs following surgery, not during surgery. Option D is incorrect because An actual postoperative, not intraoperative, nursing diagnosis would be selected for this patient. Nausea and vomiting can occur as a side effect from anesthesia when patients are recovering.

The nurse would collaborate with which team member prior to discharging a patient who has no family support? A. Surgeon B. Social worker C. Home care nurse D. Health care provider

B. A social worker would be able to coordinate resources for a patient without family support and facilitate the transition to a care facility or the initiation of home care. Option A is incorrect because The surgeon is responsible for discharging the patient but is not involved in organizing the continuation of care once the patient leaves the hospital. Option C is incorrect because The home care nurse would assist a non-independent convalescent patient without family support only after the patient has been discharged from the hospital. Option D is incorrect because The primary care provider participates in neither the postoperative discharge nor the management of a patient without family support.

Which type of surgery will a patient with acute appendicitis undergo? A. Minor B. Urgent C. Elective D. Restorative

B. Acute appendicitis is considered an urgent surgery because it is not immediately life-threatening, but failure to have the surgical procedure performed may result in complications or death. Option A is incorrect because Appendectomies require more than minimal alterations to the body. In the case of a ruptured appendix, there is significant risk to the patient. Appendectomies are not minor surgery. Option C is incorrect because Elective surgery refers to a surgical procedure when there is no life-threatening condition, but the patient decides to have surgery to improve health physically or psychologically. An appendectomy is not an elective surgery. Option D is incorrect because Restorative surgery refers to surgery that restores function or appearance. This patient's surgery will not restore function of the appendix.

Which nursing action demonstrates a primary prevention strategy for cancer? A. Assisting with clinical breast evaluation B. Administering the HPV vaccine C. Preparing the patient for a colonoscopy D. Sending Pap tests to the laboratory for analysis

B. Administering the HPV vaccine is primary prevention because it prevents cancer from ever developing. Option A is incorrect because Clinical breast evaluation is a form of screening, which demonstrates secondary prevention. Option C is incorrect because Colonoscopy is a type of screening, which demonstrates secondary prevention. Option D is incorrect because Pap testing is a type of screening, which demonstrates secondary prevention.

Which intraoperative team member acts as the patient's advocate by assessing patient safety? A. Scrub person B. Circulating nurse C. RN first assistant D. Certified RN anesthetist

B. Although the entire surgical team assesses for patient safety, the circulating nurse acts as the patient's primary advocate. Option A is incorrect because The scrub person helps assess patient safety by continually assessing for breaks in sterile technique. The scrub person is not, however, the patient advocate during surgery. Option C is incorrect because The first assistant helps assess for patient safety during the surgical procedure while working with the surgeon, but does not serve as the patient's advocate. Option D is incorrect because The CRNA (nurse anesthetist) and the entire OR team assess for patient safety, but the CRNA does not serve as the patient's advocate.

Which initial postoperative nursing intervention takes priority? A. Elevating the patient's head B. Assessing the patient's airway C. Auscultating the patient's lungs D. Administering oxygen by cannula

B. Assessing and managing the patient's airway is the priority nursing intervention during the postoperative phase of surgery. The patient's head should be positioned in a manner that facilitates breathing. Option A is incorrect because The nurse would auscultate the patient's lungs as part of routine postoperative care, but not as a priority intervention. Option C is incorrect because Oxygen is administered to PACU patients; however, this is not the priority intervention. Oxygen should be administered by mask until the patient is responsive and then administered by nasal cannula if it is still needed. Option D is incorrect because The patient's head can be elevated on pillows to facilitate breathing. To prevent risk of accidental suffocation, the nurse should not elevate the head of an unconscious patient.

Which physiological changes affect drug metabolism in the older adult? A. Slowed gastric motility B. Liver mass shrinking C. Decreased glomerular filtration D. Smaller amounts of total body water

B. Because many drugs are metabolized in the liver, a shrinking liver mass in the older adult directly affects drug metabolism. Option A is incorrect because Slowed gastric motility is associated with drug absorption in the older adult, not drug metabolism. Option C is incorrect because Decreased glomerular filtration affects the excretion of drugs in the older adult. Option D is incorrect because Smaller amounts of total body water affect the distribution of drugs in the older adult.

What assessment data will the nurse anticipate with advanced gastrointestinal cancer? A. Vaginal bleeding B. Cachexia C. Nagging cough D. Painful urination

B. Cachexia is a sign of extreme malnutrition that can occur with advanced gastrointestinal cancer. Option A is incorrect because Vaginal bleeding is associated with cancer of the reproductive system. Option C is incorrect because Nagging cough is associated with cancer of the respiratory system. Option D is incorrect because Painful urination is associated with cancer of the urinary system.

If a patient with chronic myeloid leukemia (CML) does not respond to imatinib, what is the most likely reason? A. Imatinib is only indicated for short-term use. B. Cancer cells have become resistant to imatinib. C. Newer BCR-ABL TK inhibitors are more effective than imatinib. D. Imatinib is only effective when combined with other BCR-ABL TK inhibitors.

B. Cells have the ability to develop resistance to imatinib. Option A is incorrect because Imatinib can be used for long term treatment of CML. Option C is incorrect because Other BCR-ABL TK inhibitors may treat resistant BCR-ABL clones, but they are not superior to imatinib. Option D is incorrect because Imatinib can be effective as a single medication.

A patient asks the nurse how chemotherapy works to treat cancer. Which nursing response is appropriate? A. "Chemotherapy uses the body's immune system to kill the cancer cells." B. "Chemotherapy damages the cellular DNA, which causes the cancer cells to die." C. "Chemotherapy blocks the effects of hormones, which causes cancer cells to die." D. "Chemotherapy targets specific receptors on the cancer cell to prevent the cell from growing and causes the cell to die."

B. Chemotherapy damages cellular DNA, which causes the cancer cells to die. Option A is incorrect because Immunotherapy, not chemotherapy, uses the body's own immune system to fight cancer. Immunotherapy includes biological response modifiers (BRMs) and targeted therapies. Option C is incorrect because Hormone therapy, not chemotherapy, can be used to block the effects of hormones and stop the growth of the cancer cells. Option D is incorrect because Targeted therapy, not chemotherapy, targets specific receptors on the cell that are important to cell growth.

What is the mechanism of action of imatinib in suppressing cell proliferation? A. Imatinib suppresses activation of EGFR tyrosine kinase. B. Imatinib suppresses activation of BCR-ABL tyrosine kinase. C. Imatinib directly prevents metabolism of EGFR tyrosine kinase. D. Imatinib directly prevents metabolism of BCR-ABL tyrosine kinase.

B. Imatinib inhibits BCR-ABL tyrosine kinase activation and prevents the enzyme from activating regulatory proteins for cell replication, thereby minimizing cell proliferation and promoting apoptosis. Option A is incorrect because The target of imatinib is BCR-ABL tyrosine kinase. Option C is incorrect because Imatinib does not prevent metabolism of EGFR tyrosine kinase. Option D is incorrect because Imatinib does not prevent metabolism of BCR-ABL tyrosine kinase.

Circulatory and respiratory depression are safety concerns associated with the administration of which type of anesthetic? A. Local B. General C. Regional D. Moderate

B. Circulatory and respiratory depression are safety concerns associated with the administration of general anesthesia. The fourth stage of anesthesia, if not reversed rapidly, can result in the need for cardiopulmonary resuscitation. Option A is incorrect because Circulatory and respiratory depression are rarely safety concerns associated with local anesthetics unless they are used or applied in very high doses, which is not advised. Option C is incorrect because Circulatory and respiratory depression are rarely safety concerns associated with the administration of regional anesthetics. Respiratory depression is possible from inadvertent high-dose administration of spinal anesthesia. Option D is incorrect because Circulatory and respiratory depression are rarely safety concerns associated with moderate sedation because of patient assessment is constant and patient sedation can be reversed immediately.

A patient is diagnosed with hypophosphatemia caused by an increased excretion of phosphate. Which probable cause for this condition should the nurse include in the teaching session with the patient? A. Phosphate-binding antacids B. Diabetic ketoacidosis C. Alcoholism D. Malabsorption syndrome

B. Diabetic ketoacidosis is a cause for hypophosphatemia that is related to increased excretion of phosphate. Option A is incorrect because Phosphate-binding antacids is one cause for hypophosphatemia related to poor intake of phosphate, not increased excretion. Option C is incorrect because Alcoholism is one cause for hypophosphatemia related to poor intake of phosphate, not increased excretion. Option D is incorrect because Malabsorption is one cause for hypophosphatemia related to poor intake of phosphate, not increased excretion.

Which nursing intervention will the nurse select for a patient with cancer and dysgeusia? A. Encourage frequent oral care. B. Discuss alternative seasonings for food. C. Apply lotion to the skin. D. Test the stool for occult blood.

B. Dysgeusia is altered taste that often occurs with chemotherapy treatment. An appropriate nursing intervention for a patient with dysgeusia is to discuss alternative seasonings for food. Option A is incorrect because Frequent oral care does not address dysgeusia, which is altered taste that occurs with chemotherapy treatment. Option C is incorrect because Applying lotion to the skin does not address dysgeusia, which is altered taste associated with chemotherapy. Option D is incorrect because Testing the stool for occult blood does not address dysgeusia, which is altered taste associated with chemotherapy.

A tonsillectomy is considered which type of surgery? A. Urgent B. Elective C. Ablative D. Emergency

B. Elective surgery is performed to improve the patient's health and is planned in advance by the patient and surgeon. Tonsillectomies are usually elective unless the patient has a serious infection. Option A is incorrect because Urgent surgery is required when a health condition is not immediately life-threatening but should be performed within 24 hours. Option C is incorrect because Ablative surgery is conducted to remove a diseased body part, and is not a type of surgery classified by degree of urgency. Option D is incorrect because Emergency surgery is performed when surgery is required immediately because of a life-threatening condition.

Which body substance is most commonly used to measure the concentration of electrolytes in milliequivalents per liter (mEq/L)? A. Urine B. Blood plasma C. Cerebrospinal fluid D. Insulin

B. Electrolytes are most commonly measured in blood plasma or serum. Option A is incorrect because While electrolytes can be measured in many body substances, including urine, this is not the most commonly used body substance. Option C is incorrect because While electrolytes can be measured in many body substances, including the cerebrospinal fluid, this is not the most commonly used body substance. Option D is incorrect because Insulin is a hormone secreted by the pancreas. The concentration of electrolytes is not measured in this body substance.

Gastric bypass surgery is classified as which type of surgical procedure? A. Urgent B. Elective C. Invasive D. Emergency

B. Gastric bypass surgery is classified as an elective surgery because its purpose is to improve the quality of life of the patient, but it is not required for the health of the patient. Option A is incorrect because urgent surgeries are performed when there is no immediate threat to life but there could be if the surgery is not performed within 24 hours. Gastric bypass surgery does not have to be performed immediately or within 24 hours Option C is incorrect because All surgeries are invasive, but invasive surgery is not a class of surgery. Option D is incorrect because Emergency surgeries are performed when there is an immediate threat to the life and health of the patient, such as uncontrolled bleeding from a gunshot wound. Gastric bypass is not an emergency surgery.

Which type of anesthetic is administered when the surgery necessitates temporary loss of consciousness and sensation? A. Nerve block B. General anesthesia C. Moderate sedation D. Regional anesthesia

B. General anesthesia causes central nervous system depression, temporary loss of consciousness, loss of sensation, amnesia, analgesia, and muscle relaxation. Option A is incorrect because A nerve block, a type of regional anesthesia, involves the injection of an anesthetic around or near a nerve to block pain impulses in an area of the body. It does not produce temporary loss of consciousness and sensation Option C is incorrect because Moderate sedation induces an altered state of consciousness, providing a moderate or deep level of calm, analgesia, and amnesia. It does not produce temporary loss of consciousness and sensation. Option D is incorrect because Regional anesthesia blocks pain impulses in a certain area of the body. It does not produce temporary loss of consciousness and sensation.

Which nursing teaching statement is most appropriate for the patient with dementia? A. "It's important for you to stay in bed so that you do you not get hurt." B. "Do not get out of bed." C. "If you climb out of bed, the bed alarm will be very loud." D. "If you get out of bed, restraints will be required for your safety."

B. If a patient has dementia, it is important to assess understanding and use clear, direct teaching statements. This statement is most appropriate for a patient with dementia. Option A is incorrect because When a patient has dementia, it is important to use clear, direct teaching statements. This statement is too long, and the directive to stay in bed is combined with the rationale, which is often too much for the patient with dementia to process. Option C is incorrect because When a patient has dementia, it is important to use clear, direct teaching statements. There are multiple components in this statement, all of which require additional understanding (if you climb, bed alarms, very loud). The message to stay in bed is not direct. Option D is incorrect because This statement is incorrect and threatening in nature. When a patient has dementia, it is important to assess understanding and use clear, direct teaching statements.

A patient questions a new diagnosis of chronic myelogenous leukemia (CML) because he has no symptoms. Which response by the nurse is appropriate? A. "Some patients may not ever have symptoms with CML." B. "It's very common for patients with CML to have no symptoms initially." C. "You did have symptoms; you probably just thought it was weakness or fatigue." D. "Your symptoms were disguised because you were battling the flu at that time, too."

B. In CML, patients are typically free of symptoms in the early stages of the disease. Option A is incorrect because Although patients with CML are free of symptoms at first, it is not the case that they will never have symptoms. Option C is incorrect because Although weakness and fatigue can manifest in patients with CML, telling the patient he is wrong about having no symptoms is not an appropriate nursing response. Option D is incorrect because Although infections, such as influenza, can be present in patients with CML, telling the patient he is wrong about having no symptoms is not an appropriate nursing response.

Which electrolyte may require the use of insulin for regulation and homeostasis? A. Sodium B. Potassium C. Calcium D. Phosphate

B. Insulin moves potassium into cells. Option A is incorrect because Sodium is predominantly regulated by the action of hormones on the kidneys. Option C is incorrect because Calcium is predominantly regulated by the parathyroid hormone, calcitonin, and vitamin D. Option D is incorrect because Phosphate is predominately regulated by factors that act on the kidneys.

Which factor contributes to patient stress and increases surgical risk? A. Laboratory tests B. Knowledge deficit C. Enforced NPO status D. Information overload

B. Lack of knowledge or knowledge deficit results in fear of the unknown, which increases stress. By keeping the patient informed and explaining care throughout the preoperative phase of surgery, the nurse relieves the patient's fears, thereby relieving stress and decreasing surgical risk. Option A is incorrect because Laboratory tests are an expected part of the preoperative phase of surgery. They are rarely stress-provoking for the patient and they do not increase surgical risk. Option C is incorrect because Enforced nothing per os (NPO) status can be annoying for some patients, but it is not a factor that increases surgical risk. Patients expect to be NPO and rarely complain because they know it protects their safety. Option D is incorrect because Information overload can be stress-provoking, but preoperative teaching takes place at intervals throughout the preoperative phase of surgery, not all at once. This prevents information overload.

The nurse is providing care to a patient who is diagnosed with hypomagnesemia. Which cause for this condition should the nurse include in the patient teaching? A. Constipation B. Loop diuretics C. Antacids with added magnesium D. Renal failure

B. Loop diuretics is one cause for hypomagnesemia the nurse should include in the teaching session for a patient with hypomagnesemia. Option A is incorrect because Diarrhea, not constipation, is a teaching point the nurse should include in the teaching session for a patient with hypomagnesemia. Option C is incorrect because Antacids with added magnesium can cause hypermagnesemia, not hypomagnesemia. Option D is incorrect because Renal failure is a cause for hypermagnesemia, not hypomagnesemia.

Which assessment data would cause the nurse to suspect elder neglect? A. Multiple bruises B. Malnourishment C. Circular pattern on the scalp of hair loss D. Isolation of the older adult

B. Malnourishment is a frequent indicator of neglect in the older adult. Option A is incorrect because Bruises on the older adult can be a sign of physical abuse. Option C is incorrect because Abnormal patterns of hair loss can be a sign of physical abuse in the older adult. Option D is incorrect because Isolation of the older adultIsolation of the older adult is a sign of emotional abuse of the older adult.

A patient is diagnosed with anemia related to folic acid deficiency. The patient asks the nurse what dietary changes should be made to increase folic acid intake? What is the best response by the nurse? A. "Increase your consumption of red meat." B. "Increase your consumption of whole grains." C. "Increase your consumption of fresh shellfish." D. "Increase your consumption of honey wheat bread."

B. Many grains are now fortified with folic acid, including pasta and flour. Incorporation of these foods can increase the dietary intake of folic acid. Option A is incorrect because Red meat is a good source of iron but not folic acid. Option C is incorrect because Shellfish are a great source for copper but not for folic acid. Option D is incorrect because Honey wheat bread is not a good source for folic acid consumption, although it is healthier than white bread.

Which sub-category of older adults will the nurse document for a 77-year-old patient? A. Young old B. Middle old C. Old old D. Elite old

B. Middle old is ages 75 to 84. Option A is incorrect because Young old is ages 65 to 74. Option C is incorrect because old old is ages 85 to 99. Option D is incorrect because elite old is ages 100 or older.

What is the most common route of administration for chemotherapy? A. Oral B. Intravenous C. Subcutaneous D. Intramuscular

B. Most chemotherapy is administered through the intravenous route. All other routes may be used but they are not the most common.

Which older adult patient statement requires further nursing intervention? A. "I take my medications at night." B. "I go to any pharmacy with the best prices." C. "I take three prescription medications." D. "I always request the easy-open lids on my prescriptions."

B. Older adults are encouraged to get all their medications from the same pharmacy. This statement would require further education from the nurse in an effort to increase drug safety for the older adult. Option A is incorrect because Taking medication at the same time of day can be helpful in establishing drug safety in the older adult. This statement does not require further nursing intervention. Option C is incorrect because It is not uncommon for older adults to take multiple prescriptions, but safety risks are much higher when the patient takes five or more prescriptions. This statement does not require further nursing intervention. Option D is incorrect because Difficulty opening medications can cause older adults not to take the medication. Requesting easy-open lids is an appropriate safety measure for the older adult and does not require further nursing intervention.

Which student nursing action requires intervention from the nurse? A. Assessing the site of intravenous chemotherapy administration B. Breaking an oral chemotherapeutic drug in half C. Using PPE to empty urine from a patient receiving chemotherapy D. Providing a head covering for a patient with alopecia

B. Oral chemotherapy drugs may be administered in the home or by non-oncology nurses. Oral agents cannot be crushed, split, broken, or chewed. Option A is incorrect because Assess the site of intravenous administration carefully because prevention of extravasation is imperative. Option C is incorrect because Chemotherapy drugs can be absorbed through the skin and mucous membranes; therefore, be very careful when disposing of chemotherapy medications or intravenous tubing used for administration. In addition, for 48 hours after administration, the patient's urine and feces are hazardous and require special handling (double gloves, eye protection, and masks). Option D is incorrect because Alopecia (hair loss) can occur with chemotherapy. Protecting the scalp from temperature extremes and injury is an important nursing action.

Which intervention will the nurse select to prevent mucositis? A. Administering antiemetics B. Oral cryotherapy C. Limiting visitors D. Avoiding sunlight

B. Oral cryotherapy (holding ice chips in the mouth before, during, and after infusing mucositis-causing agents) can help prevent mucositis. Option A is incorrect because Administering antiemetics is a strategy used to prevent nausea and vomiting. Option C is incorrect because Limiting visitors is a strategy used to prevent or decrease the risk of infection. Option D is incorrect because Avoiding sunlight is a method to protect the skin following radiation.

A patient is diagnosed with anemia related to an iron deficiency. Which patient statement indicates that the appropriate nursing goals are being met? A. "I will need cobalamin shots for the rest of my life." B. "I will work hard to eat more foods like spinach and lentils." C. "My primary health care provider said my folic acid levels are perfect!" D. "I am able to rest quietly on the couch without experiencing fatigue or a racing heart."

B. Oral iron supplementation is an appropriate treatment for anemia related to dietary iron deficiency. An important goal during this period is for the patient to verbalize knowledge necessary to maintain adequate nutrition and management of a medication regimen. Option A is incorrect because An important goal for the patient with iron deficiency is to verbalize knowledge necessary to manage a medication regimen. Cobalamin injections are necessary for anemia related to vitamin B12 deficiency, not iron deficiency. This patient does not have adequate knowledge, and therefore the goal has not been met. Option C is incorrect because An important goal for the patient with anemia is to attain normal blood values of nutrients necessary to prevent anemia. In this case, the patient should attain normal blood values of iron, not folic acid. Option D is incorrect because An important goal for the patient with anemia is to be able to perform activities of daily living without an increase in blood pressure and heart rate, not to sit quietly on the couch.

Mr. Johnson's assessment data reveals hypokalemia and muscle cramping leading to a priority nursing diagnosis of Pain. Which need, according to Maslow, supports this nursing diagnosis as a priority? A. Safety B. Physiological C. Self-actualization D. Self-esteem

B. Pain is an example of a physiological need, indicating that it is a priority. Pain only relates to physiological needs on Maslow's hierarchy of needs.

Which type of surgical procedure will an older adult patient undergo to alleviate hip pain from terminal cancer? A. Ablative B. Palliative C. Constructive D. Reconstructive or restorative

B. Palliative surgery is performed for the purpose of improving comfort and/or alleviating pain, but does not cure. It is most often performed on patients with terminal diseases to relieve pain. Option A is incorrect because Ablative surgery involves removal of a diseased body part, but is not performed for the purpose of relieving pain. Option C is incorrect because Constructive surgery restores body function that has been lost or reduced, but is not performed for the purpose of relieving pain. Option D is incorrect because Reconstructive or restorative surgery restores function and/or appearance of tissues that are damaged or malnourished, but is not performed for the purpose of alleviating pain.

Visitors carrying a vase of flowers approach the room of a patient with leukemia for whom neutropenia precautions have been implemented. Which is the most appropriate action by the nurse before allowing the guests to enter the patient's room? A. Stopping the visitors and introducing himself/herself B. Instructing the visitors to leave the vase of flowers at the nurses' station C. Telling the visitors to limit their visit to 60 minutes D. Telling the visitors that only two of them should be in the room at one time

B. Patients who require neutropenia precautions have a significantly low white blood cell count, putting them at risk for infections that can be caused by bacteria present on fresh fruits and plants. The nurse should instruct the visitors to leave the vase of flowers at the nurses' station for this reason. Option A is incorrect because Although greeting visitors and making introductions are important nursing actions, these are not the most appropriate actions by the nurse in relation to neutropenia precautions. Option C is incorrect because Although it may be important to limit visiting time to avoid tiring the patient, this is not the most appropriate action by the nurse in relation to neutropenia precautions. Option D is incorrect because Although it may be important to limit the number of visitors to avoid tiring the patient, this is not the most appropriate action by the nurse in relation to neutropenia precautions.

Which condition increases surgical risk because it interferes with the patient's cognitive ability for self-care postoperatively? A. Heart failure B. Schizophrenia C. Fatty liver disease D. Autoimmune disease

B. Patients with conditions that affect cognitive function such as schizophrenia and developmental delay may experience impeded ability to follow instructions and perform self-care postoperatively. Options A, C and D do not have a direct effect on a patient's cognitive ability for self-care postoperatively.

Which baseline patient laboratory value is a priority nursing assessment prior to administration of anticancer drugs? A. Chest radiographs B. Liver function test C. Electrocardiograph D. Pulmonary function test

B. A liver function test is indicated prior to administration of anticancer drugs because the liver metabolizes these medications. Option A is incorrect because Chest radiographs may be necessary prior to anticancer therapy but they are not indicated. Option C is incorrect because An electrocardiograph may be necessary before administration of anticancer drugs depending on the patient's condition, but it is not a priority test. Option D is incorrect because A pulmonary function test may be necessary before administration of anticancer drugs depending on the patient's condition, but it is not a priority test.

Which nursing diagnosis would the nurse select for a patient with a blanched area over the coccyx immediately following surgery? A. Altered Tissue Perfusion related to blanched coccyx B. Perioperative Positioning Injury related to blanched coccyx C. Risk for Ineffective Tissue Perfusion with Risk Factor of Blanched Coccyx D. Risk for Perioperative Positioning Injury with Risk Factor of Blanched Coccyx

B. Perioperative Positioning Injury related to blanched coccyx is the nursing diagnosis the nurse would select for the patient. The blanched area over the patient's coccyx is the data that supports this nursing diagnosis. Option A is incorrect because Altered Tissue Perfusion is not the nursing diagnosis the nurse would select for this patient. It is not a correctly stated nursing diagnosis. Option C is incorrect because Risk for Ineffective Tissue Perfusion is not the nursing diagnosis the nurse would select for this patient. The patient's data does not support the presence of risk factors for ineffective tissue perfusion. Option D is incorrect because Risk for Perioperative Positioning Injury is not the nursing diagnosis the nurse would select for this patient. The patient's data does not support the presence of risk factors for a positioning injury.

Which complication will the nurse assess for following spinal anesthesia? A. Amnesia B. Headache C. Hypertension D. Over-sedation

B. Post-spinal headache is a common patient complaint following spinal anesthesia. The nurse will assess for this complication. Option A is incorrect because Amnesia is an expected finding following moderate sedation. It is not a complication from this type of anesthesia. Option C is incorrect because Hypotension, not hypertension, can result from inadvertent administration of high-level spinal anesthesia. Option D is incorrect because Over-sedation is a potential complication of moderate sedation anesthesia, not spinal anesthesia.

Which older adult patient history indicates that the nurse will need to teach about fall risk? A. Recent hospitalization B. Presbyopia C. Depression D. Hypertension

B. Presbyopia is farsightedness that often worsens with aging. Any visual changes can create a fall risk, and regular eye exams and visual correction are important components of fall prevention. Option A is incorrect because Recent hospitalization does not create an inherent risk for falls in the older adult. Option C is incorrect because Depression does not create an inherent risk for falls in the older adult. Option D is incorrect because Hypotension, not hypertension, creates an inherent risk for falls in all populations. Hypertension is not an inherent risk for falls in the older adult.

Which data should the nurse identify as placing a patient at risk for hypovolemic hyponatremia? A. Profuse diaphoresis B. Water intoxication C. Hypotonic IV solution D. Excess fluid intake

B. Profuse diaphoresis is a risk factor for hypovolemic hyponatremia. Option A is incorrect because Water intoxication is a risk factor for hypervolemic, not hypovolemic, hyponatremia. Option C is incorrect because Hypotonic IV solution administration is a risk factor for hypervolemic, not hypovolemic, hyponatremia. Option D is incorrect because Excess fluid intake is a risk factor for hypervolemic, not hypovolemic, hyponatremia.

A patient is diagnosed with anemia related to iron deficiency. The health care provider orders parenteral iron supplements. When demonstrating the medication administration to the patient, which statement should be included? A. "Make sure you inject the medication and then rub the area." B. "Be sure to pull the skin taut before injecting the needle and medication." C. "When injecting the medication, you may feel a warm, flushed feeling over your skin." D. "You may use the same needle for injection that you used when withdrawing the medication."

B. Pulling the skin taut would be the correct administration technique for an iron injection. This is called the Z-track method. Option A is incorrect because Iron will stain the skin. The patient should not be told to rub the area after the injection. Option C is incorrect because The patient should not feel a warm, flushed feeling; this could be a sign of an allergic reaction. Option D is incorrect because Iron will stain the skin, so the needle should be changed once the medication has been drawn.

Which teaching will the nurse provide regarding radiation therapy? A. "Radiation is often given in a single dose." B. "Radiation stops the cancer cells from reproducing by damaging the cellular DNA." C. "The marks that are placed on the skin to guide radiation should be washed off." D. "Radiation is only used when curative therapy is the goal."

B. Radiation damages the cellular DNA, rendering the cell unable to reproduce and causing cell death. Option A is incorrect because Radiation is not given in a single dose. Rather the total radiation dose is calculated and then divided into daily doses. Option C is incorrect because Radiation marks on the skin should not be washed off. Many times, they are very small tattooed marks because precise location of the radiation beams is essential to the effect of the radiation. Option D is incorrect because Radiation can also be used for palliative therapy. Because radiation causes the cell to die, it will often decrease the size of cancer, which can relieve some pain and symptoms associated with the cancer.

Which patient statement would cause the nurse to assess for depression in the older adult? A. "I have three grandchildren that I watch once a week." B. "I retired as an architect after 34 years." C. "I have been married for 51 years." D. "I go to church each week on Sunday morning."

B. Situational depression can be triggered in the older adult after major life events such as retirement or death of a spouse. This statement would cause the nurse to assess further. Option A is incorrect because Caring for grandchildren often brings meaning and purpose; this statement does not warrant assessment for depression. Option C is incorrect because The loss of a spouse would cause the nurse to suspect risk for situational depression, not a long-lasting marriage of 51 years. Option D is incorrect because The patient is able to get out and is engaging in the community. This statement would not warrant further assessment for depression.

Which patient statement about cancer symptoms requires further nursing education? A. "A sore that doesn't heal can be a sign of cancer." B. "Sometimes it is subtle, but all cancer produces symptoms." C. "Cancer can cause you to gain or lose weight." D. "I know I should check my breast for dimpling of the skin."

B. Some cancer produces no symptoms. This is why screening for cancer is very important. All other options indicate cancer and are correct.

A patient diagnosed with high blood pressure asks, "Why do I have to monitor my salt intake?" Which explanation should the nurse include in the response to this patient? A. "Sodium has a diuretic effect. You should increase the amount you consume so that you will get rid of extra fluid and decrease your blood pressure." B. "Sodium helps to maintain blood pressure. Since your blood pressure is high, you should decrease your sodium intake." C. "Sodium affects the electrical activity within your heart. Decreasing your sodium intake will allow your heart to pump more effectively and decrease your blood pressure." D. "Sodium is the main ingredient in salt; however, sodium does not influence your blood pressure. I think the doctor told you to monitor your potassium intake instead."

B. The main ingredient in salt is sodium, which plays a role in maintaining blood pressure. A decrease in sodium intake decreases the fluid in the body; therefore, it decreases blood pressure. Option A is incorrect because Sodium does not have a diuretic effect. However, it does play a role in maintaining blood volume and blood pressure. Option C is incorrect because Potassium, not sodium, affects the electrical activity of the heart. Decreasing sodium intake will not allow the heart to pump more effectively and decrease blood pressure. Option D is incorrect because Sodium does influence blood pressure and volume.

Which serum electrolyte value in a patient should the nurse interpret as within normal limits? A. Sodium: 150 mEq/L B. Potassium: 4 mEq/L C. Calcium: 11 mg/dL D. Magnesium: 2.5 mEq/L

B. The normal range of serum potassium is 3.5 to 5 mEq/L. This potassium level is within normal limits. Option A is incorrect because The normal range for serum sodium is 135 to 145 mEq/L. This sodium level is not within normal limits. Option C is incorrect because The normal range for serum calcium is 8.5 to 10 mg/dL. This calcium level is not within normal limits. Option D is incorrect because The normal range for serum magnesium is 1.3 to 2.1 mEq/L. This magnesium level is not within normal limits.

Which assessment would the PACU nurse perform if a patient were suspected of having an airway obstruction? A. Gag reflex B. Mouth inspection C. Oxygen saturation D. Level of consciousness

B. The nurse would immediately inspect the patient's mouth. Close assessment can reveal an obvious obstruction such as the tongue, vomit, blood, secretions, loose teeth, or a foreign body that needs to be removed. Option A is incorrect because Assessing for a gag reflex should be avoided. It could cause the patient to vomit, which would further obstruct the airway. Option C is incorrect because Assessing the patient's oxygen saturation would be useful once the patient's airway obstruction has been relieved, but could delay actions to relieve the obstruction, which is an emergency situation. Option D is incorrect because If not relieved, airway obstruction does affect level of consciousness, but assessing LOC could delay actions to relieve the patient's obstruction, which is an emergency situation.

Physical therapy is consulted to assist a postoperative patient who expresses a desire to walk to reduce pain. Which nursing diagnosis will the nurse add to the patient's plan of care? A. Readiness for Prescribed Treatment Regimen related to physical therapy B. Readiness for Enhanced Health as evidenced by patient desire to ambulate and promote comfort C. Impaired Physical Mobility as evidenced by patient need to recover ambulation through physical therapy D. Readiness for Enhanced Self-Care as evidenced by patient desire to begin mobility exercise to promote comfort

B. The nursing diagnosis of Readiness for Enhanced Health as evidenced by patient desire to ambulate and promote comfort is a health-promotion nursing diagnosis. The patient's verbalized desire to walk to reduce pain supports the nurse's decision to add this nursing diagnosis to the patient's plan of care. Option A is incorrect because This nursing diagnosis is not stated correctly and does not address the patient's situation. There is no data to indicate a prescribed treatment regimen. Option C is incorrect because This nursing diagnosis does not address the patient's situation. It is not specific and does not reflect the patient's desires. There is no data to indicate impaired physical mobility, only pain. Option D is incorrect because This nursing diagnosis is not specific to the patient's situation. There is no data to indicate the patient wishes to start mobility exercises, only walking.

Which nursing diagnosis will the preoperative nurse individualize for a patient with a coagulation disorder who is scheduled for surgery? A. Bleeding B. Risk for Bleeding C. Ineffective Tissue Perfusion D. Risk for Ineffective Tissue Perfusion

B. The preoperative nurse will individualize this nursing diagnosis because the patient has the risk factor of a coagulation disorder, which places the patient at increased risk for bleeding during and after surgery. Option A is incorrect because There is no data to suggest the patient is experiencing active bleeding. The preoperative nurse will not individualize this specific nursing diagnosis. Option C is incorrect because There is no data to suggest the patient is experiencing poor or ineffective tissue perfusion. The preoperative nurse will not individualize this specific nursing diagnosis. Option D is incorrect because There is no data to suggest the patient has risk factors for this nursing diagnosis. The preoperative nurse will not individualize this nursing diagnosis.

Which nursing diagnosis will the preoperative nurse select for a patient whose surgery was delayed for six hours? A. Fluid Volume Deficit B. Risk for Fluid Volume Deficit C. Unstable Blood Glucose D. Risk for Unstable Blood Glucose

B. The preoperative nurse will select this nursing diagnosis because the patient has the risk factor of delayed surgery of six hours. This means the patient has been NPO for a prolonged time and increasing the risk for fluid volume deficit. The patient will be closely assessed and fluids delivered intravenously to prevent this problem. Option A is incorrect because This actual nursing diagnosis implies the patient has a fluid volume deficit. There is no data to support the preoperative nurse's selection of this nursing diagnosis. Option C is incorrect because This actual nursing diagnosis implies the patient has diabetes and either a high or low blood glucose level. There is no data to support the preoperative nurse's selection of this nursing diagnosis. Option D is incorrect because This risk nursing diagnosis implies the patient has diabetes mellitus and is at risk for high or low blood glucose levels. There is no data to support the preoperative nurse's selection of this nursing diagnosis.

What is the rationale for having a responsible adult present during postoperative patient teaching? A. The second adult is a witness that teaching occurred. B. The patient may be experiencing effects of anesthesia. C. The witnessing adult assumes teaching responsibility. D. The adult's presence legally protects the nurse and the surgical facility.

B. The rationale for having a responsible adult present during postoperative teaching is that the patient may be experiencing the effects of anesthetic medications. The responsible adult can recall and reinforce teaching later. The teaching is also provided in writing. Option A is incorrect because While the second adult is a witness that teaching occurred, that is not the main rationale for having a responsible adult present for postoperative patient teaching. The responsible adult serves a more important purpose. Option C is incorrect because The witnessing adult does not assume responsibility for teaching. The nurse keeps that responsibility. However, the responsible adult does serve an important role. Option D is incorrect because While the signed document that teaching was provided does legally verify that teaching did occur, that is not the main rationale for having a responsible adult present for postoperative patient teaching.

Which goal should the nurse include in the plan of care for a patient whose priority nursing diagnosis is Acute pain related to electrolyte imbalances, as evidenced by muscle cramping? A. Patient's serum electrolyte levels will be normal within 48 hours of implementing prescribed treatment. B. Patient will report a muscle cramp pain rating of no more than 3 on a 1 to 10 numeric scale within 1 hour of implementing prescribed treatment. C. Patient will achieve Pain control during hospitalization. D. Patient will consume adequate nourishment during hospitalization, including foods rich in electrolytes.

B. This is an example of an accurate and appropriate goal for the nursing diagnosis of Acute pain. Option A is incorrect because This goal is more appropriate for the nursing diagnosis Risk for electrolyte imbalance, not Acute pain. Option C is incorrect because This is an example of an NOC outcome, not a goal statement for the nursing diagnosis Acute pain. Option D is incorrect because This goal is more appropriate for the nursing diagnosis Imbalanced Nutrition: Less than body requirements not Acute Pain.

The nurse is educating a patient regarding the normal levels of potassium within the blood. Which response by the patient indicates correct understanding of the information presented? A. "The normal range for potassium is 135-145 mEq/L." B. "The normal range for potassium is 3.5-5 mEq/L." C. "The normal range of potassium is 4.0-5.0 mEq/L." D. "The normal range of potassium is 1.3-2.1 mEq/L."

B. This is the normal range for potassium and indicates correct understanding of the information presented. Option A is incorrect because The normal range for sodium, not potassium, is 135-145 mEq/L. This statement indicates the need for additional patient teaching. Option C is incorrect because The normal range of calcium, not potassium, is 4.0-5.0 mEq/L. This statement indicates the need for additional patient teaching. Option D is incorrect because The normal range for magnesium, not potassium, is 1.3-2.1 mEq/L. This statement indicates the need for additional patient teaching.

A patient presents to the emergency department with drug-induced thrombotic thrombocytopenic purpura (TTP). The patient is currently on aspirin and clopidogrel. The patient is complaining of a fever and severe discomfort in the left lower quadrant. The nurse should anticipate which treatment plan from the primary health care provider to care for this patient? A. Increase aspirin dose B. Discontinue clopidogrel C. Prepare patient for splenectomy D. Prepare patient for platelet transfusion

B. This patient is experiencing a drug-induced TTP, so the nurse would expect the health care provider to remove the offending agent(s), including clopidogrel. Option A is incorrect because This patient is experiencing a drug-induced TTP. As aspirin can cause acquired thrombocytopenia, increasing the dose will likely exacerbate the problem. Option C is incorrect because A splenectomy may be considered in patients who are refractory to plasma exchange or immunosuppression but not as the initial treatment in a patient with thrombocytopenia. Option D is incorrect because Administration of platelets to a patient with thrombocytopenia is generally contraindicated because it may lead to new von Willebrand factor-platelet (vWF) complexes and increased clotting.

A 44-year-old patient presents to the emergency department with a fever, blood clots, and history of an abnormal enzyme deficiency. The patient has not taken any medications in the past month. Why is this patient also likely to experience pain with the condition? A. This patient is presenting with signs of heparin-induced thrombocytopenia (HIT). B. This patient is presenting with signs of thrombotic thrombocytopenic purpura (TTP). C. This patient is presenting with signs of disseminated intravascular coagulation (DIC). D. This patient is presenting with signs of immune thrombocytopenic purpura (ITP).

B. This patient is presenting with signs of TTP that include fever (without an identifiable cause) and history of an enzyme deficiency (ADAMTS13) needed to break down von Willebrand factor. TTP patients need to be monitored for microthrombi that can cause ischemia and pain. Option A is incorrect because This patient is not presenting with signs of HIT. A patient with HIT will mention a history of heparin therapy and will present with a separate set of symptoms. Option C is incorrect because This patient is not presenting with signs of DIC. Option D is incorrect because this patient is not presenting with signs of ITP. Fever of unknown cause and evidence of an enzyme deficiency in this case are more typical of another disorder.

Which patient assessment data requires nursing intervention to promote wellness in the older adult? A. Vision screening 6 months ago B. One pneumococcal vaccine 1 year ago C. Tetanus booster 3 years ago D. Two shingles vaccines over the course of 1 year

B. To be fully protected, the Centers for Disease Control and Prevention recommends two pneumococcal vaccines at least 1 year apart for immunocompetent adults. This patient will require nursing education regarding the need for additional vaccination for full protection. The nurse will also need to notify the provider of the need for an additional vaccine to complete the vaccine series. Option A is incorrect because A yearly vision screening is suggested for older adults. A vision screening 6 months ago would not require additional nursing intervention to promote wellness. Option C is incorrect because Tetanus boosters are suggested every 10 years. This patient does not require additional nursing intervention because the tetanus booster was 3 years ago. Option D is incorrect because Two shingles vaccines, administered 6 months apart (over the course of 1 year), are recommended by the Centers for Disease Control and Prevention. This patient does not require additional nursing intervention because the shingles vaccine series is complete.

A nurse is caring for a patient with a history of thrombocytopenia. The patient has several complications while in the hospital and needs to be on bedrest for several days. The nurse understands that one main goal is to prevent bleeding in this patient. Which intervention needs to be considered for this patient who needs additional bed rest at home? A. Decrease the amount of leg movement B. Avoid herbal medications and supplements C. Encourage nonsteroidal anti-inflammatory drug (NSAID) usage D. Take aspirin daily for deep vein thrombosis (DVT) prophylaxis

B. To prevent bleeding complications in this patient, it will be important for the nurse to instruct the patient and caregiver to avoid taking herbal medications. Option A is incorrect because A patient on bed rest should perform leg exercises to prevent deep vein thrombosis (DVT). Option C is incorrect because NSAIDs at low dose should not be encouraged in patients with thrombocytopenia. Option D is incorrect because While DVT precautions need to be conveyed to this patient due to the increased need for bed rest, aspirin should not be encouraged as a means to prevent DVT.

In which way does nutrition deficiency increase patient surgical risk? A. Interferes with anesthesia induction B. Increases risk of poor wound healing C. Increases risk for respiratory depression D. Increases risk of fluid and electrolyte imbalance

B. Vitamin K deficiencies can contribute to poor wound healing, increasing surgical risk. Option A is incorrect because Antiseizure medications, not nutritional deficiencies, interfere with anesthesia during induction and during surgery. Option C is incorrect because Tranquilizers, not nutritional deficiencies, increase the risk for respiratory depression during surgery. Option D is incorrect because Diuretics, not nutritional deficiencies, increase the risk for fluid and electrolyte imbalance.

What does witnessing a surgical consent form mean? A. The patient understood the procedure. B. The correct patient signed the form. C. The patient was mentally sound. D. The form was completed correctly.

B. Witnessing a surgical consent means that the preoperative nurse verified the correct identity of the patient, and then observed the correct patient signed the form. Option A is incorrect because This is not what witnessing a surgical consent form means. The only way patient understanding of procedures can be verified is by asking them to verbalize understanding of procedures. Option C is incorrect because This is not what witnessing a surgical consent form means. This is a requirement for patients who sign surgical consent forms. The surgeon is responsible for ensuring patients are mentally sound when obtaining informed consent. Option D is incorrect because This is not what witnessing a surgical consent form means. However, it is the preoperative nurse's responsibility to verify that consent forms are completed correctly.

Which nursing diagnosis represents an actual intraoperative nursing diagnosis? A. Deficient Knowledge related to preoperative procedures B. Ineffective Breathing Pattern related to effects of anesthesia C. Risk for Perioperative Positioning Injury with Risk Factors of improper Positioning During Surgery D. Risk for Ineffective Breathing Pattern with Risk Factors of Diminished Lung/Chest Wall Expansion

B. neffective Breathing Pattern related to effects of anesthesia is an actual intraoperative nursing diagnosis. Actual nursing diagnoses apply when the problem or condition actually exists. Option A is incorrect because Deficient Knowledge related to preoperative procedures is an actual preoperative, not intraoperative, nursing diagnosis. Option C is incorrect because Risk for Perioperative Positioning Injury with Risk Factors of Improper Positioning During Surgery is a risk intraoperative nursing diagnosis and not an actual intraoperative nursing diagnosis. Option D is incorrect because Risk for Ineffective Breathing Pattern with Risk Factors of Diminished Lung/Chest Wall Expansion is a risk intraoperative nursing diagnosis and not an actual intraoperative nursing diagnosis.

Mr. Williams is a 53-year-old male who was recently diagnosed with non-small cell lung cancer. He will start treatment with gefitinib. Mr. Williams has never been ill before and is quite nervous about starting treatment. He also seems to be having difficulty coping with his diagnosis. His wife is available for teaching purposes, as Mr. Williams is not able to fully grasp the details of his treatment regimen. His spouse, Mrs. Williams, is very supportive and involved and attends all clinic appointments with her husband. Mr. Williams has been taking gefitinib 250 mg once daily for several weeks and has experienced intermittent diarrhea. The nurse should advise Mr. Williams to seek immediate medical attention if which condition occurs? A. Alopecia B. Chest pain C. Severe diarrhea D. An acne-like rash

B. A patient taking gefitinib should seek immediate medical attention if chest pain occurs. Option A is incorrect because this is a common occurrence with gefitinib. Option C is incorrect because this is not an emergency but could require a dose adjustment. Option D is incorrect because this is a common adverse effect.

How do oncogenes affect cancer development? A. Oncogenes are cancer-causing agents. B. Oncogenes have the potential to change a normal cell to a malignant one. C. Oncogenes are part of the surveillance system that recognizes abnormal cellular development. D. Oncogenes are a mutation in the cellular structure.

B. Oncogenes do have the potential to change a normal cell to a malignant one. Option A is incorrect because Carcinogens, not oncogenes, are cancer-causing agents. Option C is incorrect because The immune system, not oncogenes, works as a surveillance system recognizing normal and abnormal cells. Option D is incorrect because Oncogenes are not abnormal genes. A mutation in the cell's genetic structure is the first phase of cancer development.

Which strategy will the nurse teach the patient to reduce the incidence of cancer? A. "Be sure to get a colonoscopy every 10 years." B. "It's important that you connect with a support group as you are trying to stop smoking." C. "You do need to have a clinical breast exam every year, but be familiar with your breast tissue." D. "Tell the health care provider if you notice any bleeding in your stool."

B. Smoking is a known carcinogen. Smoking cessation can reduce the chance that cancer will ever develop (incidence). Connecting with a support group is an important part of meeting the needs of the patient trying to stop smoking. Option A is incorrect because A colonoscopy is an important screening tool. Screening tools do not reduce the incidence of cancer; rather they serve to identify cancer earlier, when cure is more likely. Option C is incorrect because Evidence about the timing of breast exams is mixed. The current goal is for patients to be familiar with their breast tissue. However, this is a form of screening. Screening tools do not reduce the incidence of cancer, rather they serve to identify cancer earlier, when cure is more likely. Option D is incorrect because Blood in the stool can be an indicator for many health concerns, including cancer. Testing for blood in stool (hemoccult testing) is a screening method. Screening tools do not reduce the incidence of cancer; rather they serve to identify cancer earlier, when cure is more likely.

Which nursing statement about the clinical manifestations of cancer is appropriate? A. "All cancer causes symptoms." B. "Symptoms of cancer can vary widely." C. "Moles are rarely the source of cancer." D. "Recurrent indigestion is not associated with cancer."

B. Symptoms of cancer vary widely and are often associated with the type of cancer. Option A is incorrect because Some cancer is asymptomatic and is found through routine wellness exams. Option C is incorrect because Moles are often associated with skin cancer, especially when they change shape, color, or border. Option D is incorrect because Recurrent indigestion or difficulty swallowing is a warning sign of cancer.

Why is important to encourage patients taking anticancer drugs to take the medications with fluids (at least 240 mL) and avoid dehydration? A. Adequate fluid intake reduces drowsiness. B. Adequate fluid intake reduces gastric irritation. C. Adequate fluid intake facilitates metabolism of anticancer drugs. D. Adequate fluid intake facilitates increased urination to reduce toxicity.

B. Taking anticancer drugs with fluids and maintaining adequate hydration minimizes abdominal symptoms associated with anticancer medications. Option A is incorrect because Drowsiness is associated with neurological stimulation and is not a common side effect of anticancer medications. Option C is incorrect because Anticancer drugs are primarily metabolized by the liver. Option D is incorrect because Anticancer drugs can be excreted in the feces and through the kidneys when there is adequate renal and GI function.

The nurse is reviewing orders for a patient with thalassemia minor. There is an order for 2 units of packed red blood cells (PRBCs). Which action should the nurse take next? A. Check vital signs. B. Contact the health care provider. C. Check for current blood type and cross. D. Ask another nurse to verify the unit of blood.

B. Thalassemia minor does not require treatment because the body adapts to the reduction of normal hemoglobin. Therefore the nurse should contact the health care provider and ask about the order for 2 units of PRBCs and clarify the need for this treatment if the patient has thalassemia minor. Option A is incorrect because Although checking patient vital signs is important, this is not the action the nurse should take next after seeing the order for 2 units of PRBCs for a patient with thalassemia minor. Option C is incorrect because Although verifying the correct blood type is important, this is not the action the nurse should take next after seeing the order for 2 units of PRBCs for a patient with thalassemia minor. Option D is incorrect because Although verifying the correct unit of PRBCs is important, this is not the action the nurse should take next after seeing the order for 2 units of PRBCs for a patient with thalassemia minor.

Which individual or group is primarily responsible for assessing and maintaining patient safety throughout the intraoperative phase of surgery? A. Surgeon B. Surgical team C. Anesthesiologist D. Circulating nurse

B. The surgical team as a whole is responsible for assessing and maintaining patient safety throughout the intraoperative phase of surgery. Option A is incorrect because The surgeon is responsible for the patient's surgical procedure during the intraoperative phase of surgery, but is not the one most responsible for assessing and maintaining patient safety. Option C is incorrect because The anesthesiologist is responsible for the patient's airway and anesthesia during the intraoperative phase of surgery, but is not the one most responsible for assessing or maintaining patient safety. Option D is incorrect because The circulating nurse is responsible for many aspects of patient safety during the intraoperative phase of surgery, but is not the one most responsible for assessing and maintaining patient safety.

The nurse is planning care for a patient whose nursing diagnosis is Decreased cardiac output related to electrolyte imbalance. The NOC for this nursing diagnosis is Cardiac pump effectiveness. Which indicators should the nurse monitor to determine the effectiveness of the current plan of care? Select all that apply. A. Apical heart rate and rhythm B. Blood pressure C. Heart sounds D. Serum potassium E. Nutrient intake

B. and C. Blood pressure is an indicator used by the nurse to determine the effectiveness of the plan of care to address the NOC of Cardiac pump effectiveness. Heart sounds is an indicator used by the nurse to determine the effectiveness of the plan of care to address the NOC of Cardiac pump effectiveness. Option A is incorrect because Apical heart rate and rhythm is an indicator used by the nurse to determine the effectiveness of the plan of care for the NOC of Electrolyte and acid-base balance, not of Cardiac pump effectiveness. Option D is incorrect because Serum potassium is an indicator used by the nurse to determine the effectiveness of the plan of care for the NOC of Electrolyte and acid-base balance, not of Cardiac pump effectiveness. Option E is incorrect because Nutrient intake is an indicator used by the nurse to determine the effectiveness of the NOC of Nutritional status: nutrient intake, not of Cardiac pump effectiveness.

Which team members would the nurse collaborate with about a patient's impaired physical mobility following surgery? Select all that apply. A. Social worker B. Home care nurse C. Physical therapist D. Discharge planner E. Respiratory therapist

B. and C. The nurse would collaborate with the home care nurse prior to the patient's discharge to home. Patients with impaired physical mobility generally need continued care after they are discharged from the hospital following surgery. The physical therapist and nurse would collaborate about the patient's impaired physical mobility following surgery. The physical therapist would evaluate the patient for safe transition to home after surgery and teach the patient the correct use of assistive devices such as crutches or walkers. Option A is incorrect because The social worker would provide resources for continuation of care after the patient is discharged, but would not collaborate with the nurse or patient in regard to the patient's impaired physical mobility following surgery. Option D is incorrect because A discharge planner, if available, would facilitate patient discharge plans but would not collaborate with the nurse or patient in regard to the patient's impaired physical mobility following surgery. Option E is incorrect because The respiratory therapist would be involved in the postoperative care of patients with respiratory complications, but would not collaborate with the nurse about patients who have impaired mobility following surgery.

The nurse is providing education to a patient who is diagnosed with osteoporosis who asks, "Is there anything I can take over-the-counter to treat this condition?" Which supplements should the nurse include in the response? Select all that apply. A. Potassium B. Calcium C. Magnesium D. Glucose E. Sodium

B., C. Calcium provides the building blocks for bones and teeth. Therefore, this should be included in the teaching session with the patient. Magnesium helps maintain blood calcium levels and is incorporated into bone structure. If the patient does not have much dietary magnesium intake and has normal renal function, this could be included in the teaching session. Option A is incorrect because Potassium is not a building block for bones nor does it help to maintain bone structure. Therefore, this should not be included in the teaching session with the patient. Option D is incorrect because Glucose is not a building block for bones nor does it help to maintain bone structure. Therefore, this should not be included in the teaching session with the patient. Option E is incorrect because Sodium is not a building block for bones nor does it work with calcium to maintain bone structure. Sodium can increase blood volume and raise blood pressure. Therefore, it should not be included in the teaching session.

A nurse is caring for a young adult female patient with thrombocytopenia. Which statements about the patient's menstrual cycle should the nurse include during patient education? Select all that apply. A. Discuss with the patient the benefits of using tampons. B. Teach the patient about the importance of avoiding tampons. C. Encourage the patient to use pads and count the number of pads used. D. Explain to the patient why it is normal to have missed periods with thrombocytopenia. E. Encourage the patient to go on contraceptive medication since their periods will inevitably be irregular.

B., C. Encouraging the patient to use pads instead of tampons will be helpful for monitoring blood loss. If the patient is using a large number of pads, then she should be encouraged to contact the health care provider. Encouraging the patient to use pads will be helpful for monitoring blood loss. If the patient is using a large number of pads, then she should be encouraged to contact the health care provider. Option A is incorrect because Discussing the benefits of using tampons should not be a part of the patient teaching plan. The plan should include a way that blood loss can be monitored during the menstrual cycle. Option D is incorrect because Patients with thrombocytopenia will not be presenting with missed periods, so this would not be appropriate advice for the patient. Option E is incorrect because Encouraging the patient to go on contraceptive pills will not be a part of the teaching plan. The plan should include a way to monitor the menstrual blood flow.

Which are the potential causes of phosphate moving from the extracellular to the intracellular space, resulting in hypophosphatemia? Select all that apply. A. Cellular injury from crush syndrome B. Respiratory alkalosis C. Hyperglycemia D. Renal insufficiency E. Hypoventilation

B., C. Respiratory alkalosis causes phosphate to move from the extracellular to the intracellular space. Hyperglycemia causes phosphate to move from the extracellular to the intracellular space. Option A is incorrect because Cellular injury does not cause phosphate to move from the extracellular to the intracellular space. Option D is incorrect because Renal insufficiency does not cause phosphate to move from the extracellular to the intracellular space. Option E is incorrect because Hyperventilation, not hypoventilation, causes phosphate to move from the extracellular to the intracellular space.

Which surgical procedures are classified as major surgery? Select all that apply. A. Facial mole removal B. Exploratory laparotomy C. Mastectomy (breast removal) D. Cholecystectomy (gallbladder removal) E. Breast biopsy

B., C., D. An exploratory laparotomy involves opening the abdomen or using a laparoscope to look inside the abdomen. It requires anesthesia and respiratory assistance. There is high risk to the patient, making this a major, not minor, surgery. A mastectomy requires anesthesia and respiratory assistance. There is high risk to the patient, making this a major, not minor, surgery. A cholecystectomy requires anesthesia and respiratory assistance. There is high risk to the patient, making this a major, not minor, surgery. Options A and E are incorrect because Facial mole removal and a breast biopsy require little to no anesthesia or respiratory assistance. There is minimal risk to the patient, which makes this type of procedure a minor surgery.

Which surgical procedures are commonly performed in an ambulatory care setting? Select all that apply. A. Mastectomy B. Cataract C. Lesion removal D. Endoscopy E. Bowel resection

B., C., D. Cataract surgery is commonly performed in ambulatory care settings or specialized eye surgery centers. Patients return home immediately following the surgery. The removal of lesions is considered plastic surgery. Plastic surgery centers are specialized ambulatory surgery centers. Patients undergoing plastic surgery return home immediately after surgery. Endoscopic procedures are typically performed in ambulatory care settings. Patients return home after they are fully awake from medications administered prior to the procedure. Option A is incorrect because A mastectomy is major surgery that can result in significant blood loss. A postoperative drain is required and patients are admitted to the nursing unit following surgery. This surgery is not performed in the ambulatory care setting. Option E is incorrect because A bowel resection is a complex, major surgery. Patients are admitted to the nursing unit following surgery. This surgery is not performed in the ambulatory care setting.

Which clinical manifestations should the nurse anticipate when assessing a patient who is diagnosed with hypernatremia? Select all that apply. A. Hyperactive deep tendon reflexes B. Confusion C. Thirst D. Lethargy E. Seizures

B., C., D., E. Confusion is a clinical manifestation the nurse would anticipate for a patient diagnosed with hypernatremia because osmotic shifts cause brain cells to shrivel. Thirst is a clinical manifestation the nurse would anticipate for a patient diagnosed with hypernatremia. Lethargy is a clinical manifestation the nurse would anticipate for a patient diagnosed with hypernatremia. Seizures are a clinical manifestation the nurse would anticipate for a patient diagnosed with severe hypernatremia. Option A is incorrect because Hyperactive deep tendon reflexes are a clinical manifestation the nurse would anticipate for a patient diagnosed with hypocalcemia or hypomagnesemia, not hypernatremia.

Which are the causes of water depletion hypernatremia? Select all that apply. A. Diuretics B. Dehydration C. Hyperthermia D. Emesis E. Diarrhea

B., C., D., E. Dehydration causes water depletion hypernatremia. Insensible fluid loss due to fever, or hyperthermia, is a cause of water depletion hypernatremia. Emesis, or vomiting, causes water depletion hypernatremia. Diarrhea is a cause of water depletion hypernatremia. Option A is incorrect because Diuretics cause hyponatremia, not hypernatremia.

Which risk nursing diagnoses apply to patients during the intraoperative phase of surgery? Select all that apply. A. Risk for Acute Pain B. Risk for Fluid Imbalance C. Risk for Ineffective Tissue Perfusion D. Risk for Ineffective Breathing Pattern E. Risk for Perioperative Positioning Injury

B., C., D., E. Risk for Fluid Imbalance does apply to patients during the intraoperative phase of surgery. It applies to patients who experience blood loss or low fluid volume from NPO status prior to surgery. Risk for Ineffective Tissue Perfusion does apply to patients during the intraoperative phase of surgery. It applies to patients who may experience decreased peripheral circulation or immobility as complications from surgery. Risk for Ineffective Breathing Pattern does apply to patients during the intraoperative phase of surgery. It applies to patients who may experience side effects or breathing difficulties as complications from anesthesia. Risk for Perioperative Positioning Injury does apply to patients during the intraoperative phase of surgery. It applies to patients who may experience pressure injuries as a complication from positioning.

Which patient report may cause the nurse to suspect cancer? Select all that apply. A. A mild headache for 3 days B. Blood in the stool intermittently for 3 months C. Enlargement of the left breast D. Left calf pain following exercise E. Sore on left forearm that is not healed after 2 months F. New onset of chest pain

B., C., E. Unusual bleeding or changes in bowel habits is a symptom associated with cancer. Changes in breast shape and size are symptoms associated with cancer. A sore that does not heal is a symptom associated with cancer. Symptoms of Cancer: (CAUTION) Changes in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickening or lump in breast or other location in body Indigestion or difficulty swallowing Obvious change in a wart or sore Nagging cough or hoarseness that is not resolved Option A is incorrect because a mild headache for only three days would not cause the nurse to suspect cancer. Option D is incorrect because this is most likely associated with exercise, not cancer. Option F is incorrect because this is most likely associated with a myocardial infarction, not cancer.

Which nursing actions are appropriate to avoid the use of restraints in a patient with dementia? Select all that apply. A. Use a bed sheet across the patient to remind him or her to stay in bed. B. Move the patient to a room across from the nurse's station. C. Frequently remind the patient who and where they are. D. Encourage family to adhere to visiting hours with no overnight visitors. E. Ask the patient to fold washcloths at the nurse's station. F. Use gauze to cover the patient's intravenous tubing.

B., C., E., F. Placing the patient where he or she can be directly supervised is an appropriate nursing intervention to avoid the use of restraints. Frequently remind the patient who and where they are.Reorienting the patient frequently can help avoid the use of restraints. Giving the patient a task to keep him or her busy is an appropriate action to avoid the use of restraints. Use gauze to cover the patient's intravenous tubing. Covering tubes and lines so they are out of sight is an appropriate action to avoid the use of restraints. Option A is incorrect because This is a form of restraint. Therefore, this action is inappropriate to avoid the use of restraints in the patient with dementia. Option D is incorrect because For the patient with dementia, family should be encouraged to stay with the patient.

Which questions should the nurse ask when conducting a health history assessment for a patient who has a potassium imbalance? Select all that apply. A. "Do you have lactose intolerance?" B. "Do you take a diuretic, such as furosemide (Lasix)?" C. "Are you experiencing swelling in your feet?" D. "Do you use a salt substitute on your food?" E. "Do you eat canned meats or vegetables often?"

B., D. Furosemide is a potassium-wasting diuretic, which can cause hypokalemia. Overuse of potassium-rich salt substitutes by people who have poor renal excretion may cause hyperkalemia. Option A is incorrect because Lactose intolerance would not cause a potassium imbalance. Option C is incorrect because Edema is not a clinical manifestation of potassium imbalance. Option E is incorrect because Canned meats and vegetables provide a hidden source of sodium not potassium.

The nurse is assessing a patient with hypomagnesemia and anticipates which manifestations? Select all that apply. A. Diaphoresis B. Seizures C. Hypotension D. Nystagmus

B., D. Seizures are a clinical manifestation of hypomagnesemia, which causes increased neuromuscular excitability. Nystagmus is a clinical manifestation of hypomagnesemia, which causes increased neuromuscular excitability. Option A is incorrect because Diaphoresis is a clinical manifestation of hypermagnesemia, not hypomagnesemia. Option C is incorrect because Hypotension is a clinical manifestation of hypermagnesemia, not hypomagnesemia.

Who is included in planning for the entire preoperative phase of surgery? Select all that apply. A. Surgeon B. Preoperative nurse C. Anesthesiologist D. Patient E. Patient family

B., D. The preoperative nurse plans for the entire perioperative period and collaborates with all members of the surgical team for the entire preoperative phase of surgery. The patient is the most important person who is included in planning for the entire preoperative phase of surgery. All other options are included in parts of the preoperative phase of surgery but not the entire phase.

Which nursing actions would the nurse implement for a patient with atelectasis? Select all that apply. A. Suction the airway frequently B. Encourage frequent coughing C. Administer expectorant medications D. Promote use of an incentive spirometer E. Place patient in Fowler or semi-Fowler position

B., D., E. Frequent coughing promotes lung expansion, improves oxygenation, and clears the airway of secretions. The nurse would encourage this action for a patient with atelectasis. Use of an incentive spirometer promotes expansion of the lungs and improves oxygenation. The nurse would implement this action for a patient with atelectasis. Place patient in Fowler or semi-Fowler positionPlacing the patient in the Fowler or semi-Fowler position promotes chest and lung expansion and facilitates oxygenation. The nurse would implement this action for a patient with atelectasis. Option A is incorrect because Suctioning the airway is not indicated for patients with atelectasis and could be harmful because suction is irritating to the patient's mucous membranes. Suctioning should be avoided except in extreme circumstances in which patients cannot clear their airways. Option C is incorrect because Administering expectorant medications is not indicated for patients with atelectasis. Expectorants are prescribed for patients with pneumonia. The nurse would not implement this action for a patient with atelectasis.

Which are the potential causes of hypomagnesemia? Select all that apply. A. Excessive intake of antacids containing magnesium B. Loop and thiazide diuretics usage C. TPN with added electrolytes D. Crohn's disease E. Alcohol abuse

B., D., E. Loop and thiazide diuretics lead to excess excretion of magnesium, and consequently, hypomagnesemia. Crohn's disease interferes with the absorption of electrolytes and can lead to hypomagnesemia. Alcohol abuse interferes with the absorption of electrolytes and can lead to hypomagnesemia. Option A is incorrect because Intake of magnesium-based antacids does not result in hypomagnesemia. Option C is incorrect because TPN with added electrolytes does not contribute to hypomagnesemia.

Which health assessment items should the nurse report immediately to the health care provider prior to administering the first dose of imatinib? Select all that apply. A. History of diabetes B. Current breastfeeding C. History of hypertension D. Current antibiotic therapy E. Current dialysis treatment

B., D., E., Imatinib can affect breastfed children of women who take this medication. Patients with active infections should not take imatinib to prevent increased risk of infections. Dialysis patients have renal impairment, which can reduce excretion of imatinib. Option A is incorrect because Patients with diabetes may take imatinib if there are no risks of adverse reactions. Option C is incorrect because Hypertension is not contraindicated with imatinib.

Which teaching will the nurse include regarding skin care following radiation therapy? Select all that apply. A. "You may wash off the markings used to guide the radiation." B. "Use gentle soap to wash the irradiated area." C. "Use a washcloth, not your hand, to wash the area." D. "Do not expose the area to sunlight." E. "Soft clothing is suggested." F. "Do not apply heating pads to the area."

B., D., E., F. Following radiation, wash the area with mild soap daily, using the hand instead of washcloth, which can irritate the tissue. Patients should not expose the irradiated area to sunlight and should protect the area from extremes in temperature. Following radiation, patients should avoid clothing that irritates the skin.Patients should not expose the irradiated area to sunlight and should protect the area from extremes in temperature. Option A is incorrect because Patients should not remove the markings on their skin because these are the guides for the radiation therapy. These markings are used to make sure that radiation is directed at the exact same location with each treatment. Option C is incorrect because Following radiation, wash the area with mild soap daily, using the hand instead of washcloth, which can irritate the tissue.

Mr. Williams is a 53-year-old male who was recently diagnosed with non-small cell lung cancer. He will start treatment with gefitinib. Mr. Williams has never been ill before and is quite nervous about starting treatment. He also seems to be having difficulty coping with his diagnosis. His wife is available for teaching purposes, as Mr. Williams is not able to fully grasp the details of his treatment regimen. His spouse, Mrs. Williams, is very supportive and involved and attends all clinic appointments with her husband. Prior to administering gefitinib, the nurse should obtain which for Mr. Williams? Select all that apply. A. Baseline urinalysis B. Baseline chest x-ray C. Occupational history D. Food and drug allergies E. Baseline skin assessment F. Detailed medication history

B., D., E., F., A baseline chest x-ray is necessary prior to starting gefitinib due to possible pulmonary adverse effects. Assessment of food and drug allergies is necessary prior to starting any medication. A baseline skin assessment is necessary prior to starting gefitinib due to possible dermatological adverse effects. A detailed medication history is necessary to evaluate for drug-drug interactions prior to starting any medication. Option A and C are incorrect because they are not necessary prior to administration of gefitinib.

The circulating nurse is responsible for which assessments during the intraoperative phase of surgery? Select all that apply. A. Vital signs B. Urinary output C. Respiratory status D. Electrocardiogram E. Patient positioning

B., E. The circulating nurse assesses urinary output when the patient has an indwelling catheter in place for long or complicated surgical procedures. Scrubbed personnel have no access to view catheter drainage, and their viewing of it would contaminate the sterile field. The circulating nurse frequently assesses the patient's position during surgery. The patient cannot change positions while anesthetized, but movements of the OR table, surgeon, scrub person, and equipment can cause patient movement. Option A is incorrect because The anesthesiologist or CRNA continually assesses patient vital signs throughout the surgical procedure. This is necessary to balance anesthesia with the patient's hemodynamic status. Option C is incorrect because The anesthesiologist or CRNA continually assesses the patient's respiratory status throughout the surgical procedure. This is necessary to ensure the patient maintains a patent airway. Option D is incorrect because The anesthesiologist or CRNA continually assesses the patient's electrocardiogram throughout the surgical procedure. This is necessary to balance anesthesia with the patient's hemodynamic status.

A patient reports headaches and fatigue related to anemia caused by chronic blood loss that interfere with the ability to prepare meals and perform weekly chores. Which nursing interventions are appropriate to ensure the goals for this patient are met? Select all that apply. A. Monitor liver function B. Help the patient to ambulate in order to minimize energy output C. Educate patient and caregivers on home care if fatigue persists after treatment D. Provide patient teaching on how to increase oral consumption of folic acid E. Provide guidance on modifying activities to build tolerance for activities of daily living

B., E. Increased endurance and ability to perform activities of daily living without significant anemia symptoms are two important goals for the patient with anemia. Assisting with physical activities to minimize patient fatigue is an important nursing intervention. Increased endurance and ability to perform activities of daily living without significant anemia symptoms are two important goals for the patient with anemia. The nurse should provide guidance to the patient on how to modify and prioritize activities of daily living until tolerance is built. Option A is incorrect because Patients with iron deficiency anemia need to have liver function monitored to check for side effects of iron supplements, but this is not necessary for patients with other anemias. Moreover, monitoring liver function does not directly address the goals for a patient experiencing fatigue and headaches when performing daily chores. Option C is incorrect because The nurse should instruct patient and caregiver to notify a primary health care provider if signs and symptoms of fatigue persist, not provide education on appropriate home care. Option D is incorrect because Although a goal for the patient with anemia is that the patient maintains dietary intake that provides minimum daily requirements of nutrients, this patient's anemia is related to chronic blood loss, not dietary deficiency. Patient teaching on increasing oral consumption of folic acid is more appropriate for a patient with folic acid deficiency anemia than anemia from chronic blood loss.

Which health promotion teaching will the nurse include for the older adult patient? Select all that apply. A. "Be sure to get an annual pneumococcal vaccine." B. "See your health care provider at least once a year." C. "Sun exposure for 20 minutes a day is good for you." D. "Eat at least three servings of fruit and vegetables every day." E. "Try to reduce fat intake to no more than 30% of calories." F. "Depression is never a normal part of aging."

B., E., F. The older adult should see the health care provider at least once per year. Fat intake should be reduced to no more than 30% of calories. Depression is never a normal part of aging. Option A is incorrect because Influenza vaccines, not pneumococcal (pneumonia) vaccines, are annual. Option C is incorrect because Sun exposure for 10-15 minutes weekly (not daily) is recommended to enhance Vitamin D. Option D is incorrect because The diet should include at least five servings of fruit and vegetables daily.

Which teaching will the nurse include to promote wellness and reduce risk in the older adult? Select all that apply. A. "Exercising every day is important to decrease the risk of fractures." B. "Annual vision and hearing screening can help prevent accidents." C. "Be sure that you have had a tetanus booster within the last 10 years." D. "You will need one shingles vaccine to protect you." E. "Place a throw rug in the kitchen if you stand for long periods." F. "You need to get a flu shot every year."

B.., C., F. Annual vision and hearing screenings are important in the prevention of accidents for older adults. A tetanus booster is required every 10 years. Older adults are encouraged to get the flu shot yearly. Option A is incorrect because Older adults should be encouraged to exercise regularly 3 to 5 days per week, not every day. Option D is incorrect because The Centers for Disease Control and Prevention (CDC) recommends two shingles vaccines at least 1 year apart for adults 50 and over. Option E is incorrect because Throw rugs should be avoided because they create a fall hazard in the home of the older adult.

A patient will undergo which type of surgical procedure to determine if a tumor is cancerous? A. Ablative B. Palliative C. Diagnostic D. Transplantation

C. A diagnostic surgery is conducted to determine or confirm a diagnosis, such as malignancy. This type of surgery is considered diagnostic. Option A is incorrect because Ablative surgery involves removal of a diseased body part. It is not used to determine if a tumor is cancerous. Option B is incorrect because Palliative surgery is conducted to improve symptoms and/or alleviate pain, not to determine if a tumor is cancerous. Option D is incorrect because Transplantation surgery is performed to replace a dysfunctional body part, not to determine if a tumor is cancerous.

Which cultural factor has the potential for increasing surgical risk? A. Need for strong family support B. Stoic attitude toward pain control C. Disbelief in traditional medications D. Same-gender surgeon requirement

C. A disbelief in traditional medications such as antibiotics or anesthetics definitely has the potential for increasing surgical risk. The surgeon and anesthesiologist will need to be creative to meet the needs of this patient and will have limited options if the patient develops a postoperative infection. Option A is incorrect because People from some cultures have a very strong need for family support. This need can be usually accommodated during the preoperative period and does not increase surgical risk. Option B is incorrect because People from some cultures do not believe in expressing pain or asking for pain medication. This belief might compromise recovery if the pain prevents movement, but does not increase risk during surgery. Option D is incorrect because People from some cultures have a strong belief about the gender of their health care providers. This need can usually be accommodated and does not increase surgical risk.

Which team member would the nurse consult when discharging a patient needing wound care? A. Surgeon B. Social worker C. Home care nurse D. Physical therapist

C. A home care nurse would be able to provide care for a patient needing wound care after discharge to home or another living situation. Option A is incorrect because The surgeon is responsible for deciding the patient can be discharged, but is not involved in organizing the continuation of care once the patient is discharged. Option B is incorrect because A social worker would facilitate the patient's transition to a care facility or the initiation of home care, but would not be directly involved with patients needing wound care. Option D is incorrect because Physical therapists evaluate patients with impaired mobility for the safe transition to home or care, but they do not consult with nurses about patients who need wound care.

Which goal is realistic for a PACU patient complaining of postoperative pain? A. The patient will be free of pain. B. The patient will report reduced pain level. C. The patient will report pain level of 3 or less. D. The patient will decrease complaints of pain.

C. A patient-rated pain level of three or less is a realistic goal for a patient complaining of postoperative pain. Pain is an expected response to surgery, but pain should be managed so that patients report pain that is controlled to allow maximum participation in postoperative activities. Option A is incorrect because The complete absence of pain is not a realistic goal for a postoperative patient. Pain is an expected response to surgery. Option B is incorrect because Reporting of a reduced pain level is not a measurable goal; therefore, it is not a realistic goal for a postoperative patient. For example, decreasing a patient's pain level from 10 to 9 is not effective pain control. Option D is incorrect because Decreasing pain complaints is not the objective of pain-related patient goals. The objective is achieving satisfactory pain control for the patient.

Which surgery takes priority based on degree of urgency? A. Breast biopsy B. Lasik eye surgery C. Perforated appendix D. Bone-marrow transplant

C. A perforated appendix presents an immediate threat to life from infection and peritonitis. Based on degree of urgency this surgery takes priority because it requires emergency surgery. Option A is incorrect because A breast biopsy is considered a minor surgery, with no immediate threat to life. Based on degree of urgency, it does not require emergency surgery and does not take priority. Option B is incorrect because Lasik eye surgery is considered an elective surgery for a condition which is not-life threatening. It can be planned in advance. Based on degree of urgency, it does not require emergency surgery and does not take priority. Option D is incorrect because A bone-marrow transplant is necessary to save the life of the patient, but is performed when the condition is not immediately life-threatening. Based on degree of urgency, it does not require emergency surgery and does not take priority. However, it is urgent.

Which histologic grade is associated with severe dysplasia? A. Grade 1 B. Grade 2 C. Grade 3 D. Grade 4

C. Grade 3 cells are poorly differentiated and have very little normal cellular appearance, demonstrating severe dysplasia. Option A is incorrect because Grade 1 cells are well differentiated and demonstrate mild dysplasia. Option B is incorrect because Grade 2 cells are moderately differentiated and demonstrate moderate dysplasia. Option D is incorrect because Grade 4 cells are immature with no normal cellular appearance, demonstrating anaplasia.

The nurse should expect that a patient with a serum potassium concentration of 3.1 mEq/L would have which clinical manifestation? A. Hyperactive deep tendon reflexes B. Confusion C. Decreased bowel sounds D. Decreased heart rate

C. A serum potassium concentration of 3.1 mEq/L indicates hypokalemia. Decreased bowel sounds are associated with hypokalemia because intestinal smooth muscle becomes weak. Normal serum potassium levels are 3.5 to 5 mEq/L. Option A is incorrect because A serum potassium concentration of 3.1 mEq/L indicates hypokalemia. Hyperactive deep tendon reflexes are associated with hypocalcemia and hypomagnesemia, not hypokalemia. Option B is incorrect because A serum potassium concentration of 3.1 mEq/L indicates hypokalemia. Confusion is a clinical manifestation associated with hyponatremia, hypernatremia, or hypercalcemia, not hypokalemia. Option D is incorrect because A serum potassium concentration of 3.1 mEq/L indicates hypokalemia. A decreased heart rate, or bradycardia, is a clinical manifestation associated with hyperkalemia, not hypokalemia.

What information does a previous surgical history provide about the patient's current surgical risk? A. Presence of systemic diseases or disorders B. Capacity for maintaining electrolyte balance C. Risk for surgical and anesthesia complications D. Potential for medication or substance interactions

C. A surgical history can help determine a patient's risk for surgical and anesthetic complications. Patients who experienced complications with one surgery are likely to experience the same problem again unless different medications, anesthesia, and techniques are used.

A patient has developed a clot in a coronary artery and the heart muscle cells did not make enough ATP. When a nursing student asks, what should the nurse explain about the effect of a poor ATP supply on electrolyte movement? A. There should be no effect because electrolytes move in and out of cells by facilitated diffusion. B. Diffusion of electrolytes will be impaired but active transport should continue normally. C. Active transport will be impaired, so the sodium-potassium pumps will not work normally. D. There should be no effect because electrolytes do not move once they are inside cells.

C. Active transport requires ATP. Sodium-potassium pumps move sodium and potassium across cell membranes by active transport. This process will be impaired with low ATP. Option A is incorrect because Active transport also moves electrolytes across cell membranes and requires ATP for normal function. Active transport will be impaired with low ATP. Option B is incorrect because Diffusion does not require ATP but active transport does require ATP. Active transport will be impaired with low ATP. Option D is incorrect because Electrolytes move across cell membranes by active transport, which requires ATP. Active transport will be impaired with low ATP.

Which nursing action is appropriate to improve nutrition for a patient with cancer? A. Provide large meals so the patient can eat more. B. Avoid the use of high protein shakes. C. Use alternative seasonings for food. D. Encourage nothing by mouth until chemotherapy is complete.

C. Alternative seasonings and spices (as long as they do not irritate the oral cavity) may be helpful if the patient has dysgeusia. Option A is incorrect because Provide small, frequent, high-calorie, high-protein foods because small meals may be tolerated better than a large meal. Option B is incorrect because Most patients with cancer require nutritional supplements, and if malnutrition becomes a concern, then enteral or parenteral nutrition may be used. Option D is incorrect because Unless the patient is actively vomiting, intake should be encouraged because dehydration and malnutrition are significant risks for patients with cancer.

Which test should the nurse anticipate for a patient with hyperkalemia? A. Urine specific gravity B. Serum calcium C. Electrocardiogram D. Urine osmolality

C. An electrocardiogram (ECG) should be anticipated for a patient with hyperkalemia in order to diagnose and monitor cardiac dysrhythmias. Option A is incorrect because Urine specific gravity is a laboratory test used to assess and monitor sodium imbalances, not hyperkalemia. Option B is incorrect because A serum calcium concentration is used to assess and monitor patients who are experiencing a calcium imbalance such as hypocalcemia and hypercalcemia. This laboratory test would not be useful to monitor a patient with hyperkalemia who is experiencing cardiac dysrhythmia. Option D is incorrect because Urine osmolality is a laboratory test that might be used for a patient experiencing sodium imbalances, not hyperkalemia.

A patient with a B12 deficiency asks the nurse how long B12 injections must be taken. Which is the best response by the nurse? A. "It is a one-time injection." B. "Until your hematocrit level returns to normal." C. "You will need to take injections for the rest of your life." D. "Weekly for a month and then they will recheck your blood levels."

C. B12 injections are given daily for two weeks, and then weekly until the hematocrit level returns to normal, and then typically monthly for life. Option A is incorrect because B12 injections are not a one-time treatment and stating so would not be an appropriate response by the nurse. Option B is incorrect because Even once the hematocrit level returns to normal, injections are typically needed after that. This is not an appropriate response from the nurse Option D is incorrect because B12 injections are given daily for two weeks, and then weekly until the hematocrit level returns to normal. The remaining injections do not depend on rechecking levels, so this is not an appropriate response from the nurse.

What is the mechanism of action of anticancer drugs? A. Anticancer cells inhibit metastasis of abnormal cells. B. Anticancer drugs inhibit proliferation of abnormal cells. C. Anticancer drugs interfere with cell replication and cause cell death. D. Anticancer drugs interfere with bone marrow production of stem cells.

C. By interfering with cell replication at various phases of the cell cycle, anticancer drugs allow destruction of old cells to occur at a faster rate than replication of new cells. Option A is incorrect because Anticancer drugs primarily block cell replication and may not prevent metastasis of existing cancer cells. Option B is incorrect because The actions of many anticancer drugs are not cell specific. Option D is incorrect because although Anticancer drugs may suppress bone marrow activity, but they are not intended to do so.

Which lab value is consistently decreased in all types of anemias? A. MCV B. Folate C. Hemoglobin D. Reticulocytes

C. Hemoglobin is decreased in all types of anemia due to the decrease in red blood cells. Option A is incorrect because MCV can be normal, decreased, or increased dependent on the type of anemia. Option B is incorrect becaue Folate is only decreased in folic acid deficiency anemia. Option D is incorrect because Reticulocytes can be normal, decreased, or increased dependent on the type of anemia.

Which electrolyte supplement is most important for the nurse to include in the teaching session for a patient who is recovering from a broken bone? A. Sodium B. Potassium C. Calcium D. Magnesium

C. Calcium provides the building blocks for bones and teeth. Therefore, the nurse should advise calcium supplement for a patient who is recovering from a broken bone. Option A is incorrect because Sodium plays a role in maintaining blood pressure and blood volume. It should not be recommended for a patient who is recovering from a broken bone. Option B is incorrect because Potassium should not be recommended for a patient who is recovering from a broken bone. Potassium plays a role in the electrical conduction of the heart, not in broken bone recovery. Option D is incorrect because While magnesium does play a role in maintaining calcium levels in the body and is important for bone health, it is not the most important electrolyte supplement to recommend for a patient who is recovering from a broken bone.

Which teaching regarding secondary screening measures will the nurse include? A. Annual mammography beginning at 20 years of age B. Yearly clinical breast exam for all adult women C. Colonoscopy at age 50 D. Annual Pap and HPV test beginning at 21 years of age

C. Colonoscopy, a secondary screening method, is suggested for all patients at age 50 and then every 10 years. Option A is incorrect because Women should be offered the choice of annual mammography beginning at age 40, and annual mammography is recommended for women 45 to 54 years of age. Annual or biennial mammography is suggested for women over 55 years. Annual mammography beginning at 20 years of age is not recommended. Option B is incorrect because While clinical breast exams are still quite common, evidence indicates that this exam does not lower the rate of dying from breast cancer. Therefore, yearly clinical breast exams are not required. Option D is incorrect because All women should begin cervical screening at age 21 with a Pap test every 3 years. At age 30, the Pap test should be combined with an HPV test and conducted every 5 years. Women at high risk should be screened more often. Both tests are not warranted annually.

Lasik eye surgery that corrects vision and eliminates the need for eye glasses is which type of procedure? A. Ablative B. Diagnostic C. Constructive D. Reconstructive

C. Constructive surgery restores body function that has been lost or reduced. Lasik eye surgery to correct vision is constructive surgery. Option A is incorrect because Ablative surgery is conducted to remove a diseased body part but does not restore function that has been lost or reduced. Option B is incorrect because A diagnostic surgery is conducted to determine or confirm a diagnosis, but does not restore function that has been lost or reduced. Option D is incorrect because Reconstructive or restorative surgery restores function and/or appearance of traumatized tissue but does not restore a function that has been lost or reduced such as vision.

The nurse is explaining why deferasirox for thalassemia is being added to a patient's oral medication regimen. Which patient statement demonstrates the patient's need for further education? A. "Deferasirox doesn't replace my blood transfusions." B. "If deferasirox works, it will reduce iron in my system." C. "Deferasirox will prevent me from having frequent crises." D. "I will not see the complications from repetitive blood transfusions."

C. Deferasirox is a medication that affects iron in the blood and should be given simultaneously with blood transfusions. Hydroxyurea will prevent a patient from having sickle cell crises. The patient has confused the effects of the two drugs, which indicates a need for further patient education. Option A is incorrect because Deferasirox is given along with blood transfusions and does not replace them. This patient statement is correct and does not demonstrate the need for further patient education. Option B is incorrect because Deferasirox will reduce iron in the patient's system. This patient statement is correct and does not demonstrate the need for further patient education. Option D is incorrect because Deferasirox will reduce the iron overload caused by frequent blood transfusions and prevent complications from long-term transfusion therapy. This patient statement is correct and does not demonstrate the need for further patient education.

Which type of anesthesia places patients in an altered state of consciousness but allows them to respond to verbal cues and maintain their own airways? A. Topical anesthesia B. General anesthesia C. Moderate sedation D. Medullary paralysis

C. During moderate sedation, patients are placed in an altered state of consciousness, but they are able to respond to verbal cues and maintain their own airways. Option A is incorrect because Topical anesthesia is used to decrease discomfort in the localized site of surgery. Patients are able to respond to verbal cues and maintain their own airways, but they do not have an altered state of consciousness. Option B is incorrect because During general anesthesia, patients are placed in a drug-induced coma. They are not able to respond to verbal cues or maintain their own airways. Option D is incorrect because Medullary paralysis is the fourth stage of general anesthesia. This represents anesthesia overdose. If it is not rapidly reversed, death occurs.

Which type of surgery will a patient undergo for cataract removal? A. Major B. Urgent C. Elective D. Emergency

C. Elective surgery is a class of surgery performed when the condition does not threaten the life of the patient. Since cataract removal is for improving the patient's health and cataracts do not threaten the patient's life, the surgery can be scheduled at the convenience of the patient and surgeon. Option A is incorrect because this procedure does not need anesthesia or respiratory assistance. Option B is incorrect because Urgent surgeries are performed when there is a non-immediate threat to the life of the patient. Cataracts pose no threat to the life of the patient; this is not an urgent surgery. Option D is incorrect because Emergency surgeries take place when there is an immediate threat to the life of the patient. Cataracts do not pose any threat to the life of the patient; this is not an emergency surgery.

Which nursing action addresses the patient's anxiety during the intraoperative phase of surgery? A. Asking the patient to take deep breaths prior to anesthesia induction B. Reassuring the patient that there is no need to be anxious before surgery C. Explaining to the patient what to expect after being moved to the OR table D. Requesting the patient to remain quiet with eyes closed until he or she is sleepy

C. Explaining to the patient what can be expected after he or she moves to the OR table eliminates surprises and fear of the unknown. These actions reduce anxiety during this phase of surgery. Option A is incorrect because This action assists the anesthesiologist's role during anesthesia induction, but it does not address patient anxiety. Option B is incorrect because The action of reassuring the patient that there is no need to be anxious fails to acknowledge the patient's anxiety and does not address the patient's anxiety prior to surgery. Option D is incorrect because Requesting the patient to remain quiet with eyes closed until he or she feels sleepy fails to acknowledge the patient's anxiety and does not address the patient's anxiety prior to surgery.

A health care provider tells the patient that she has anemia because her red blood cells are being destroyed faster than they can be made. The patient asks the nurse for more information on the cause of her condition. The nurse provides information to the patient on which type of anemia? A. Thalassemia B. Acute anemia C. Hemolytic anemia D. B12 deficiency anemia

C. Hemolytic anemias are due to an increase in the destruction of red blood cells resulting in a lower red blood cell count. Option A is incorrect because thalassemia is due to a decreased production of red blood cells, not to an increase in the destruction of red blood cells. Option B is incorrect because Acute anemia is due to acute blood loss related to trauma or rupture of a blood vessel, not to an increase in the destruction of red blood cells. Option D is incorrect because B12 deficiency results in a decreased production of red blood cells, not an increase in the destruction of red blood cells.

Which action of herbal medications can increase a patient's surgical risk? A. Increase risk of blood clots B. Stimulate respiratory secretions C. Potentiate anesthetic agent effects D. Contribute to electrolyte imbalance

C. Herbals such as kava, St. John's wort, and valerian may potentiate anesthetic agents and prolong their effects. Option A is incorrect because Several herbals, such as ginkgo biloba, increase the risk for bleeding, but increased risk for blood clotting is not commonly associated with herbal medications. Option B is incorrect because Herbals can have numerous effects that increase the patient's surgical risk, but the stimulation of respiratory secretions is not a commonly encountered adverse reaction. Option D is incorrect because Herbals can have numerous effects that increase the patient's surgical risk, but electrolyte imbalance is not a commonly encountered adverse reaction.

Which nursing intervention has the highest priority for the nurse caring for a patient experiencing a sickle cell crisis? A. Monitor the patient's appetite. B. Provide frequent rest periods. C. Administer intravenous fluids. D. Instruct the patient about coping methods.

C. Hydration is important to decrease blood viscosity and prevent renal failure. This is the highest priority at this point in time. Option A is incorrect because A patient in sickle cell crisis will have a decreased appetite, but it is not monitoring the patient's appetite is the highest priority at this time. Option B is incorrect because It is important for the nurse to provide the patient adequate time to rest; however, the patient is in sickle cell crisis now, and rest is not the highest priority at this time. Option D is incorrect because the nurse should teach the patient about coping methods, but it is not the highest priority when a patient is in sickle cell crisis.

The nurse is providing care to a patient who is diagnosed with end-stage renal disease. Which clinical manifestation assessed by the nurse indicates the patient is experiencing hyperphosphatemia? A. Decreased blood pressure B. Anorexia C. Irritated and itchy eyes D. Confusion

C. In patients who have end-stage renal disease, hyperphosphatemia will cause calcium phosphate crystals to form in soft tissues, causing itching or irritated eyes. Option A is incorrect because Decreased blood pressure, or hypotension, is a clinical manifestation of hypophosphatemia, not hyperphosphatemia. Option B is incorrect because Anorexia is a clinical manifestation of hypophosphatemia, not hyperphosphatemia. Option D is incorrect because Confusion is a clinical manifestation of hypophosphatemia, not hyperphosphatemia.

Which nursing diagnosis would the nurse select following surgical drape removal if assessment reveals lower extremity coolness and pallor? A. Risk for Nerve Damage B. Impaired Skin Integrity C. Ineffective Tissue Perfusion D. Risk for Ineffective Tissue Perfusion

C. Ineffective Tissue Perfusion is the nursing diagnosis the nurse would select for the patient whose assessment reveals lower extremity coolness and pallor following postoperative surgical drape removal. Option A is incorrect because Risk for Nerve Damage is not the correct nursing diagnosis because the patient's data does not suggest nerve damage or the risk factors for nerve damage. Option B is incorrect because Impaired Skin Integrity does not apply to the patient because there is no evidence such as broken or torn skin to support this nursing diagnosis. Option D is incorrect because Risk for Ineffective Tissue Perfusion does not apply to this patient. The patient's data does not support the presence of risk factors for tissue perfusion.

Which actual intraoperative nursing diagnosis is stated correctly? A. Nausea related to effects from anesthesia B. Pain related to tissue injury at the surgical site C. Injury from Equipment related to failure of OR table D. Risk of Ineffective Tissue Perfusion with Risk Factor of Immobility

C. Injury from Equipment is an actual nursing diagnosis for the intraoperative patient. It is correctly stated. Option A is incorrect because Nausea is an actual nursing diagnosis. However, it applies to the postoperative patient, not the intraoperative patient. Option B is incorrect because pain related to tissue injury is an actual nursing diagnosis and is stated correctly. However, it applies to the postoperative patient, not the intraoperative patient. Option D is incorrect because Risk of Ineffective Tissue Perfusion is a risk nursing diagnosis, not an actual diagnosis.

What is the focus during the postoperative phase of surgery? A. Assessment for medical risk factors B. Admission of patient to the outpatient unit C. Intervention for problems after the procedure D. Protection of patient privacy during the procedure

C. Intervention for problems after the procedure takes place and is the focus of the nurse and anesthesiologist (as needed) during the postoperative phase of surgery. Option A is incorrect because Assessment for medical risk factors takes place during the preoperative phase of surgery, not the postoperative phase of surgery. Option B is incorrect because Admission of the patient to the outpatient unit takes place during the preoperative, not the postoperative, phase of surgery if the surgery is taking place in an outpatient surgical setting. Option D is incorrect because Protection of patient privacy during the procedure is the focus of all members of the surgical team during the intraoperative phase of surgery.

The nurse should expect that a patient with severe hypocalcemia would have which clinical manifestation? A. Stupor B. Personality changes C. Laryngospasm D. Constipation

C. Laryngospasm is a clinical manifestation of severe hypocalcemia. All other options are clinical manifestations of hypercalcemia.

Which finding in the patient's medical history necessitates the nurse to provide education related to hypermagnesemia? A. Crohn's disease B. Alcoholism C. Leukemia D. Diabetic ketoacidosis

C. Leukemia is one cause associated with the development of hypermagnesemia. Option A is incorrect because Crohn's disease is a cause for hypomagnesemia, not hypermagnesemia. Option B is incorrect because Alcoholism is a cause for hypomagnesemia, not hypermagnesemia. Option D is incorrect because Diabetic ketoacidosis is a cause for hypomagnesemia, not hypermagnesemia.

How do monoclonal antibodies halt proliferation of cells? A. They directly inhibit the action of CYP34. B. They directly inhibit the action of EGRF tyrosine kinase. C. They bind with and prevent activation of EGFR tyrosine kinase. D. They bind with and prevent activation of BCR-ABL tyrosine kinase.

C. Monoclonal antibodies bind with EGFR tyrosine kinase receptors to prevent activation of EGFR tyrosine kinase and halt uncontrolled proliferation of cells. Option A is incorrect because Monoclonal antibodies are not designed to directly influence the activity of CYP34. Option B is incorrect because Monoclonal antibodies do not act directly on EGFR tyrosine kinase. Option D is incorrect because Monoclonal antibodies do not bind with and prevent activation of BCR-ABL tyrosine kinase.

The hemoglobin level of a patient who has been taking an iron supplement for anemia has returned to normal. The patient asks the nurse if there is a need to keep taking the iron supplement. What is the most appropriate response from the nurse? A. "No. You can stop taking the supplement immediately." B. "You will likely need to take the iron supplement for the rest of your life." C. "You will need to continue the iron supplement for a few months longer." D. "You'll need to have a second normal lab result in a month before you can stop taking the supplement."

C. Once hemoglobin levels return to normal, iron supplements need to be taken for 2-3 additional months to replenish the body's iron stores. Option A is incorrect because Although the patient's hemoglobin levels have returned to normal, the body's iron stores are not necessarily replenished. Immediate discontinuation of iron is not advised. Moreover, a nurse does not have the prescriptive authority to discontinue a medication. Option B is incorrect because Iron supplements are not typically needed lifelong. Option D is incorrect because A second normal lab result is not typically the criterion for discontinuation of iron supplements.

The nurse is receiving a report on a patient with sickle cell disease being admitted from the emergency department. Which question by the nurse exhibits an awareness of the primary symptom of the disease? A. "Is the patient receiving oxygen?" B. "Has the patient voided yet?" C. "When did the patient last receive pain medications?" D. "What was the last hemoglobin and hematocrit?"

C. Pain is the most common symptom of sickle cell disease. Therefore the nurse should know the last time pain medication was given. Option A is incorrect because Although it is always important for the nurse to know whether any patient is receiving oxygen, this question does not demonstrate awareness of the primary symptom of sickle cell disease. Option B is incorrect because Although it may be important to know whether a patient has voided to measure accurate input and output, this question does not demonstrate awareness of the primary symptom of sickle cell disease. Option D is incorrect because Although it is important for the nurse to know any laboratory results that have come in, this question does not demonstrate awareness of the primary symptom of sickle cell disease.

Which nursing action may help alleviate relocation stress syndrome in the older adult? A. Encourage the family to move the patient quickly. B. Allow the family to select the patient's room. C. Pair the patient with a buddy in the new environment. D. Provide new bedding and décor for the patient's room.

C. Pairing the patient with a buddy can help ease the transition into the new environment and will help to alleviate relocation stress syndrome. Option A is incorrect because The older adult, when possible, should be involved in the decision and allowed time to process the move. Allowing time in the decision making will help to alleviate relocation stress syndrome. Option B is incorrect because The patient should be encouraged and empowered to make decisions in his or her care, including room selection when possible. Option D is incorrect because It is helpful to bring items that belong to the patient versus all new bedding and décor. Items belonging to the patient that are placed in the new environment can help decrease relocation stress syndrome.

What is the primary objective of palliation therapy? A. To cure cancer B. To allow the patient to live longer C. To enhance quality of life D. To control the cancer

C. Palliation takes place when the goal of care is to relieve symptoms associated with the cancer while maintaining the quality of life as the primary objective. Option A is incorrect because Curative treatment, not palliative therapy, seeks to eradicate and cure the cancer. Option B is incorrect because Palliation takes place when the goal of care is to relieve symptoms associated with the cancer while maintaining the quality (not the quantity) of life as the primary objective. Option D is incorrect because Palliation takes place when the goal of care is to relieve symptoms associated with the cancer (not to control the cancer) while maintaining the quality of life as the primary objective.

Which intraoperative goal is correct for a patient who is at risk for ineffective tissue perfusion? A. Patient will maintain a patent airway. B. Patient will remain hemodynamically stable. C. Patient will demonstrate adequate tissue perfusion. D. Patient will maintain correct position during surgery.

C. Patient will demonstrate adequate tissue perfusion is an appropriate goal for the nursing diagnosis of risk for intraoperative ineffective tissue perfusion. Risk factors are present, but the patient does not have the actual problem. Option A is incorrect because Patient will maintain a patent airway is an appropriate goal for the nursing diagnosis of risk of ineffective breathing pattern. However, a prolonged non-patent airway can affect tissue perfusion if not corrected. Option B is incorrect because Patient will remain hemodynamically stable is an appropriate goal for the nursing diagnosis of imbalanced fluid volume, which compromises patient stability during surgery. Option D is incorrect because Patient will maintain correct position during surgery is an appropriate goal for the nursing diagnosis of risk of perioperative positioning injury. Patient movements can occur during surgery, not by the patient, but from movements of the surgical team and equipment. Patient position is checked frequently during surgery.

The amount of radiation absorbed by the tissue is referred to as what term? A. Teletherapy B. Exposure C. Radiation dose D. Brachytherapy

C. The amount of radiation absorbed by the tissue is the radiation dose. Option A is incorrect because Teletherapy is radiation delivered by an external beam. Option B is incorrect because The amount of radiation delivered to a tissue, not absorbed by the tissue, is the exposure. Option D is incorrect because Brachytherapy is radiation delivered by an internal device or seed.

Which goal would the nurse add to the intraoperative plan of care for a patient at risk for ineffective tissue perfusion? A. Patient's airway will remain patent during surgery. B. Patient will maintain correct position during surgery. C. Patient will remain hemodynamically stable during surgery. D. Patient will remain free from hypothermia throughout surgery.

C. Patient will remain hemodynamically stable during surgery addresses the nursing diagnosis of risk for ineffective tissue perfusion. The nurse would add this goal to the patient's plan of care. Option A is incorrect because Patient's airway will remain patent during surgery addresses the nursing diagnosis of risk of ineffective breathing pattern, not risk for ineffective tissue perfusion. Option B is incorrect because Patient will maintain correct position during surgery addresses the nursing diagnosis of risk of perioperative positioning injury, not risk for ineffective tissue perfusion. Option D is incorrect because The patient will remain free from hypothermia throughout surgery addresses the nursing diagnosis of risk for hypothermia, not risk for ineffective tissue perfusion intraoperatively.

Which goal was most likely derived from a nursing diagnosis and interventions designed to maintain patient cardiovascular normality throughout surgery? A. Patient will remain normothermic throughout surgery. B. Airway will remain clear and patent throughout surgery C. Patient will remain hemodynamically stable during surgery. D. Tissue perfusion will remain intact and stable during surgery.

C. Patient will remain hemodynamically stable is an appropriate goal. It addresses a nursing diagnosis and interventions to maintain patient cardiovascular normality throughout surgery. Option A is incorrect because Patient will remain normothermic is an appropriate goal for a nursing diagnosis and interventions that address risk for imbalanced body temperature. Option B is incorrect because Airway will remain clear and patent is an incomplete patient goal as written, but addresses a nursing diagnosis and interventions for risk of ineffective breathing pattern. Option D is incorrect because Tissue perfusion will remain intact is an incomplete patient goal as written, but addresses a nursing diagnosis and interventions for risk for ineffective tissue perfusion.

What is the rationale for administering extra pain medication to postoperative patients who experience chronic pain? A. Decrease anxiety related to postoperative pain B. Prevent complications from medication withdrawal C. Reduce the likelihood of postoperative complications D. Continue the patient's use of previous pain medications

C. Patients who experience chronic pain may require extra pain medications to facilitate postoperative exercises, ambulation, coughing, and deep breathing. These activities reduce the likelihood for developing postoperative complications. Option A is incorrect because Patients with chronic pain sometimes do have anxiety about postoperative pain, but reassurance about treatment of pain relievers this anxiety. This is not the rationale for administering extra pain medication to chronic pain patients. Option B is incorrect because This is a judgmental statement. Medication withdrawal is not a concern when additional medication is administered to patients who suffer from chronic pain. This is not the rationale for administering extra pain medication to chronic pain patients. Option D is incorrect because Patients with chronic pain often do not receive the same pain medications for their chronic condition as for their pain following surgery. This is not the rationale for administering extra pain medication to chronic pain patients.

Which action will the nurse take to prevent falls in the older adult? A. Place a brief on a patient who is incontinent. B. Provide a dark environment to promote sleep. C. Place a cup of water on the bedside table, next to the bed. D. Encourage the family to hold the call light to operate the television.

C. Placing items the patient may need within reach is an appropriate action to prevent falls. Option A is incorrect because Placing a brief on a patient who is incontinent is not a fall prevention measure. Patients who are incontinent often feel the urge to urinate, which is what prompts them to try to get up out of bed. As a result, the incontinent patient should be assisted to the bathroom every 1 to 2 hours. Option B is incorrect because Adequate lighting, especially to the bathroom, is important. A night light should be used at night. Option D is incorrect because The patient, not the family, should be able to reach the call light.

Which electrolyte is the principal cation in the intracellular fluid (ICF) compartment? A. Sodium B. Phosphate C. Potassium D. Calcium

C. Potassium is the most abundant cation found in the ICF compartment. Option A is incorrect because Sodium is the major extracellular fluid (ECF) compartment cation. Option B is incorrect because Phosphate, although found in the ICF compartment, is negatively charged; therefore, it is an anion. It is, however, the most abundant anion in the ICF compartment. Option D is incorrect because Calcium is a cation; however, it is not the most abundant in the ICF or the ECF compartment.

What is the focus during the intraoperative phase of surgery? A. Admitting the patient to the surgical unit B. Evaluating patient conditions and risk factors C. Preventing patient injuries and complications D. Assessing for and treating patient complications

C. Preventing patient injuries and complications is the focus of all team members during the intraoperative phase of surgery. Option A is incorrect because Admitting the patient to the surgical unit is the focus during the preoperative, not intraoperative, phase of surgery. Option B is incorrect because Evaluating the patient's conditions and risk factors is the focus during the preoperative, not intraoperative, phase of surgery. Option D is incorrect because Assessing for and treating patient complications is the focus during the postoperative, not the intraoperative, phase of surgery.

Which type of anesthesia prevents pain sensation at the surgical site but allows the patient to be fully awake? A. General anesthesia B. Moderate sedation C. Regional anesthesia D. Balanced anesthesia

C. Regional anesthesia is a type of anesthesia in which the patient is fully awake but has complete loss of sensation at the surgical site. Option A is incorrect because General anesthesia places the patient in a drug-induced coma, which means the patient is not awake. Option B is incorrect because Moderate sedation, or conscious sedation, allows for an altered state of consciousness; the patient is not fully awake. Option D is incorrect because Balanced anesthesia produces temporary loss of consciousness, loss of sensation, amnesia, analgesia, and muscle relaxation.

A patient's goal is "Patient will remain free from hypervolemia or hypovolemia throughout surgery." Which intraoperative nursing diagnosis does this goal address? A. Imbalanced Fluid Volume B. Ineffective Tissue Perfusion C. Risk for Imbalanced Fluid Volume D. Risk for Ineffective Tissue Perfusion

C. Risk for Imbalanced Fluid Volume is the intraoperative nursing diagnosis addressed by this goal. The patient is at risk for hypervolemia and hypovolemia during surgery, and the goal is for the patient to remain free from those complications. Option A is incorrect because Imbalanced Fluid Volume addresses the actual problem of hypervolemia and hypovolemia. There is no data to indicate that the patient has either of those conditions. The goal is to prevent them. Option B is incorrect because Ineffective Tissue Perfusion addresses the actual problem of decreased peripheral circulation and immobility. There is no data to indicate that the patient has decreased circulation related to immobility or other related factors. Option D is incorrect because Risk for Ineffective Tissue Perfusion addresses risk factors associated with decreased peripheral circulation and immobility. There is no data to support this nursing diagnosis.

What is the primary goal of the surgical team during the intraoperative phase of surgery? A. Providing patient support B. Completing the procedure C. Maintaining patient safety D. Adhering to surgical asepsis

C. Safety is the primary goal of the surgical team during the intraoperative phase of surgery because the patient is completely dependent on the team while anesthetized. Option A is incorrect because Providing patient support is part of the surgical team's primary goal, but not all if it. The surgical team's primary goal, which includes patient support, is very important during this phase of surgery. Option B is incorrect because Completing the procedure is primarily the goal of the surgeon. The surgical team assists, but completing the procedure is not their primary goal. Option D is incorrect because Adhering to surgical asepsis is the role of the scrub person, the surgeon, the RN first assistant, and the circulating nurse. The surgical team has another primary goal.

Which nursing action demonstrates secondary prevention of cancer? A. Teaching a class on smoking cessation B. Administering the HPV vaccine C. Assisting a patient undergoing mammography D. Encouraging the teenage patient to apply sunscreen

C. Secondary prevention is the use of screening to detect cancer early, when cure is more likely. Mammography is used to screen for breast cancer. As such, the nurse is demonstrating secondary prevention. All other options are primary prevention.

A patient with Hodgkin's lymphoma has been receiving chemotherapy for several months. Aside from managing chemotherapy side effects, which is the most appropriate intervention to be included in the patient's plan of care? A. Recommend appropriate rehabilitation resources once chemotherapy ends B. Suggest alternative therapies to replace the chemotherapy C. Support the patient by providing resources for optimal psychosocial health D. Have the patient adhere to a strict dietary pattern to ensure D. adequate caloric intake

C. Since survival of patients with Hodgkin's lymphoma depends on their response to treatment, one intervention to be included in the patient's plan of care is providing support for the patient by addressing the physical, psychological, social, and spiritual consequences of the patient's disease and its treatment. Option A is incorrect because Recommending rehabilitation is not the most appropriate intervention to be included in the patient's plan of care. The nurse may review available resources, but this is not necessarily needed while the patient is receiving chemotherapy. Option B is incorrect because The nurse should not give any advice regarding which therapy to choose. The nurse may educate the patient about alternative therapy that may be used in conjunction with chemotherapy, but this is at the primary health care provider's discretion. Option D is incorrect because Having the patient adhere to a strict dietary pattern should not be an intervention included in the patient's plan of care. While nutrition and diet are important at this time, the patient will not need to adhere to a strict diet.

Which is an advantage of completing patient education prior to admission to the presurgical unit? A. Reduced patient teaching time B. Decreased presurgery wait time C. Increased patient compliance D. Ensured patient understanding

C. Teaching completed prior to admission can increase patient compliance, decrease anxiety, and contribute to better performance of postoperative care, such as exercises and deep breathing. These are advantages of completing patient education prior to admission to the presurgical unit. Option A is incorrect because Teaching in advance of patient admission does not reduce overall patient teaching time. The same amount of time is required for teaching and evaluating patient teaching, regardless of where or when teaching occurs. Option B is incorrect because Teaching prior to presurgical admission does not decrease patient presurgery wait time. Wait time depends on the time the patient was admitted, how many surgeries are scheduled, and when the surgeon is ready to perform the surgery. Surgery is neither delayed nor scheduled earlier because of patient teaching. Option D is incorrect because Ensuring patient understanding of teaching is not an advantage of teaching prior to admission to the presurgical unit. The only way to ensure patient understanding is to have patients verbalize their understanding of teaching.

A nurse is caring for a patient newly diagnosed with thrombocytopenia who is an active sports player and has a number of bruises. Which intervention should the nurse implement to improve the chances of a desired patient outcome? A. Teach the patient about appropriate use of low-dose heparin during sporting events. B. Advise the patient to take low-dose aspirin, which can help to reduce bruising and prevent clots during exercise. C. Teach the patient about harmful effects that vigorous exercise can cause and encourage walking instead. D. Remind the patient to stay well hydrated during vigorous exercise since this can help to reduce thrombocytopenic events.

C. Teaching the patient about the harmful effects of vigorous exercise and encouraging them to walk would be a good intervention, since this is teaching them to avoid causative factors. Option A is incorrect because This teaching intervention should not be implemented since heparin should be avoided in many patients with thrombocytopenia. Option B is incorrect because This teaching intervention should not be implemented since aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided in patients with thrombocytopenia. Option D is incorrect because Reminding the patient to stay well hydrated is appropriate, but it is not good advice to promote or encourage vigorous exercise in a patient with thrombocytopenia.

What is the focus during the preoperative phase of surgery? A. Protection of patient privacy during surgery B. Prevention of patient injury during procedure C. Patient assessment and preparation for surgery D. Intervention for complications after the procedure

C. The focus of the preoperative period is patient admission, assessment, and preparation for the surgical procedure. Option A is incorrect because Protection of patient privacy and dignity during surgery is the focus of the intraoperative, not preoperative, phase of surgery. Option B is incorrect because Prevention of injury during the procedure is the focus of the intraoperative, not preoperative, phase of surgery. Option D is incorrect because Intervention for any post-surgery complications is the focus during the postoperative phase of surgery, not the preoperative phase.

Which action should the nurse implement prior to allowing the patient out of bed the first time? A. Assess the patient's blood pressure. B. Provide a walker or cane for stability. C. Request the patient to call for assistance. D. Advise the patient to move to the chair quickly.

C. The nurse should instruct the patient to call for assistance before getting out of bed for the first time. Many patients feel weak and dizzy and need the assistance of two caregivers when getting out of bed the first time to prevent falls. Option A is incorrect because There is no need to assess the patient's blood pressure prior to allowing the patient out of bed for the first time. The patient's blood pressure is routinely assessed. Option B is incorrect because There is no need to provide a walker or cane unless the patient required a walker or can prior to surgery. Most surgical patients do not need assistive devices to ambulate after surgery. Option D is incorrect because The nurse should advise the patient to move to the side of the bed, stand with assistance, and move to the chair slowly. Standing quickly can result in a fall or injury.

Which nursing diagnosis will the nurse individualize for a patient with inability to sleep and anxiety about a scheduled surgery? A. Fear B. Risk for Fear C. Insomnia D. Risk for Insomnia

C. The patient's data supports the presence of problems that need to be addressed, including inability to sleep and anxiety. These are characteristics of insomnia. The nurse will individualize this nursing diagnosis for the patient. Option A is incorrect because The patient's data does not support individualizing the nursing diagnosis of Fear, which includes characteristics such as panic, feelings of alarm and apprehension, and dread. Option B is incorrect because The patient's data does not support individualizing the nursing diagnosis of Risk for Fear because the patient is experiencing inability to sleep and anxiety. Those are not risk factors they are problems that need to be addressed. Option D is incorrect because The patient's data does not support individualizing the nursing diagnosis of Risk for Insomnia because the patient is experiencing inability to sleep and anxiety. Those are not risk factors; they are problems that need to be addressed.

Which preoperative assessments assist the nursing plan for the patient's discharge following ambulatory surgery? A. Emotional preparation for surgery B. Patient's socioeconomic status C. Availability of family for support D. Existence of chronic health conditions

C. The preoperative nurse does need to identify the availability and ability of family members for postoperative support when the patient is discharged following surgery. Patients are not discharged from ambulatory surgery centers alone. A family member or other support person is required to accompany the person. Option A is incorrect because The preoperative nurse does assess the patient's emotional preparation for surgery, but this does not assist with planning for the patient's discharge following ambulatory surgery. Option B is incorrect because Identifying the patient's socioeconomic status is not required while the patient is in the presurgical care unit or for patient discharge. Financial arrangements were made before the patient was scheduled for surgery. Option D is incorrect because The preoperative nurse does assess for pre-existing medical conditions. Knowledge of these conditions enables the surgical team to ensure patient safety during surgery, but it does not affect discharge planning. Patients with unstable medical conditions are not scheduled for surgery in ambulatory surgical settings.

Ms. Lewis is a 29-year-old African American woman who comes to the emergency department seeking treatment for an acute episode of sickling. She complains of severe pain in her arms, legs, joints, and abdomen and in her chest when she takes a deep breath. Ms. Lewis was diagnosed with sickle cell anemia when she was 4 months old but has only had a few episodes of sickling in the last 4 to 5 years. Her last episode was 6 months ago. Ms. Lewis has had a cold for the last several days and also complains of a sore throat and cough. Ms. Lewis rates her pain as a 9 on a scale of 0 to 10. She is not currently taking any medications. Ms. Lewis does not smoke but occasionally drinks alcohol when out with friends. On assessment, her lips and oral mucous membranes are found to be dry and pale and her skin turgor is fair. Her vital signs are as follows: blood pressure (BP) 108/68 mm Hg, heart rate (HR) 94 beats/min and regular, respiratory rate (RR) 22 breaths/min and unlabored, and temperature 102° F (38.9° C). She has crackles in her left and right lower lobes. Heart sounds are normal. Her abdomen is soft and nondistended but painful on palpation. Bowel sounds are active in all quadrants. Her ankles, knees, wrists, and elbows are swollen, warm to touch, and very painful. Which nursing goal would be an appropriate primary goal for Ms. Lewis? A. Ms. Lewis will not experience fluid overload. B. Ms. Lewis will be free of adventitious breath sounds. C. Ms. Lewis will experience relief from pain as evidenced by a pain score of 3 or lower. D. Ms. Lewis will have adequate understanding and knowledge of the disease process.

C. The primary goal for a patient with sickle cell disease is control of pain. Ms. Lewis has adequate respiratory status and no evidence of fluid overload or knowledge deficit. Pain control should be addressed as the primary nursing goal. Option A is incorrect because Although not experiencing fluid overload is important for any patient, fluid overload is not the primary goal for Ms. Lewis, given her symptoms. Option B is incorrect because Although it is important for a patient with sickle cell disease to be free of crackles and other adventitious breath sounds, this is not a primary goal of care for Ms. Lewis, given her symptoms. Option D is incorrect because Although having a good understanding and knowledge of the disease process is important, adequate knowledge of sickle cell disease is not the primary goal for Ms. Lewis, given her symptoms.

The nurse is caring for an older adult patient who has been admitted with abdominal distension and has a history of sickle cell anemia. Which findings would the nurse expect to see on an abdominal x-ray report? A. Enlarged spleen B. Enlarged kidney C. Small to nonexistent spleen D. Liver atrophy

C. The spleen in a sickle cell patient becomes infarcted, dysfunctional, and small because of repeated scarring. An abdominal x-ray may reveal a very small spleen in a patient with sickle cell disease. Option A is incorrect because An abdominal x-ray would show an image of the spleen, but an enlarged spleen would not be observed in a patient with sickle cell anemia. Option B is incorrect because An abdominal x-ray may show an image of a kidney, but an enlarged kidney would not be observed in a patient with sickle cell anemia. Option D is incorrect because Patients with sickle cell disease may have an enlarged liver or cirrhosis, but not liver atrophy.

Drugs used for chemotherapy fall into which class of anticancer drugs? A. Targeted drugs B. Hormonal agents C. Cytotoxic drug therapy D. Biologic response modifiers

C. The term chemotherapy specifically refers to cytotoxic drugs. All other options are not used for chemotherapy.

The nurse should include which statement regarding over-the-counter (OTC) medications when teaching a patient with thrombocytopenia? A. "Over 65 percent of OTC medications have a mild thrombocytopenic effect." B. "As long as the medicine is taken according to the directions on the bottle, there is no need to be overly cautious." C. "There are certain medications that should be avoided altogether, including aspirin." D. "Many medications should be avoided, but herbal supplements are mostly harmless."

C. There are certain medications that should be avoided. Aspirin is one since it can increase the risk of bleeding in a thrombocytopenic patient. Option A is incorrect because Most OTC medications do not cause a thrombocytopenic effect, so the nurse should not make this statement. Option B is incorrect because Any patient with thrombocytopenia should be cautious about taking any OTC medication; therefore, this statement would not be appropriate. Option D is incorrect because There are certain medications that should be avoided, and there are also herbal supplements that can increase the risk of bleeding; therefore, this statement would not be appropriate.

Which postoperative patient goal is measurable? A. The patient will have minimal drainage on leg dressing. B. The patient will tolerate ice chips for at least two hours. C. The patient will move all extremities without assistance. D. The patient will remain comfortable until PACU discharge.

C. This is a measurable postoperative patient goal. The nurse can observe the patient's ability to move without assistance and evaluate when the goal is met. Option A is incorrect because This goal is not measurable. The goal does not indicate what the term "minimal" means or on which leg the dressing is located. Option B is incorrect because This is not a measurable goal because it does not indicate what the term "tolerate" means. Adding a phrase such as "without nausea" would make this goal measurable. Option D is incorrect because This is not a measurable goal. There is no reference, such as a scale, for measuring the term "comfortable". Comfort varies for each patient.

Mr. Johnson continues to exhibit poor skin turgor and reports redness and irritation to the skin. The nurse adds Risk for impaired skin integrity to the plan of care. Which is an accurate goal that the nurse should include for the new nursing diagnosis? A. Turn and reposition the patient every 2 hours. B. Patient will participate in physical therapy. C. Patient will report altered sensation or pain at risk areas as soon as noted. D. Inspect patient's skin for problem areas every shift.

C. This is an example of an appropriate, measurable, timed, and attainable goal for the nursing diagnosis. Option A is incorrect because Turning and repositioning the patient every 2 hours is an example of a nursing intervention, not a goal statement. Option B is incorrect because This goal statement lacks a time frame and is, therefore, not an example of an accurate goal statement. Option D is incorrect because Inspecting the patient's skin for problem areas every shift is an example of a nursing intervention, not a goal statement.

The nurse is providing care to a patient with electrolyte imbalance showing edema and shortness of breath. Which nursing diagnosis should the nurse include in the updated patient plan of care? A. Imbalanced nutrition: less than body requirements r/t electrolyte imbalance, as evidenced by shortness of breath B. Acute confusion related to electrolyte imbalances, as evidenced by edema and shortness of breath C. Fluid volume excess related to electrolyte imbalances, as evidenced by edema and shortness of breath D. Altered cardiac output related to fluid in the lungs, as evidenced by edema and shortness of breath

C. This nursing diagnostic statement is accurate because the electrolyte imbalance is causing the nursing diagnosis of Fluid volume excess, which is manifested by edema and shortness of breath. Option A is incorrect because Electrolyte imbalance is a manifestation of Imbalanced nutrition: less than body requirements. It is not the cause of the nursing diagnosis. Option B is incorrect because Edema and shortness of breath are not clinical manifestations associated with Acute confusion. Option D is incorrect because Altered cardiac output is caused by (or related/to) electrolyte imbalances, which are manifested by cardiac arrhythmias and blood pressure changes, not edema and shortness of breath.

Which patient would be considered dual eligible for federal health care resources? A. 51-year-old with diabetes mellitus who lives below the poverty index B. 78-year-old with dementia who is on a fixed income C. 67-year-old with end-stage renal disease who receives government food stamps D. 70-year-old with atrial fibrillation who is working as president of a bank

C. This patient is eligible for both Medicare, due to age and condition, and Medicaid, due to income as indicated by eligibility for governmental food stamps and renal disease diagnosis. Being eligible for both Medicare and Medicaid creates dual eligibility for federal health care resources. Option A is incorrect because this patient is eligible only for Medicaid due to income level. The patient has not yet reached the eligibility age for Medicare. Option B is incorrect because This patient is eligible for Medicare based on age. Many older adults live on a fixed income, but this does not indicate that they live within the poverty guidelines required for access to Medicaid. Option D is incorrect because This patient is eligible for Medicare based on age. This patient is still working and does not meet the poverty guidelines or need required for access to Medicaid.

Symptoms of anemia are primarily caused by which pathological effect? A. Increased oxygen demand B. Stimulation of bone marrow C. Decreased tissue oxygenation D. Activation of the renin-aldosterone response

C. Tissue hypoxia, or decreased tissue oxygenation, occurs due to lack of hemoglobin from the decreased amount of red blood cells. This leads to clinical manifestations such as fatigue and activity intolerance. Option A is incorrect because Increased oxygen demand is a compensatory mechanism related to the primary cause of anemia but is not the primary pathological effect that causes patient symptoms of anemia. Option B is incorrect because Stimulation of bone marrow is a compensatory mechanism related to the primary cause of anemia but is not the primary pathological effect that causes patient symptoms of anemia. Option D is incorrect because ctivation of the renin-aldosterone response is a compensatory mechanism related to the primary cause of anemia but is not the primary pathological effect that causes patient symptoms of anemia.

Which teaching will the nurse include for a patient with low platelets from chemotherapy? A. Do not change pet litter boxes. B. Do not share personal items. C. Use a soft-bristle toothbrush. D. Wash dishes between uses.

C. Using a soft-bristle toothbrush can reduce the risk of bleeding gums that can occur with low platelets. Option A is incorrect because Not changing pet litter boxes is associated with decreasing the risk for infection, not decreasing the risk of bleeding from low platelets. Option B is incorrect because Not sharing personal items is associated with decreasing the risk for infection, not decreasing the risk of bleeding from low platelets. Option D is incorrect because Washing dishes between uses is associated with decreasing the risk for infection, not decreasing the risk of bleeding from low platelets.

Which goal is measurable for the nursing diagnosis of Deficient Knowledge about surgical procedure related to lack of previous experience? A. Patient will demonstrate signs of readiness for surgery after teaching. B. Patient will report reading about the scheduled surgery and its complications. C. Patient will verbalize understanding of the surgical procedure. D. Patient will receive information and teaching about scheduled surgical procedure.

C. Verbalizing an understanding of the procedure is evidence that the patient's knowledge deficiency was addressed and corrected. This goal is measurable. Option A is incorrect because Reporting readiness for surgery after teaching is not measurable because it does not indicate if the patient's knowledge deficiency was addressed or corrected. Option B is incorrect because The patient reading about the scheduled surgery is not measurable because it does not indicate if the patient's knowledge deficiency was addressed or corrected. Option D is incorrect becauseThe patient receiving information and teaching about the scheduled surgery is not measurable because it does not indicate if the patient's knowledge deficiency was addressed or corrected.

A nurse is caring for a patient with sickle cell disease. The nurse realizes the patient's hypoxemia and dehydration are primarily caused by which characteristic of sickle cell disease? A. Diuresis B. Acute pain C. Vessel occlusion D. Inheritance aspect

C. Vessel occlusion occurs because sickled erythrocytes are prevented from passing through the capillaries. Option A is incorrect because Diuresis is increased urine production taking place in the kidneys, often caused by medications. Giving medications to aid diuresis may be a helpful way to treat a patient with sickle cell disease but diuresis is not the cause of the patient's hypoxia and dehydration. Option B is incorrect because Acute pain is one of the clinical manifestations of sickle cell disease, but it is not the cause of the patient's hypoxia and dehydration. Option D is incorrect because The inheritance aspect causes the sickling of erythrocytes found in the patient with sickle cell disease. However, the fact that sickle cell disease is inherited is not the cause of the patient's hypoxia and dehydration.

Which cancer can significantly impair immunity? A. Gastrointestinal tumors B. Spinal tumors C. Bone marrow cancer D. Brain cancer

C. Bone marrow cancer can significantly alter immunity as that is where blood cells are formed. Option A alters gastrointestinal function. Option B alters peripheral nerve function. Option D alters central motor and sensory function.

Which statement by a nursing mother who is taking anticancer medication (imatinib) would require intervention by the nurse? A. "I need to stop breastfeeding prior to beginning my medication." B. "I can resume breastfeeding 60 days after completing my medication." C. "I can resume breastfeeding my child 1 month after completing my medication." D. "I need to avoid getting pregnant for at least 12 months after completing my medication."

C. Breastfeeding can resume after 60 days. Options A, B and D are incorrect because Imatinib is contraindicated for lactating mothers, and breastfeeding should not resume until 60 days after completion of this medication.

What will the nurse include when teaching about the development of cancer cells? A. Cancer cells exhibit differentiated function. B. Cancer cells respect the boundaries of other cells. C. Cancer cells have loose adherence which helps the cancer spread. D. Cancer cells demonstrate euploidy.

C. Cancer cells have loose adherence because they lack the protein needed to stick together, allowing the cancer cells to spread. All other options describe normal cells, not cancer cells.

A patient taking tyrosine kinase inhibitors (imatinib) at home calls the nurse and reports having a fever, chills, and a persistent sore throat. What action by the nurse is most appropriate? A. Instruct the patient to self-monitor vital signs for any abnormalities. B. Instruct the patient to take the next dose with food to minimize side effects. C. Instruct the patient to immediately call and report the symptoms to the prescriber. D. Instruct the patient to review the medication instructions and dosage to rule out any wrong dosing.

C. Fever, chills, and sore throat indicate a severe adverse drug reaction that requires prompt attention from the health care provider. Option A is incorrect because It is important to perform additional assessment, but the priority intervention should be management of the severe drug reaction. Option B is incorrect because Fever, chills, and sore throat are not common side effects that can be resolved by taking the medication with food. Option D is incorrect because Regardless of the dosing, the patient is developing adverse reactions to the medication and requires the prescriber's attention.

A nurse preceptor is preparing to teach new nurses about classes of anticancer drugs. Which drug class should the nurse preceptor identify as the class most commonly used for treatment of prostate cancer? A. Targeted drugs B. Cytotoxic agents C. Hormone antagonists D. Biologic response modifiers

C. Hormone antagonists are most commonly used for the treatment of breast and prostate cancers. Option A is incorrect because Targeted drugs are used to target cancer cells in different systems of the body. Option B is incorrect because Cytotoxic drugs are used for a variety of cancers. Option D is incorrect because Biologic response modifiers are not primarily used to treat breast and prostate cancer.

Which age-related characteristic increases the surgical risk for older adults? A. Smaller airways B. Small circulatory volume C. Lack of subcutaneous tissue D. Immature sympathetic nervous system

C. Older adults lose subcutaneous tissue as they age. This places them at risk for pressure injuries related to positioning during long surgical procedures. Options A, B and D describe infant surgical risks.

Which interventions prevent many postoperative complications, including constipation and deep vein thrombophlebitis? Select all that apply. A. Soft diet B. Oral laxatives C. IV fluid therapy D. Early ambulation E. Opioid analgesics

C. and D. IV fluid therapy promotes fluid balance and hydration, prevents constipation and urinary stasis, and keeps lung secretions thin. However, IV fluids do not prevent other complications such as thrombophlebitis and pneumonia. The implementation of ambulation as early as the patient is able to stand without dizziness or lightheadedness helps prevent many postoperative complications, such as constipation, deep vein thrombosis, atelectasis, pneumonia, and urinary stasis. It also reduces abdominal distention and gas pains. Option A is incorrect because Patients are progressed to a soft diet after they are able to tolerate fluids without nausea and peristalsis has returned. A soft diet facilitates normal bowel function, but does not prevent complications such as thrombophlebitis. Option B is incorrect because Oral laxatives are administered to treat constipation, but they do not prevent other postoperative complications such as thrombophlebitis. Option E is incorrect because Opioid medications are often prescribed for pain following surgery, but they decrease peristalsis and therefore contribute to the development of constipation.

A patient presents with thrombocytopenia secondary to heparin administration. The nurse should assess the patient for which potential complication(s)? Select all that apply. A. Epistaxis B. Gingival bleeding C. Venous thrombosis D. Altered cognitive status E. Bleeding from the intravenous (IV) site

C., D. Venous thrombosis is the major clinical complication of heparin-induced thrombocytopenia and can lead to further life-threatening complications. Neurologic abnormalities, resulting in altered cognitive status, can occur as part of thrombotic stroke. This is a complication of heparin-induced thrombocytopenia. Option A is incorrect because Epistaxis, or nasal bleeding, is not a common complication of heparin-induced thrombocytopenia because platelet count rarely drops below 60,000/µL. Option B is incorrect because Gingival bleeding is not a common complication of heparin-induced thrombocytopenia because platelet count rarely drops below 60,000/µL. Option E is incorrect because Bleeding from the IV site is not a common complication of heparin-induced thrombocytopenia because platelet count rarely drops below 60,000/µL.

Which assessment findings help assure the nurse of patient safety for general anesthesia following correct positioning on the OR table? Select all that apply. A. Safety straps tightly fitted B. Patient limbs well covered C. Peripheral circulation intact D. Pressure points well padded E. Airway accessible to anesthesia

C., D., E. Peripheral circulation intact ensures patient safety because it indicates that positioning and devices used for positioning have not compromised the patient's circulation. Well-padded pressure points ensure patient safety because they prevent development of postoperative pressure ulcers. Airway accessible to anesthesia ensures patient safety because it facilitates the administration of anesthesia and assessment of the patient during anesthesia Option A is incorrect because tightly fitted safety straps do not ensure patient safety. Depending on where the straps are placed, they may compromise circulation or place pressure over joints or bones. Option B is incorrect because Well-covered patient limbs do not ensure patient safety. Depending on the type of surgery and the patient's condition, it may be necessary to assess the patient's circulation or skin color. At least one arm and hand must be exposed for the administration of fluids and medications.

Which factors determine the type of diagnostic tests completed prior to surgery? Select all that apply. A. Location of surgery site B. Anesthetic to be given C. Surgery to be performed D. Overall health status E. Patient's medical history

C., D., E. The surgery to be performed is an important consideration in determining which tests are completed prior to surgery. For example, an electrocardiogram is essential before performing cardiac procedures. Overall health status is an important consideration in determining which tests are completed prior to surgery. For example, a person with a coagulation disorder will need coagulation studies completed prior to surgery. The patient's medical history is an important consideration in determining which tests are completed prior to surgery. For example, a patient with kidney disease will have renal studies completed prior to surgery. Option A is incorrect because The location of the surgical site is not a factor that determines which tests are completed prior to surgery. Surgical site is considered for positioning and anesthesia administration. Option B is incorrect because The anesthetic to be administered is not a factor that determines which tests are completed prior to surgery. However, anesthesia does review pre-surgical tests and considers findings prior to administering anesthetics and preoperative drugs.

Which assessment findings must be present before patients are discharged from the PACU? Select all that apply. A. Free from pain B. Without nausea C. Controlled drainage D. Normal temperature E. Vital signs at baseline

C., D., E. Wound drainage should be controlled, but does not necessarily have to be resolved prior to discharge from the PACU. Patients often have to continue wound care once at home. Normal temperaturePatients should be normothermic before discharge from the PACU. Vital signs at baselinePatients should have stable vital signs as compared to their preoperative baseline data prior to discharge from PACU. Option A is incorrect because Pain following surgery is an expected assessment finding. Pain should be at a tolerable level as verbalized by the patient. Patients generally continue analgesic therapy at home. Option B is incorrect because Patients should exhibit minimal anesthesia-related nausea but do not have to be without feelings of nausea prior to discharge from the PACU. Patients experiencing nausea generally continue anti-nausea medications at home.

Which assessment should the nurse perform to detect any further complications from a patient with B12 deficiency? A. Bowel sounds B. Pulse and blood pressure C. Color and amount of urine D. Pain and sensation of the extremities

D. A B12 deficiency can cause a diminished sensation to heat and pain, therefore a further neurological assessment is warranted. Option A is incorrect because A B12 deficiency has no further effect on the gastrointestinal system, so the nurse has no need to assess bowel sounds to detect further complications. Option B is incorrect because A B12 deficiency has no further effect on the cardiopulmonary system. The nurse has no need to take pulse and blood pressure to detect further complications. Option C is incorrect because A B12 deficiency has no further effect on the urinary system. The nurse has no need to assess color and amount of urine to detect further complications.

Which cancer stage reflects distant metastasis? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

D. Stage 4 is metastasis. Option A is incorrect because stage 1 is tumor is local tumor growth. Option B is incorrect because stage 2 is limited local spread. Option C is incorrect because stage 3 is extensive local and regional spread.

What is the rationale for assessing the patient's level of consciousness prior to surgery? A. Facilitates postoperative phase teaching B. Determines the patient's thought patterns C. Evaluates the patient's response to questions D. Provides a postoperative base for comparison

D. A baseline assessment of the patient's level of consciousness is important to provide a source of comparison for the postoperative nurse. This is the rationale for assessing the patient's level of consciousness prior to surgery. Option A is incorrect because Knowing the patient's level of consciousness postoperatively does facilitate postoperative teaching because it allows the nurse to plan teaching. However, this is not the rationale for assessing the patient's level of consciousness prior to surgery. Option B is incorrect because Determining the patient's thought pattern is part of the preoperative assessment of the patient's level of consciousness, not the rationale for the assessment. Option C is incorrect because Evaluating the patient's response to questions is part of the preoperative assessment of the patient's level of consciousness, not the rationale for the assessment.

In which patient with thrombocytopenia would a platelet transfusion be appropriate? A. A patient with heparin-induced therapy (HIT) and platelet count <10,000/μL B. A patient with thrombocytopenic purpura (ITP), painful splenomegaly, and platelet count <60,000/μL C. A patient with heparin-induced therapy (HIT) and a platelet count <30,000/μL D. A patient with immune thrombocytopenic purpura (ITP) with a platelet count <10, 000/μL

D. A patient with ITP and a platelet count <10,000 will receive a platelet transfusion. Usually ITP can be treated effectively with steroids, but if this treatment fails and the platelet level falls, the patient will need a transfusion Option A is incorrect because A patient with HIT and a platelet count <10,000 will not benefit from a transfusion; a transfusion could exacerbate the problem. The heparin will need to be removed, which will help increase the patient's platelet count. Option B is incorrect because A patient with thrombocytopenic purpura (ITP), painful splenomegaly, and platelet count <60,000/μL This patient with ITP, painful splenomegaly, platelet count 60,000 would not require transfusion. This patient will benefit more from steroid treatment. Option C is incorrect because A patient with HIT and a platelet count <30,000 will not usually benefit from a transfusion; a transfusion could exacerbate the problem. The heparin will need to be removed, which will help increase the patient's platelet count.

A patient newly diagnosed with leukemia presents to the clinic for the first chemotherapy session. The patient states, "This disease won't defeat me. It will not interrupt my life." Which statement by the nurse is most appropriate? A. "I think that's great! A positive attitude is half the battle." B. "Don't be so sure. Leukemia treatment is extremely stressful." C. "Yes, leukemia therapy is pretty straightforward." D. "Although your response to treatment is unknown right now, you have a good outlook."

D. A patient's response to treatment varies, is unknown initially, and is a huge stressor on the patient and his or her support system. Encouraging the patient's positive outlook while still letting him or her know about the varied treatment response is an appropriate response by the nurse Option A is incorrect because A patient's response to treatment varies. Saying that a positive outlook is half the battle may be misleading the patient about the stress leukemia and its treatment will cause the patient and his or her support system. Option B is incorrect because A patient's response to treatment varies; however, the nurse should not discourage a positive outlook. Option C is incorrect because A patient's response to treatment varies. Leukemia therapy is not "pretty straightforward," and the nurse should not tell the patient this.

A pediatric patient needs a new liver due to a genetic disorder. What type of surgical procedure will this patient undergo? A. Ablative B. Palliative C. Reconstructive D. Transplantation

D. A transplantation surgery is conducted to replace a dysfunctional body part, such as a damaged liver. Option A is incorrect because Ablative surgery involves removal of a diseased body part, but does not involve replacement or transplantation of an organ. Option B is incorrect because Palliative surgery is conducted to improve comfort and/or alleviate pain, but does not involve transplantation or replacement of an organ. Option C is incorrect because Reconstructive or restorative surgery restores function and/or appearance of damaged tissue, but does not involve transplantation or replacement of an organ.

Which drug classification should the nurse identify as a cause of hyperkalemia? A. Corticosteroids B. Chemotherapeutics C. Loop diuretics D. ACE inhibitors

D. ACE inhibitors is a drug classification that can cause hyperkalemia. All other options cause hypokalemia.

A patient has undergone radiation therapy for leukemia. Which assessments should the nurse complete to determine whether a patient has experienced adverse effects of this therapy? A. Take vital signs B. Perform a retinal examination C. Measure urine output D. Examine skin color and appearance

D. After radiation therapy, the skin of the radiated area is assessed for irritation, hair loss, and inflammation or swelling. Describing the skin color and appearance is part of this skin assessment. Option A is incorrect because Taking vital signs initially does not assess for radiation side effects. Option B is incorrect because A retinal examination will not provide the nurse information about radiation therapy side effects. Option C is incorrect because Measurement of urine output is not an appropriate assessment for radiation side effects, as the urine is not affected by radiation.

Which neurological assessment, performed by tapping the side of the face, should the nurse perform for a patient with risk factors for hypocalcemia? A. Level of consciousness exam B. Trousseau sign C. Electrocardiogram D. Chvostek sign

D. Chvostek sign is a neurological assessment that is performed by tapping the side of the face over the facial nerve. A positive Chvostek sign, spasm of the facial muscle, indicates increased neuromuscular excitability, consistent with hypocalcemia. Option A is incorrect because While a level of consciousness exam is an appropriate neurological assessment to conduct for a patient with documented hypocalcemia, this test is not administered by tapping on the side of the patient's face. Option B is incorrect because Trousseau sign is a neurological assessment used to monitor for hypocalcemia. However, the assessment is performed using a blood pressure cuff to assess for spasm of the hand and wrist muscles. Option C is incorrect because An electrocardiogram is a cardiovascular diagnostic tool, not a neurological assessment.

Which is the reason for the movement of electrolytes from one compartment to another compartment in the body? A. To maintain the process of diffusion B. To facilitate active transport C. To balance the fluids D. To preserve electrolyte distribution

D. Electrolyte distribution is part of electrolyte homeostasis. Physiological distribution of electrolytes is necessary for cells, and thus the organ systems, to function normally. Option A is incorrect because The transport of electrolytes may occur by active transport, but this is not the reason for the transport of electrolytes from one compartment to another within the body. Option B is incorrect because The transport of electrolytes may occur by diffusion, but this is not the reason for the transport of electrolytes from one compartment to another within the body. Option C is incorrect because Fluids are the solvent in which the electrolytes may move and will be affected by the concentration of electrolytes. But this does not specifically address why electrolytes move from one compartment to another compartment.

Which statement regarding electrolyte movement from one compartment to another should the nursing student include in a class presentation? A. "The movement of electrolytes is necessary to maintain the process of diffusion." B. "The move of electrolytes is necessary to facilitate active transport." C. "The movement of electrolytes is necessary to maintain fluid balance." D. "The movement of electrolytes is necessary to preserve their distribution."

D. Electrolyte distribution is part of electrolyte homeostasis. Physiological distribution of electrolytes is necessary for cells, and thus the organ systems, to function normally. Option A is incorrect because The transport of electrolytes may occur by diffusion, but this is not the reason for the transport of electrolytes from one compartment to another within the body. Option B is incorrect because The transport of electrolytes may occur by active transport, but this is not the reason for the transport of electrolytes from one compartment to another within the body. Option C is incorrect because Fluids are the solvent in which the electrolytes may move and will be affected by the concentration of electrolytes. But this does not specifically address why electrolytes move from one compartment to another compartment.

Which type of surgery is required to stop hemorrhage from a patient's injuries sustained during an accident? A. Urgent B. Elective C. Ablative D. Emergency

D. Emergency surgery is immediate surgery performed for life-threatening conditions such as hemorrhage. This is the type of surgery required for this patient. Option A is incorrect because urgent surgery is required when a health condition is not immediately life-threatening but surgery should be performed within 24 hours. This type of surgery is not appropriate for a hemorrhaging accident victim. Option B is incorrect because Elective surgery is planned in advance by the patient and surgeon. Elective surgery is not appropriate for a hemorrhaging accident victim. Option C is incorrect because Ablative surgery removes a diseased body part, and is not a classification of surgery based on degree of urgency.

Gefitinib is used to treat which type of cancer? A. Leukemia B. Kaposi Sarcoma C. Hodgkin Lymphoma D. Non Small Cell Lung Cancer

D. Gefitinib is used to treat non-small cell lung cancer. Gefitinib is not used to treat the other types of cancer listed.

The nurse is reviewing a patient's chart and the patient is found to have a decreased platelet count (60,000/µL). How can the nurse determine the type of thrombocytopenia the patient is experiencing? A. Vital signs B. Radiology reports C. Physical examination D. Prior medical history

D. Heparin-induced thrombocytopenia (HIT) occurs in response to heparin administration, and thrombotic thrombocytopenic purpura (TTP) may follow drug toxicity, pregnancy or preeclampsia, infection, or known autoimmune disorder. Therefore, the patient history can help differentiate the type of thrombocytopenia Option A is incorrect because The patient's vital signs cannot identify the type of thrombocytopenia the patient is experiencing. Option B is incorrect because A radiology report will not identify a complication of thrombocytopenia. Option C is incorrect because A physical examination may indicate a problem or complication of thrombocytopenia but will not differentiate among types of thrombocytopenia.

Which serum sodium concentration should the nurse identify as hypernatremia? A. 135 mEq/L B. 140 mEq/L C. 145 mEq/L D. 150 mEq/L

D. Hypernatremia is a serum sodium concentration that is greater than 145 mEq/L. Normal serum sodium levels are between 135 and 145.

Which age-related characteristic increases surgical risk for infants? A. Increased risk for hemorrhage B. Decreased physiologic reserves C. A smaller body water percentage D. Immature physiological mechanisms

D. Immature physiological mechanisms prevent infants from maintaining normal body temperatures, thus increasing patient risk for hypothermia and hyperthermia when undergoing anesthesia during surgery. Option A is incorrect Older adults, not infants, have an increased risk for hemorrhage during surgery. Option B is incorrect because Older adults, not infants, have decreased physiologic reserves that make the maintenance of homeostasis during and after surgery more difficult. Option C is incorrect because Older adults, not infants, have a smaller body water percentage and increased risk of fluid and electrolyte imbalances during surgery.

Which statement by a patient with iron deficiency anemia would prompt the nurse to provide further patient education? A. "I will take my iron supplement with orange juice." B. "I will take my iron supplement one hour before eating." C. "I will increase the amount of green leafy vegetables in my diet." D. "I will cluster my activities together in the morning after a good night's sleep."

D. In order to prevent fatigue and activity intolerance, the patient should pace activities throughout the day. The nurse would need to provide further teaching if the patient made this statement. Option A is incorrect because Vitamin C and the acid in orange juice help increase the absorption of iron. This is an appropriate statement by the patient and would not require further patient education by the nurse. Option B is incorrect because Iron should be taken one hour before meals as it is absorbed best in an acidic environment and should avoid binding with food. This is an appropriate statement by the patient and would not require further patient education by the nurse. Option C is incorrect because Green leafy vegetables are a good source of dietary iron. This is an appropriate statement by the patient and would not require further patient education by the nurse.

A patient with leukemia asks why he or she has to take extra precautions against infection. What is the best response by the nurse? A. "Leukemia puts you at risk for anemia." B. "There is no clear etiology for risk of infection." C. "Your white blood cells are infiltrating your organs." D. "Bone marrow failure can result in decreased white blood cells."

D. Leukemia causes bone marrow failure, leading to a decrease in the number and function of white blood cells. This decreases the immune defenses of the patient and increases the chance for infection. Option A is incorrect because Although leukemia does put patients at risk for anemia, decreases in red blood cells do not directly increase a patient's risk for infection. Option B is incorrect because Although there is no clear etiology for the development of leukemia, the reason for an increased risk for infection is known. Option C is incorrect because Although leukemia can lead to infiltration of organs by white blood cells (causing splenomegaly, hepatomegaly, lymphadenopathy, bone pain, meningeal irritation, and oral lesions), this does not directly increase a patient's risk for infection.

A patient is positioned flat with feet in stirrups for genitourinary surgery. Which position does the nurse document in the patient's intraoperative record? A. Sitting B. Lateral C. Supine D. Lithotomy

D. Lithotomy positioning is used for gynecologic, perineal, rectal, and genitourinary procedures. Option A is incorrect because Sitting positioning is used for breast, thoracic, head, or neck surgeries. Option B is incorrect because Lateral positioning is used for thoracic, kidney, or hip surgeries. Option C is incorrect because Supine positioning is used for thoracic, heart, or abdominal surgeries.

Which medical order should the nurse question for a patient experiencing hypokalemia? A. Aldosterone prescription B. Calcium supplements C. Potassium supplements D. Loop diuretic prescription

D. Loop diuretics are a known cause for hypokalemia. Option A is incorrect because Aldosterone is a medication that causes hyperkalemia, not hypokalemia. Option B is incorrect because Calcium supplements are not a known cause of hypokalemia. Option C is incorrect because Potassium supplements are often prescribed to treat hypokalemia.

A patient has the postoperative goal of "The patient will remain free of nausea." The goal is based on which patient need? A. Need for electrolyte balance B. Freedom from fluid imbalance C. Need for hemodynamic stability D. Avoidance of postoperative discomfort

D. Nausea is a complication that can result from gastrointestinal surgery, manipulation of the GI tract, and/or anesthesia. This goal was individualized based on the patient's need to avoid the postoperative discomfort caused by nausea. Option A is incorrect because the need for electrolyte balance does not relate to this goal. Nausea does not cause electrolyte imbalance. Vomiting, if severe, can cause electrolyte imbalance if electrolytes are not replaced. Option B is incorrect because Freedom from fluid imbalance does not relate to this goal. Nausea does not cause fluid imbalance. Vomiting, if severe, can cause dehydration when fluid loss is not replaced. Option C is incorrect because The need for hemodynamic stability does not relate to this goal. Nausea does not cause hemodynamic instability.

Which assessment finding would alert the nurse to the potential for wound dehiscence? A. Purulent drainage B. Granulation tissue C. Reddened incisional site D. Edge non-approximation

D. Non-approximation of incisional edges is a warning sign of wound dehiscence. It can result from closure device failure and needs to be reported. Option A is incorrect because Purulent drainage is a sign of infection. Option B is incorrect because The presence of granulation tissue is a sign that the incision is healing. It is not a sign of wound dehiscence. Option C is incorrect because Mild redness of the incisional site is an expected assessment finding for 1 to 2 days after surgery. Severe redness may be a sign of infection.

A nurse is caring for a patient with multiple myeloma who is experiencing significant skeletal pain. The patient expresses an interest in nonpharmacological pain relief. About which therapy would the nurse provide the patient more information? A. Chemotherapy B. Ambulation C. Watchful waiting D. Use of a back brace

D. Orthopedic support may help to reduce skeletal pain and does not require use of drugs. Option A is incorrect because Chemotherapy is a treatment for multiple myeloma and may relieve pain, but it involves administration of drugs. Option B is incorrect because Weight bearing through ambulation may help the bones resorb calcium and prevent renal tubular obstruction, but it will not address skeletal pain. Option C is incorrect because Watchful waiting is a strategy used for early stages of multiple myeloma and does not address pain.

Which goal is correct for a patient at risk for intraoperative positioning injury? A. Patient's skin will remain intact. B. Patient will maintain tissue perfusion C. Patient will be free of skin breakdown after surgery. D. Patient will maintain correct position during surgery.

D. Patient will maintain correct position during surgery is the correct goal for the nursing diagnosis of risk for intraoperative positioning injury. Patient position can change during surgery, not by the patient, but from movements of the surgeon and scrub person, use of equipment, and adjustments in OR table level and angles. Patient position is assessed frequently during surgery. Option A is incorrect because Patient's skin will remain intact is an appropriate goal for the diagnosis of risk for impaired skin integrity. It does not address risk related to intraoperative positioning. Option B is incorrect because Patient will maintain tissue perfusion is an appropriate goal for the nursing diagnosis of ineffective tissue perfusion. It does not specifically address risks related to intraoperative positioning unless more information is provided. Option C is incorrect because Patient will be free of skin breakdown after surgery addresses tissue breakdown from scratching, shearing, or tearing, but does not address risk related to intraoperative positioning.

The nurse is caring for a patient with advanced multiple myeloma. Which action by the nurse is appropriate to meet the goals of collaborative care for this patient? A. Draw blood for laboratory tests B. Educate patient on bone marrow examination C. Provide emotional support to the patient D. Review patient's analgesia administration record

D. Patients with multiple myeloma have skeletal pain, and a major goal of collaborative care is alleviating that pain. Therefore the nurse should review the medication administration record to determine when pain medication was last given. Option A is incorrect because Drawing bloods for laboratory tests is an important part of the diagnosis of multiple myeloma but is not necessary to meet the primary goals of collaborative care. Option B is incorrect because A bone marrow examination is used to diagnose multiple myeloma, not to treat it. Option C is incorrect because Although emotional support is an important nursing responsibility, it is not necessary to meet the primary collaborative care goals for the patient with multiple myeloma.

A patient is diagnosed with anemia related to impaired cobalamin (vitamin B12) absorption. Which treatment would the nurse anticipate the health care provider to prescribe? A. A ferrous sulfate tablet B. A strict vegetarian diet C. Transfusion of packed red blood cells D. Discontinuation of the proton-pump inhibitor

D. Proton pump inhibitors, if used for a long period of time, can cause cobalamin malabsorption. The best approach is to discontinue the medication to regain cobalamin absorption. Option A is incorrect because Ferrous sulfate replaces iron and would not help a patient with anemia related to cobalamin absorption. Option B is incorrect because A vegetarian diet would not be helpful in treating the problem of cobalamin absorption. This would only make the problem worse. Option C is incorrect because Packed red blood cells are transfused for acute or chronic blood loss and would not be appropriate for a patient with anemia related to cobalamin absorption.

A patient undergoing radiation therapy for breast cancer reports feeling fatigued during normal daily activities. The nurse indicates that the patient may be at risk for anemia due to which physiological effect of cancer treatment? A. Excessive blood loss B. Destruction of red blood cells C. Decreased synthesis of hemoglobin D. Decreased number of red blood cell precursors

D. Radiation can decrease the production of red blood cell precursors, leading to a decrease in the production of red blood cells, resulting in anemia. Option A is incorrect because Radiation therapy does not result in blood loss and therefore would not cause anemia. Option B is incorrect because Sickle cell disease and certain enzyme deficiencies, not radiation therapy, lead to an increase in the destruction of red blood cells. Option C is incorrect because Iron deficiency and thalassemia, not radiation therapy, lead to a decrease in the synthesis of hemoglobin, resulting in anemia.

Which type of surgical procedure will a patient undergo to restore appearance following breast removal for cancer? A. Ablative B. Palliative C. Constructive D. Reconstructive

D. Reconstructive surgery is performed to restore appearance or function. Breast reconstruction following breast surgery is the type of surgery this patient will undergo. Option A is incorrect because ablative surgery is performed to remove a diseased body part, not to restore appearance. Option B is incorrect because Palliative surgery is performed to relieve symptoms or alleviate pain, not to restore appearance. Option C is incorrect because Constructive surgery restores body function that has been lost or reduced, not appearance.

Which nursing diagnosis would the nurse select for a patient who is scheduled for heart surgery that is projected to last eight hours? A. Impaired Skin Integrity B. Ineffective Tissue Perfusion C. Perioperative Positioning Injury D. Risk for Perioperative Positioning Injury

D. Risk for Perioperative Positioning Injury is the correct nursing diagnosis for a patient scheduled for a projected lengthy procedure. The longer the procedure, the greater risk the patient has of developing a positioning injury, regardless of the weight of the patient. Option A is incorrect because Impaired Skin Integrity is an actual nursing diagnosis. This diagnosis cannot be supported until after the patient's surgery when evidence of actual impaired skin injury is present. Option B is incorrect because Ineffective Tissue Perfusion is an actual nursing diagnosis. This diagnosis cannot be supported until after the patient's surgery when evidence of actual altered skin color, temperature, and diminished pulse are present. Option C is incorrect because Perioperative Positioning Injury is an actual nursing diagnosis. This diagnosis cannot be supported until after the patient's surgery when evidence of an actual injury is present.

Which nursing diagnosis is appropriate for an intraoperative patient with factors related to a problem but no actual problem? A. Deficient Knowledge related to preoperative procedures B. Ineffective Breathing Pattern related to effects of anesthesia C. Ineffective Breathing Pattern with Risk Factor of Diminished Lung/Chest Wall Expansion D. Risk for Perioperative Positioning Injury with Risk Factor of Improper Positioning During Surgery

D. Risk for Perioperative Positioning Injury with Risk Factor of Improper Positioning During Surgery is a risk intraoperative nursing diagnosis because risk factors are present rather than an actual problem. Options A, B and C are incorrect because they diagnose actual problems.

Which disease process should the nurse identify as the cause of the patient's serum potassium concentration of 5.3 mEq/L? A. Anorexia B. Alcoholism C. Hyperaldosteronism D. Severe infections

D. Severe infections, causing the release of intracellular potassium, are a cause of hyperkalemia. Option A is incorrect because norexia can cause hypokalemia, not hyperkalemia. Option B is incorrect because Alcoholism can cause hypokalemia, not hyperkalemia. Option C is incorrect because HyperaldosteronismHyperaldosteronism can cause hypokalemia, not hyperkalemia.

A patient diagnosed with immune thrombocytopenic purpura (ITP) will be undergoing a splenectomy. A family member asks why this procedure is necessary. Which response by the nurse is appropriate? A. "Removal of the spleen will enable the production of ADAMTS13." B. "The splenectomy will increase the number of platelets being produced." C. "This procedure is necessary to correct the chronic splenomegaly." D. "Removal of the spleen will stop the unwarranted destruction of your platelets."

D. Since ITP is autoimmune in nature, a person with chronic ITP may benefit from the removal of the spleen since it is a major source of autoantibody production. Option A is incorrect because ADAMTS13 deficiency is associated with thrombotic thrombocytopenic purpura (TTP), not ITP. This response would not indicate why the patient is undergoing a splenectomy. Option B is incorrect because As platelets are made in the bone marrow, a splenectomy, or removal of the spleen, will not affect platelet production. =Option C is incorrect because There is no indication that the patient has splenomegaly. Splenomegaly may be a cause of acquired, nonimmune thrombocytopenia, but not of ITP.

In which way does smoking increase a patient's surgical risk? A. Increases risk for excessive bleeding B. Increases overall cellular metabolism C. Decreases overall inflammatory response D. Decreases ability to maintain a clear airway

D. Smoking inhibits the function of cilia in the trachea and bronchi and leads to increased irritation and mucus production, especially with anesthesia. This increases surgical risk because it decreases the patient's ability to maintain a clear airway. Option A is incorrect because Smoking increases the patient's risk for clotting, but not for excessive bleeding. Option B is incorrect because Smoking influences cellular metabolism by decreasing, not increasing, cellular oxygenation. This is damaging to cells and increases surgical risk. Option C is incorrect because Smoking contributes to overall increased, not decreased, inflammatory response. This increased response increases surgical risk.

Which surgical procedure is restorative? A. Excisional biopsy B. Heart transplantation C. Congenital heart defect repair D. Carpal ligament reconstruction

D. Surgery that repairs function of a previously damaged or diseased body part is categorized as a restorative surgery. Option A is incorrect because All biopsies are categorized as diagnostic, not restorative, surgeries Option B is incorrect because Heart transplants are categorized as transplantation, not restorative, surgeries. Option D is incorrect because Surgery that repairs function of a previously damaged or diseased body part is categorized as a restorative surgery.

Which intraoperative team member protects patient safety by continually assessing surgical asepsis? A. Surgeon B. Scrub person C. RN first assistant D. Circulating nurse

D. The circulating nurse assesses for safety and aseptic practice and is the intraoperative team member who continually assesses for surgical asepsis. Option A is incorrect because The surgeon concentrates on performing the procedure and maintains sterile practice, but is not responsible for assessing surgical asepsis. Option B is incorrect because The scrub person prepares and maintains asepsis of the surgical field, but is not responsible for continually assessing surgical asepsis. Option C is incorrect because The RN first assistant collaborates with and assists the surgeon, but is not responsible for assessing surgical asepsis.

Which surgical team member is responsible for initiating the "time-out" during the intraoperative phase of surgery? A. Surgeon B. Scrub person C. Anesthesiologist D. Circulating nurse

D. The circulating nurse is responsible for initiating the time-out before surgery can take place. The circulating nurse's role includes coordination of all patient care during the intraoperative phase of surgery. Option A is incorrect because The surgeon participates in the time-out, but does not initiate the time-out. The surgeon cannot begin the surgical procedure until after the time-out has taken place. Option B is incorrect because The scrub person participates in the time-out, but does not initiate the time-out. The scrub person cannot participate with the surgeon until after the time-out has taken place. Option C is incorrect because The anesthesiologist does not initiate the time-out, but does stand by and participate in the time-out procedure.

Which nursing diagnosis would the nurse select for a homeless person admitted to the PACU following emergency surgery? A. Injury related to patient being homeless B. Risk for Suicide related to patient being homeless C. Social Isolation related to patient being homeless D. Risk for Insufficient Post-Discharge Care related to limited resources

D. The diagnosis addresses the patient's current situation. There is data to indicate the patient is homeless, which is a risk factor associated with limited resources for post-discharge care. Option A is incorrect because The diagnosis does not address the patient's situation. There is no data to indicate the patient sustained an injury related to homelessness. Option B is incorrect because The diagnosis does not address the patient's situation. There is no data to indicate that the patient is suicidal because of homelessness. Option C is incorrect because The diagnosis does not address the patient's situation. There is no data to indicate the patient is socially isolated due to homelessness.

Which goal would best address a postoperative patient's nursing diagnosis of acute nausea? A. Being able to eat normally B. Having normal bowel elimination C. Having normal fluid and electrolyte levels D. Having reduced or absent nausea and vomiting

D. The goal of reduced or absent nausea and vomiting addresses the diagnosis of acute nausea. Option A is incorrect because The goal of eating normally would address a nursing diagnosis of postoperative anorexia, but not acute nausea. Option B is incorrect because The goal of normal bowel elimination after surgery would address a nursing diagnosis of constipation, but not acute nausea. Option C is incorrect because the goal of normal fluid electrolyte levels would address a nursing diagnosis of dehydration, but not acute nausea.

The nurse implemented early ambulation and leg exercises for a patient. Which postoperative complication was the nurse attempting to prevent? A. Atelectasis B. Pneumonia C. Constipation D. Thrombophlebitis

D. The nurse was attempting to prevent thrombophlebitis by focusing on preventing clots from developing. Antiembolism stockings, sequential compression devices, leg exercises, and early ambulation promote circulation and help prevent thrombus formation. Option A is incorrect because Early ambulation can facilitate breathing, but leg exercises would not help prevent atelectasis. Option B is incorrect because Early ambulation can facilitate breathing, but leg exercises would not help prevent pneumonia. Option C is incorrect because Early ambulation does facilitate peristalsis, but leg exercises would not help prevent constipation.

Which team member would the nurse collaborate with about a postoperative patient with shortness of breath? A. Surgeon B. Anesthesiologist C. Speech therapist D. Respiratory therapist

D. The nurse would collaborate with the respiratory therapist for a postoperative patient experiencing shortness of breath. The patient could need to learn how to use an incentive spirometer to facilitate lung expansion. The respiratory therapist would help the nurse determine the cause of the patient's shortness of breath, the treatment for it, and whether or not the surgeon needs to be contacted. Option A is incorrect because The nurse would not contact the surgeon unless there was a breathing emergency. Shortness of breath is not an emergency, but it does need to be addressed. Option B is incorrect because The anesthesiologist would not be contacted by the nurse unless the patient had a respiratory obstruction. Shortness of breath is not a sign of an obstruction. However, it does need to be addressed. Option C is incorrect because Speech therapists are rarely involved in the care of patients during the immediate postoperative phase of surgery. The nurse would not collaborate with the speech therapist.

Which data supports the achievement of the preoperative goal, "Patient will exhibit vital signs within normal limits during the preoperative period"? A. Temperature 99.6° F orally; BP 90/50 mm Hg B. HR 102 bpm; BP 180/100 mm Hg C. Temperature 98.6° F orally; BP 150/90 mm Hg D. HR 72 bpm; BP 110/70 mm Hg

D. This set of vital signs supports the achievement of the goal. Both the heart rate and blood pressure are normal and reflect a lowered state of anxiety. Option A is incorrect because This set of vital signs does not support achievement of the goal. The vital signs are not within normal limits. Temperature is elevated and blood pressure is low. Option B is incorrect because This set of vital signs does not support achievement of the goal. The heart rate is elevated (tachycardia) and the blood pressure is elevated. Option C is incorrect because This set of vital signs does not support achievement of the goal. The temperature is normal but the blood pressure is elevated.

Which action would the nurse implement for a patient who needs frequent dressing changes but whose skin is irritated by tape? A. Apply lotion to the irritated skin B. Leave the dressing off periodically C. Reduce the number of dressing changes D. Replace the tape with Montgomery straps

D. The nurse would implement this action. Because frequent dressing changes are required, tape can be replaced with Montgomery straps (ties) that are specifically designed to decrease skin irritation caused by repeated removal of tape. Option A is incorrect because This is not an action the nurse would implement. Lotion is contraindicated without first consulting with the surgeon because it increases the risk for infection and compromises wound healing. Option B is incorrect because Leaving the dressing off periodically is not an option for a patient who requires frequent dressing changes. The likely reason for frequent dressing changes is copious drainage. Drainage and tape are both very irritating to skin. This is not an action the nurse would implement. Option C is incorrect because This is not an action the nurse would take because it is already established that the patient needs frequent dressing changes. This action also does not address the problem of skin irritation caused by tape.

Which nursing diagnosis would the nurse select for a patient who develops a fever and purulent incisional drainage 48 hours after surgery? A. Purulent wound related to incision B. Risk for infection related to surgery C. Infection related to surgical incision D. Impaired skin integrity related to infection

D. The nurse would select this nursing diagnosis for the patient. It addresses the patient's impaired skin integrity (actual nursing diagnosis) related to infection (fever, purulent incisional drainage). Option A is incorrect because This nursing diagnosis is not a correctly formulated diagnosis, since purulent wound drainage is not a nursing diagnostic label. Option B is incorrect because This nursing diagnosis is not stated correctly because the related factor is not specific, e.g. surgical incision. Additionally, the patient has clinical manifestations of a problem, which makes a risk diagnosis incorrect. Option C is incorrect because Infection related to surgical incisionThis nursing diagnosis is not stated correctly. Infection is not a nursing diagnostic label and surgical incision is not a related factor.

Which surgical setting will the surgeon select for a patient's leg amputation? A. Rehabilitation center B. Outpatient surgery C. Ambulatory surgery D. Inpatient surgery

D. The patient will not be dismissed to home following surgery, but will be admitted to the nursing unit for care of the limb, teaching, and physical therapy. This surgery will be performed in the inpatient setting. Option A is incorrect because The patient may be transferred to a rehabilitation center following recovery, but rehabilitation centers are generally not arenas where surgeries are performed. This setting is not suitable for performing an amputation. Option B is incorrect because The patient will not be dismissed to home following surgery. Postoperative education and care will be required. This surgery center is not suitable for this type of surgery. Option C is incorrect because he patient will not be dismissed to home following surgery. Postoperative education and care will be required. This surgery center is not suitable for this type of surgery.

Which goal for the patient during the intraoperative period is both stated correctly and measurable? A. Patient will understand operative instructions. B. Patient will be correctly positioned for surgery. C. Patient will exhibit vital signs within normal limits in the preoperative phase D. Patient will remain hemodynamically stable during surgery.

D. The patient will remain hemodynamically stable during the intraoperative phase is an intraoperative goal. It is correctly stated and measurable. Option A is incorrect because This goal is not stated correctly and is not measurable. Patient understanding must be verbalized or measured by some means. When stated correctly, this goal is applied to the preoperative, not the intraoperative, phase of surgery. Option B is incorrect because This goal is not stated correctly and is not measurable. It states the nurse's action, not the goal for the patient. It is not measurable because it does not delineate the correct position for the patient. Option C is incorrect because he patient will exhibit vital signs within normal limits in the preoperative phase is a preoperative goal, not an intraoperative goal. The goal is measurable.

Which nursing diagnosis would the PACU nurse select for a postoperative patient with decreased blood pressure, poor capillary refill, and copious wound drainage? A. Wound infection B. Risk for vomiting C. Risk for hemorrhage D. Deficient fluid volume

D. The patient's clinical manifestations support the selection of this nursing diagnosis. Actual nursing diagnoses apply when there is evidence of an actual problem, such as deficient fluid volume. Option A is incorrect because There is inadequate patient data to support this actual nursing diagnosis. There is copious wound drainage, but there is no indication that the drainage is purulent or foul-smelling. Option B is incorrect because There is no data to support this risk nursing diagnosis. The patient has clinical manifestations that suggest more than a risk from surgery is present. Option C is incorrect because This nursing diagnosis is a risk diagnosis. The patient has clinical manifestations that suggest more than a risk from surgery is present.

The patient's goal is "Patient airway will remain open during surgery." What is the intraoperative nursing diagnosis for this patient? A. Ineffective Tissue Perfusion B. Breathing Pattern C. Risk for Ineffective Tissue Perfusion D. Risk for Ineffective Breathing Pattern

D. The patient's goal fits the nursing diagnosis of Risk for Ineffective Breathing Pattern. Because the patient is undergoing anesthesia, the risk factor for ineffective breathing pattern does exist. Option A is incorrect because The patient's goal does not fit the nursing diagnosis of Ineffective Tissue Perfusion. While inadequate oxygenation can affect tissue perfusion, there is no data to support that the patient has inadequate oxygenation. Option B is incorrect because The patient's goal does not fit the nursing diagnosis of Ineffective Breathing Pattern. There is no data to support that the patient currently has a breathing problem. Option C is incorrect because The patient's goal does not fit the nursing diagnosis of Risk for Ineffective Tissue Perfusion. While inadequate oxygenation can affect tissue perfusion, there is no data to support risk factors for inadequate oxygenation.

When the nurse is addressing surgical risk during the preoperative phase of surgery, which cultural factor takes priority? A. Obesity B. Smoking C. Pain control D. Language barrier

D. The patient's language barrier is the cultural factor that takes priority during the preoperative phase of surgery. The patient's inability to understand teaching and understand what is happening can increase stress and anxiety and thereby increase the patient's surgical risk. Option A is incorrect because While obesity is a surgical risk factor and can be considered a cultural factor in many instances, it is not the factor that takes priority during the preoperative phase of surgery. Option B is incorrect because While smoking does increase surgical risk and can be considered a cultural factor in some instances, it is not the factor that takes priority during the preoperative phase of surgery. Option C is incorrect because Pain and pain control are cultural factors that affect the patient during the postoperative phase of surgery. The patient's pain plan begins during the preoperative phase, but it is not the factor that takes priority during the preoperative phase of surgery.

Which person will the preoperative nurse collaborate with when a patient has a concern about postoperative ambulatory care? A. Surgeon B. Anesthesiologist C. RN first assistant D. PACU nurse

D. The post-anesthesia care unit (PACU) nurse provides immediate care and commonly provides discharge care in ambulatory surgery centers. The preoperative nurse frequently collaborates with the postoperative nurse when patients have questions or concerns about postoperative care. Option A is incorrect because The surgeon performs surgery, but does not provide postoperative patient care. The preoperative nurse will consult with another team member about postoperative care. Option B is incorrect because The anesthesiologist administers medications and anesthesia, but does not provide postoperative patient care. The preoperative nurse will consult with another team member about postoperative care. Option C is incorrect because The RN first assistant assists the surgeon with the surgery, but does not provide postoperative patient care. The preoperative nurse will consult with another team member about postoperative care.

Which nursing diagnosis will the preoperative nurse select for a patient with a history of chronic pain scheduled for a painful procedure? A. Acute Pain B. Anxiety C. Risk for Chronic Pain D. Risk for Acute Pain

D. This diagnosis addresses the patient's current pain situation because it acknowledges the risk factor of scheduled painful procedure. Option A is incorrect because There is no data to support this diagnosis because the patient is not yet experiencing acute pain. Option B is incorrect because There is no data to support this diagnosis because the patient is not yet verbalizing anxiety about the procedure. Option C is incorrect because This diagnosis does not address the patient's current pain situation. It addresses risk for chronic pain. However, the patient already has chronic pain, not the risk factors for chronic pain.

Which nursing diagnosis would the nurse individualize for a postoperative patient scheduled for discharge who is expressing interest in home self-care? A. Readiness for enhanced knowledge of disease process B. Readiness for enhanced comfort as evidenced by patient readiness for discharge C. Readiness for education as evidenced by patient request for reading materials and videos D. Readiness for enhanced self-care as evidenced by patient verbalizations of interest in learning

D. This nursing diagnosis addresses the patient's interest in home self-care. The nurse can individualize the nursing diagnosis to meet the patient's needs. Option A is incorrect because This nursing diagnosis does not address the patient's interest in home self-care. It addresses teaching about the surgical procedure or disease that resulted in the surgery. Option B is incorrect because This nursing diagnosis does not address the patient's interest in home self-care. It addresses the patient's comfort level prior to discharge. Option C is incorrect because This nursing diagnosis indicates that the patient is ready to learn but does not address the patient's interest in self-care.

Which nursing diagnosis would the PACU nurse individualize for a patient with a genetic bleeding disorder? A. Wound dehiscence related to coagulation issues B. Risk for impaired skin integrity related to genetic bleeding disorder C. Impaired skin integrity related to wound dehiscence as evidenced by poor coagulation D. Risk for postoperative complications related to surgical incision and coagulation disorder

D. This nursing diagnosis can be individualized for the patient. The patient has risk factors including a genetic bleeding disorder as well as a surgical incision, which both may contribute to postoperative complication(s). One such complication includes lack of coagulation necessary for wound healing. Option A is incorrect because Wound dehiscence is not a nursing diagnostic label. As well, there is no data to indicate the actual problem of wound dehiscence has occurred. Option B is incorrect because A surgical incision constitutes impaired skin integrity, so the patient has an actual problem. They are not at risk for this problem, since it has already occurred via the surgery. Option C is incorrect because This diagnosis cannot be individualized for this patient. There is no data to suggest that wound dehiscence has occurred; there is only a risk for this complication. The impaired skin integrity is an actual problem, but it is related to the surgical incision, not would dehiscence.

A patient presents to the clinic with possible immune thrombocytopenic purpura (ITP) due to a rash on the upper legs and arm and is also recovering from a bad case of strep throat. The patient has no significant medical history. The nurse should anticipate which medication will be administered to this patient? A. Heparin B. Platelets C. Antibiotic D. Prednisone

D. This patient is presenting with signs of ITP. Many cases will resolve on their own, but if needed, the best medication for this patient would be a low-dose steroid. Option A is incorrect because This patient is presenting with ITP and heparin is therefore not the best medication for this patient. Option B is incorrect because Platelets would not be used for this patient since the treatment is not indicated. Option C is incorrect because This patient has ITP and therefore an antibiotic will not be helpful. Although the patient has a history of strep throat, it is resolving and the new symptom needs to be addressed.

The nurse is caring for a 20-year-old patient with thalassemia major. Which finding would be expected when reviewing the patient history? A. Heart failure B. Hypertension C. No previous symptoms D. Failure to meet cognitive milestones

D. Thalassemia major can cause both physical and mental delays. A delay in meeting cognitive milestones would be an expected finding in the patient's history. Option A is incorrect because Sickle cell disease, not thalassemia major, is associated with heart disease. Option B is incorrect because Hypertension is an expected finding for a patient with sickle cell disease, not thalassemia. Option C is incorrect because Thalassemia minor, not major, may be associated with no significant symptoms of disease.

Which patient admission assessment is documented accurately by the intraoperative nurse? A. "No evidence of anxiety. Anesthesia induction initiated." B. "Patient admitted. CRNA adjusting IV fluids. Vital signs stable." C. "Preoperative checklist completed. Patient admitted for appendectomy." D. "Patient placed in supine position on OR table. Assessment per flowsheet."

D. This statement correctly documents patient admission to the OR and patient assessment. Patient position is indicated and reference to documentation of assessment findings is also indicated. Option A is incorrect because While anxiety is part of admission assessment, induction of anesthesia does not relate to patient assessment. Option B is incorrect because This documentation contains only one reference to patient assessment. The CRNA, not the intraoperative nurse, documents adjustments to IV fluid rates. Option C is incorrect because This statement does not document the patient's admission assessment.

Which patient response suggests risk for postoperative complications following discharge to home? A. "I have plenty of room for all the equipment I'll need at home." B. "I have a plan to meet my incision care needs when I get home." C. "I'll call my surgeon if I develop the symptoms we discussed earlier." D. "My daughter can help me with my dressing at least twice each week."

D. This statement suggests risk for the postoperative complication of wound infection. If the patient's daughter is only able to assist twice each week, does that mean the patient's dressing will only be changed twice each week? More information needs to be gathered from this patient to determine this patient's risk for complications. Option A is incorrect because This statement indicates the patient has thought about and planned for the placement of needed equipment following discharge. It does not suggest risk for postoperative complications. Option B is incorrect because This statement indicates the patient has thought about and planned for care upon discharge. It does not suggest risk for postoperative complications. Option C is incorrect because This statement indicates the patient understands symptoms that indicate complications and the need for reporting them. It does not suggest risk for postoperative complications.

What is the rationale for placing warmed blankets over a patient prior to surgical draping? A. Increase comfort B. Reduce infection risk C. Avoid contamination D. Prevent hypothermia

D. Warmed blankets placed over the patient prevent hypothermia caused by the decreased metabolic rate from anesthesia and drugs that lower the patient's body temperature during surgery. Option A is incorrect because Warmed blankets increase comfort for patients who are awake but do not affect the comfort of those who are anesthetized during surgery. Option B is incorrect becauseA cool surgical environment, not warmed blankets, facilitate reduced risk for infection during the intraoperative phase of surgery. Option C is incorrect because warmed blankets are not water or solution-repellant or sterile. They are not used to avoid or prevent contamination.

A nurse in the oncology unit is planning to begin patient assessment at the onset of his or her shift. Which patient should the nurse assess first? A. A patient with lung cancer who is taking imatinib B. A patient with a history of smoking who is taking gefitinib C. A patient with a family history of alcohol abuse who is receiving gefitinib D. A patient with a history of recent radiation therapy who is receiving gefitinib

D. A patient with a history of recent radiation therapy who is taking gefitinib has an increased risk for adverse drug reactions and should be assessed first. Option A is incorrect because A patient with lung cancer who is taking imatinib requires regular routine assessment. Option B is incorrect because a patient with a history of smoking may need cessation counseling to reduce risk of cancer, but this patient is not the priority assessment. Option C is incorrect because Family history of alcohol abuse poses no personal risks for a patient taking gefitinib.

A patient with multiple myeloma asks the nurse why this disease developed. Which statement is the best response by the nurse regarding the cause for multiple myeloma? A. "The cause and risk factors for multiple myeloma are unknown and under debate." B. "Hypercalcemia leads to bone degeneration and multiple myeloma." C. "The etiology is unknown, but risk factors include skeletal fractures, family history, and chemical exposure." D. "There is no primary cause for multiple myeloma, but some risk factors, such as radiation and obesity, are associated with the disease."

D. Although the cause of multiple myeloma is still unknown, risk factors include exposure to radiation, organic chemicals, obesity, genetic factors, and viral infections. Option A is incorrect because Although the cause of multiple myeloma is still unknown, there are some known risk factors for multiple myeloma that are not under debate. Option B is incorrect because Bone degeneration from hypercalcemia is a clinical sign of multiple myeloma, not a cause of it. Option C is incorrect because Although the cause of multiple myeloma is still unknown, there are some known risk factors. While the risk factors include chemical exposure and genetic predisposition, skeletal fractures are not included. Skeletal fractures are a possible manifestation of multiple myeloma, not a risk factor for multiple myeloma.

Hematopoietic drugs and immunomodulating drugs belong to which class of anticancer drugs? A. Targeted drugs B. Cytotoxic drugs C. Hormonal antagonists D. Biologic response modifiers

D. Hematopoietic drugs and immunomodulating drugs are biologic response modifiers that alter the body's response to cancer and other diseases. Option A is incorrect because Hematopoietic drugs and immunomodulating drugs are not targeted drugs. Option B is incorrect because Cytotoxic drugs do not include hematopoietic drugs and immunomodulating drugs. Option C is incorrect because Hematopoietic drugs and immunomodulating drugs are not classified as hormone antagonists.

Uncomplicated laparoscopic surgeries are generally performed in which type of setting? A. Surgeon's office B. Surgical clinic C. Inpatient surgery D. Ambulatory surgery

D. Laparoscopic procedures are typically outpatient or ambulatory procedures. They are performed in ambulatory surgery centers with specialized equipment. Option A is incorrect because Many minor surgeries, such as removal or lesions, are performed in surgeon offices, but not uncomplicated laparoscopic surgeries that require specialized equipment and supplies. Option B is incorrect because any surgeries, such as eye surgery and plastic surgery, are performed in surgical clinics, but not uncomplicated laparoscopic surgeries that require specialized equipment and supplies. Option C is incorrect because Uncomplicated laparoscopic abdominal surgeries are not commonly performed in inpatient surgical suites because most patients can return home after they recover from the procedure.

Which surgical procedure is ablative? A. Tummy tuck B. Biopsy of a breast mass C. Pain reduction procedure D. Removal of the gallbladder

D. Removing a diseased body part, such as a diseased gallbladder, is ablative surgery. Option A is incorrect because A tummy tuck procedure used to improve appearance is a cosmetic surgery, not an ablative surgery. Option B is incorrect because Biopsies are diagnostic procedures used to confirm a diagnosis, not ablative procedures. Option C is incorrect because Surgery to reduce pain is palliative surgery, not ablative surgery.

The nurse is planning to implement an order to monitor a cancer patient's complete blood count (CBC) following commencement of anticancer medication therapy. Which scheduling of this order is most appropriate? A. Monthly for the first and second months and periodically there after B. Bi-weekly for the first and second months and periodically thereafter C. Every third week for the first and second months and periodically thereafter D. Weekly for the first month, bi-weekly for the second month, and periodically thereafter

D. Risk of adverse effects of anticancer therapy is high at onset of medication and lessens after subsequent doses. The standard monitoring schedule for blood cell abnormalities associated with anticancer medications is weekly for the first month, bi-weekly for the second month, and periodically thereafter. All other options are not an appropriate schedule.

Which surgical team member is responsible for assessing patient positioning during the intraoperative phase of surgery? A. Scrub person B. RN first assistant C. Anesthesiologist D. Circulating nurse

D. The circulating nurse is responsible for patient positioning to ensure patient comfort and safety throughout the surgical procedure. The nurse assesses the patient's position throughout the surgery and makes adjustments to the OR table as directed by the surgeon. Option A is incorrect because The scrub nurse is responsible for setting up the surgical field and maintaining surgical asepsis during the surgery, but is not responsible for assessing the patient's position. Option B is incorrect because The RN first assistant is responsible for assisting the surgeon with the surgical procedure. Sometimes the RN first assistant will assist with positioning the patient, but he or she does not take responsibility for assessing the patient's position. Option C is incorrect because The anesthesiologist is responsible for maintaining the patient's airway and administering anesthesia. Sometimes the anesthetist will offer advice about positioning to maintain airway patency, but he or she does not assist with or assess the patient's position.

Which serum potassium concentrations would the nurse identify as hyperkalemia in the patient's medical record? Select all that apply. A. 2.5 mEq/L B. 3.0 mEq/L C. 4.6 mEq/L D. 5.1 mEq/L E. 5.5 mEq/L

D., E. A serum potassium concentration of 5.1 mEq/L is hyperkalemia. Therefore, the nurse would identify this as hyperkalemia. 5.5 mEq/LA serum potassium concentration of 5.5 mEq/L is hyperkalemia. Therefore, the nurse would identify this as hyperkalemia. Option A is incorrect because A serum potassium concentration of 2.5 mEq/L would cause the nurse to identify hypokalemia, not hyperkalemia. Option B is incorrect because 3.0 mEq/LA serum potassium concentration of 3.0 mEq/L would cause the nurse to identify hypokalemia, not hyperkalemia. Option C is incorrect because 4.6 mEq/LA serum potassium concentration of 4.6 mEq/L is considered normal. Normal potassium levels range between 3.5 to 5.

A patient is diagnosed with hypermagnesemia related to an increased intake of magnesium. Which topic should the nurse include when providing patient education regarding the cause of the condition? Select all that apply. A. Adrenal insufficiency B. Leukemia C. Poor renal function D. Antacid use E. Magnesium-containing laxatives

D., E. Antacid use is a cause of hypermagnesemia related to increased intake of magnesium. Excessive intake of magnesium-containing laxatives is a cause of hypermagnesemia related to increased intake of magnesium. Option A is incorrect because While adrenal insufficiency is a cause of hypermagnesemia, this is not a cause related to increased intake of magnesium. Option B is incorrect because While leukemia is a cause of hypermagnesemia, this is not a cause related to increased intake of magnesium. Option C is incorrect because Poor renal functionWhile poor renal function is a cause of hypermagnesemia, this is not a cause related to increased intake of magnesium.