Ch 18 M/S
The drug interleukin-2 is an example of which type of biologic response modifier?
Cytokine
What are considered carcinogens? Parasites Medical procedures Dietary substances Infective genes
Dietary substances (326) Carcinogens include chemical agents, environmental factors, dietary substances, viruses, defective genes, and medically prescribed interventions
A client with cancer is being evaluated for possible metastasis. What is one of the most common metastasis sites for cancer cells?
Liver
A patient with uterine cancer is being treated with internal radiation therapy. What would the nurse's priority responsibility be for this patient? Explain to the patient that she will continue to emit radiation while the implant is in place. Maintain as much distance as possible from the patient while in the room. Alert family members that they should restrict their visiting to 5 minutes at any one time. Wear a lead apron when providing direct patient care.
Explain to the patient that she will continue to emit radiation while the implant is in place.
A nurse is providing in-home hospice care to a terminally ill client. The client experiences a medical crisis requiring monitoring and medication administration. Which level of hospice care would the nurse implement? Routine home care Continuous care Inpatient respite care General inpatient care
Continuous care Continuous care is provided in the home for management of medical crisis. Routine home care would be used to provide the usual services to a client, such as nursing care, medical social services, counseling, home health aide/homemaker servies, and various therapies. Inpatient respite care would be used for a 5-day stay to provide relief for family caregivers. General inpatient care is used for symptom management that cannot be provided in the home.
In which phase of the cell cycle does cell division occur? Mitosis G1 phase S phase G2 phase
Mitosis (341) Cell division occurs in mitosis. RNA and protein synthesis occurs in the G1 phase. DNA synthesis occurs during the S phase. DNA synthesis is complete, and the mitotic spindle forms in the G2 phase.
The nurse observes bloody drainage on the surgical dressing of the client who has just arrived on the nursing unit. Which intervention should the nurse plan to do next? a) Make the client NPO and order a stat hemoglobin and hematocrit. b) Outline the drainage with a pen and record the date and time next to the drainage. c) Take the client's vital signs and call the surgeon. d) Remove the dressing, assess the wound, and apply a new sterile dressing.
Outline the drainage with a pen and record the date and time next to the drainage. Explanation: Areas of drainage on the dressing should be outlined with a pen, and the date and time should be recorded next to the drainage. Blood drainage from the incision is a normal expected finding in the immediate postoperative period; however, excessive amounts should be reported to the surgeon.
A client with a brain tumor is undergoing radiation and chemotherapy for treatment of cancer. The client has recently reported swelling in the gums, tongue, and lips. Which is the most likely cause of these symptoms? Neutropenia Extravasation Nadir Stomatitis
Stomatitis
The client is receiving a vesicant antineoplastic for treatment of cancer. Which assessment finding would require the nurse to take immediate action? Extravasation Stomatitis Nausea and vomiting Bone pain
Extravasation
Which of the following factors may contribute to rapid and shallow respirations in a postoperative client? Select all that apply. a) Pain b) Obesity c) Effects of analgesics and anesthesia d) Constricting dressings e) Abdominal distention
• Pain • Obesity • Constricting dressings • Abdominal distention Correct Explanation: Often, because of the effects of analgesic and anesthetic medications, respirations are slow. Shallow and rapid respirations may be caused by pain, constricting dressings, gastric dilation, abdominal distention, or obesity.
Which type of hematopoietic stem cell transplantation (HSCT) is characterized by cells from a donor other than the patient?
Allogenic
A client is recovering from a craniotomy with tumor debulking. Which comment by the client indicates to the nurse a correct understanding of what the surgery entailed?
"I guess the doctor could not remove the entire tumor."
A serum sodium concentration lower than 115 mEq/L (115 mmol/L) is associated with anorexia. seizure. weight gain. myalgia.
seizure. Explanation: A serum sodium concentration lower than 115 mEq/L (115 mmol/L) is associated with seizures, abnormal reflexes, papilledema, coma, and death. Anorexia, weight gain, and myalgia are associated with serum sodium concentrations lower than 120 mEq/L.
The Sims' or lateral position as shown in Option D would be used for renal surgery. The dorsal recumbent position (Option A) is used for most abdominal surgeries, except those for the gallbladder or pelvis. The Trendelenburg position (Option B) is used for surgery on the lower abdomen and pelvis. The lithotomy position (Option C) is used for nearly all perineal, rectal, and vaginal surgical procedures.
(see full question) A patient is to undergo surgery on his kidney. The patient would be placed in which position for the surgery?
A patient undergoes induction for general anesthesia at 8:30 a.m. and is being assessed continuously for the development of malignant hyperthermia. At which time would the patient be most likely to exhibit manifestations of this condition? a) 9:00 to 9:10 a.m. b) 9:30 to 9:40 a.m. c) 10:00 to 10:10 a.m. d) 8:40 to 8:50 a.m
8:40 to 8:50 a.m. Explanation: Malignant hyperthermia usually manifests about 10 to 20 minutes after the induction of anesthesia, which in this case would 8:40 to 8:50 a.m.
The hazards of surgery for the aged increase as the number and severity of coexisting health problems increase. Which of the following are structural or functional changes in the elderly that impact the surgical experience? Select all that apply
Answer: b. Increased fatty tissue prolongs elimination of anesthesia. c. Decreased ability to compensate for hypoxia increases the risk of an embolism. e. Loss of collagen increases the risk of skin complications. f. Reduced tactile sensitivity can lead to assessment and communication problems
5-Fluorouracil (5FU) is classified as which type of antineoplastic agent? Antimetabolite Alkylating Nitrosoureas Mitotic spindle poisons
Antimetabolite (343) 5-FU is an antimetabolite. An example of an alkylating agent is nitrogen mustard. A nitrosourea is streptozocin. A mitotic spindle poison is vincristine (VCR)
A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan?
Avoiding using soap on the irradiated areas
Which of the following medications may increases the hypotensive action of anesthesia?
Chlorpromazine (Thorazine)
A client has just received stem cell transplantation as treatment for leukemia. What are the post procedural nursing interventions for clients receiving any form of stem cell transplantation? Closely monitor the client for at least 3 months. Closely monitor the client for at least 3 days. Closely monitor the client for at least 4 weeks. Closely monitor the client for at least 5 months.
Closely monitor the client for at least 3 months. (348)
The nurse is admitting the older adult to the PACU. Which information about this client would be most important for the PACU nurse to obtain? a) What was estimated blood loss? b) Does the client have a history of dementia? c) What procedure was performed? d) Are family members available?
Does the client have a history of dementia? Correct Explanation: Acute confusion is a common side effect of anesthesia in older adults. The nurse needs to know whether any confusion displayed by the client is a result of the surgery and anesthesia or a usual state for the client.
The nurse is providing an educational presentation on dietary recommendations for reducing the risk of cancer. Which of the following food selections would demonstrate a good understanding of the information provided in the presentation? Select all that apply. Egg white omelet with spinach and mushrooms Crispy chicken Caesar Salad Steamed broccoli and carrots Turkey breast on whole wheat bread Smoked salmon Vegetable and cheddar quiche
Egg white omelet with spinach and mushrooms Steamed broccoli and carrots Turkey breast on whole wheat bread
A nurse has agreed to draft a medication teaching plan for a patient who is taking the hormonal agent, Aromasin, an aromatase inhibitor for postmenopausal women with breast cancer. The nurse knows that a major teaching point is to tell the patient to: a. Report the unusual sign of nausea. b. Increase her intake of calcium-rich foods. c. Be alarmed if she notices fluid retention d. Report the unexpected sign of increased appetite and weight gain.
b. Increase her intake of calcium-rich foods.
The nurse is reviewing the medications of a postoperative client. Which of the following medications may be of concern to the nurse? a) digoxin (Lanoxin) b) allopurinol (Zyloprim) c) predinisone (Deltasone) d) furosemide (Lasix)
predinisone (Deltasone) Correct Explanation: Corticosteroids impair the normal inflammatory process and may mask infection.
The client is experiencing intractable hiccups following surgery. The nurse expects the surgeon to order: a) chlorpromazine (Thorazine) b) omeprazole (Prilosec) c) metoclopramide (Reglan) d) ranitidine (Zantac)
chlorpromazine (Thorazine) Explanation: Chlorpromazine (Thorazine) is used to treat intractable hiccups.
The root cause of cancer is damage to cellular deoxyribonucleic acid (DNA) which can be caused by many factors, or carcinogens. What factors can be carcinogenic? Select all that apply. dietary substances environmental factors viruses gender age
dietary substances environmental factors viruses
The nurse is evaluating the client's risk for cancer and recommends changes when the client states she uses the treadmill for 30 minutes on 5 days each week eats red meat such as steaks or hamburgers every day works as a secretary at a medical radiation treatment center drinks 1 glass of wine at dinner each night
eats red meat such as steaks or hamburgers every day (329) Dietary substances such as nitrate-containing, nitrite-containing, and red meats appear to increase the risk of cancer. Exercising 30 minutes on 5 days or more is recommended for adults. Measures are taken to protect those people who work around radiation. It is OK to drink 1 glass of wine per day.
Monitored anesthesia care differs from moderate sedation in that monitored anesthesia care:
may result in the administration of general anesthesia. Explanation: Monitored anesthesia care may require the anesthsiologist to convert to general anesthesia.
A client develops a hemorrhage one hour post surgery. The nurse knows this is most likely an intermediary hemorrhage from a vein because it occurred: within the first few hours, and has darkly colored blood that bubbles out slowly. during surgery, and has bright red blood that flows freely. at a suture site, and the blood appears intermittently in spurts. a few hours after surgery, and the bright red blood appears with each heartbeat.
within the first few hours, and has darkly colored blood that bubbles out slowly. Explanation: An intermediary hemorrhage appears within the first few hours following surgery. Darkly colored blood that bubbles out quickly indicates a venous hemorrhage. A hemorrhage that occurs during surgery is classified as a primary hemorrhage. A bright red color indicates that a hemorrhage's source is an artery. Secondary hemorrhages occur when sutures slip or drainage tubes dislodge insecure vessels.
The nurse is assessing the client for wound complications following surgery. For which clinical manifestation should the nurse assess? Select all that apply. a) Paralytic ileus b) Dehiscence c) Hematoma d) Atelecstasis e) Thrombophlebitis
• Dehiscence • Hematoma Correct Explanation: A hematoma can form within the wound and result in delayed healing. Dehiscence is a disruption of the surgical incision. Atelecstasis, thromobophlebitis, and paralytic ileus are potential complications following surgery. Atelecstasis is a collapse of the alveoli, which interferes with gas exchange. Thromobophlebitis is the development of a blood clot, usually in the lower extremity. Paralytic ileus is an absence of intestinal peristalsis.
A patient has received general anesthesia and is progressing through the stages. Using the manifestations below, place them in the proper sequence from stage I to stage IV. Pupil dilation Unconsciousness Shallow respirations Ringing in the ears
1.Ringing in the ears 2.Pupil dilation 3.Unconsciousness 4.Shallow respirations Explanation: In stage I of general anesthesia, the paitent may have a ringing in the ears. During stage II, excitement occurs along with pupil dilation. During stage III, the patient is unconscious. Stage IV is marked by too much anesthesia and manifested by shallow respirations.
After a bone marrow transplant (BMT), the client should be monitored for at least 30 days 14 days 100 days 60 days
100 days (351) After a BMT, the nurse closely monitors the client for at least 100 days or more after the procedure because complications related to the transplant can occur 100 days or more as post procedure infections are one common complication that may lead to sepsis and transplant failure.
A nurse is developing a care plan for bone marrow suppression, the major dose-limiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable? 24 hours 2 to 4 days 7 to 14 days 21 to 28 day
7 to 14 days Bone marrow suppression becomes noticeable 7 to 14 days after floxuridine administration. Bone marrow recovery occurs in 21 to 28 days.
The surgical unit nurse is developing a postoperative plan of care. In which client's plan of care would the nurse document interventions of coughing and deep breathing, gastrointestinal assessment, and effective regulation of temperature?
A client with gastrointestinal surgery and general anesthesia
The nurse determines that a patient has postoperative abdominal distention. What does the nurse determine that the distention may be directly related to?
A temporary loss of peristalsis and gas accumulation in the intestines
The client is scheduled for a breast lump excision and sentinel node biopsy. What should the nurse know in planning care for the client with a negative biopsy report? A lump excision is not necessary. A wide excision of lump will be performed. The lump and all axillary lymph nodes will be excised. The entire breast and all regional lymph nodes will be excised.
A wide excision of lump will be performed. (336) The sentinel node is the first node in which a tumor will drain; if no malignant cells are found there, additional excision or radical removal will not be necessary. Excision of the lump along with a wide margin of cancer-free tissue is standard treatment for malignant tumors.
A client has received several treatments of bleomycin. It is now important for the nurse to assess Skin integrity Lung sounds Urine output Hand grasp
Bleomycin has cumulative toxic effects on lung function. Thus, it will be important to assess lung sounds.
The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function?
Central venous pressure
The nurse is assigned a client scheduled for an outpatient colonoscopy in an ambulatory care setting. During which phase of perioperative care would the nurse document the admission vital signs in the recovery room?
During the postoperative phase
A patient who has undergone surgery and received spinal anesthesia is reporting a headache. Which of the following would be most appropriate? a) Turn on the television for distraction. b) Encourage increased fluid intake. c) Position the patient on the side. d) Notify the anesthesiologist immediately.
Encourage increased fluid intake. Explanation: Headache may be an after-effect of spinal anesthesia. To aid in relieving the headache, the nurse would maintain a quiet environment and keep the patient flat and well-hydrated. There is no need to notify the anesthesiologist because this report is not unexpected.
A patient is to receive general anesthesia. The nurse anticipates that which of the following would be used for induction? a) Etomidate b) Nitrous oxide c) Isoflurane d) Tetracaine
Etomidate Explanation: Anesthesia induction begins with IV anesthesia, such as etomidate, and then is maintained at the desired stage by inhalation methods, such as isoflurane or nitrous oxide. Tetracaine is used for local or regional anesthesia.
The client is receiving a vesicant antineoplastic for treatment of cancer. Which assessment finding would require the nurse to take immediate action?
Extravasation
When malignant cells are killed (tumor lysis syndrome), intracellular contents are released into the bloodstream. This leads to which of the following? Select all that apply. Hypercalcemia Hyperkalemia Hyperuricemia Hyperphosphatemia
Hyperphosphatemia Hyperuricemia Hyperkalemia (383) When intracellular contents are released into the bloodstream, phosphorous is elevated. This results in an inverse decline in the levels of calcium, so hypercalcemia would not occur.
When caring for an older client who is receiving external beam radiation, which is the key point for the nurse to incorporate into the plan of care? Time, distance, and shielding The use of disposable utensils and wash cloths Avoid showering or washing over skin markings. Inspect the skin frequently.
Inspect the skin frequently. Explanation: Inspecting the skin frequently will allow early identification and intervention of skin problems associated with external radiation therapy. The external markings should not be removed, but clients may shower and lightly wash over the skin. Time, distance, and shielding are key in the management of sealed, internal radiation therapy and not external beam radiation. The use of disposable utensils and care items would be important when caring for clients following systemic, unsealed, internal radiation therapy.
Corticosteroids have which effect on wound healing? Reduce blood supply Mask the presence of infection Cause hemorrhage May cause protein-calorie depletion
Mask the presence of infection
Which of the following is the most common cause of anaphylaxis? a) Plastic b) Fibrin sealants c) Medications d) Latex
Medications Explanation: Because medications are the most common cause of anaphylaxis, intraoperative nurses must be aware of the type and method of anesthesia used as well as the specific agents. Latex, fibrin sealants, and plastic are not the most common cause of anaphylaxis
A patient is taking vincristine, a plant alkaloid for the treatment of cancer. What system should the nurse be sure to assess for symptoms of toxicity? Gastrointestinal system Nervous system Pulmonary system Urinary system
Nervous system Explanation: With repeated doses, the taxanes and plant alkaloids, especially vincristine, can cause cumulative peripheral nervous system damage with sensory alterations in the feet and hands.
A list of commonly used medications for a particular surgical procedure is provided to the nurse. The anesthesiologist announces the administration of a nondepolarizing muscle relaxant. Which of the following medications should the nurse document as having been administered? a) Fentanyl (Sublimaze) b) Succinylcholine (Anectine) c) Morphine sulfate d) Pancuronium (Pavulon)
Pancuronium (Pavulon) Explanation: Pavulon is a nondepolarizing muscle relaxant. Succinylcholine is a polarizing muscle relaxant. Fentanyl and morphine sulfate are opioid analgesic agents.
What intravenous anesthetic administered by the anesthesiologist has a powerful respiratory depressant effect sufficient to cause apnea and cardiovascular depression? Versed Pentothal Amidate Ketalar
Pentothal
In what phase of postanesthesia care (PACU) is the client prepared for self-care or care in the hospital or an extended care setting?
Phase II PACU Explanation: In some hospitals and ambulatory surgical centers, postanesthesia care is divided into three phases. In the phase I PACU, used during the immediate recovery phase, intensive nursing care is provided. In the phase II PACU, the patient is prepared for self-care or care in the hospital or an extended care setting. In phase III PACU, the patient is prepared for discharge.
An obese patient is scheduled for open abdominal surgery. What priority education should the nurse provide this patient?
Prevention of respiratory complications
The physician, concerned about aspiration during a surgical procedure, orders a medication to increase gastric pH. Which of the following medications would the nurse document as given? a) Vecuronium (Norcuron) b) Famotadine (Pepcid) c) Sodium citrate (Bicitria) d) Midazolam (Versed)
Sodium citrate (Bicitria) Explanation: Sodium citrate increases the gastric pH therefore reducing the damage to the respiratory tract if aspiration should occur. Vecuronium is a muscle relaxant, famotidine decreases gastric acid production, and midazolam is an anesthetic agent.
As the moment of death approaches, which of the following does the nurse encourage the family to do? Have the family sit in front of the client so they can be seen. Rub the client's hand and arm to comfort the client. Speak to the client in a calm and soothing voice. Lie next to the client and hold the client.
Speak to the client in a calm and soothing voice.
A patient is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications?
Splint the incision site using a pillow during deep breathing and coughing exercises
The client vomits during the surgical procedure. The best action by the nurse is: a) Suction the client to remove saliva and gastric secretions. b) Lower the head of the operating table to promote circulation to the brain. c) Increase the IV infusion rate to compensate for lost fluids. d) Administer an anti-emetic to alleviate nausea.
Suction the client to remove saliva and gastric secretions. Explanation: The nurse immediately suctions the client to prevent aspiration of vomitus.
Which question is most important for the nurse to ask the client when obtaining the preoperative admission history?
When is the last time you ate or drank?
The nurse is to administer a vesicant chemotherapeutic drug to a client who had a right mastectomy and inserts the intravenous line In the client's left hand With a butterfly needle In the client's right forearm With a soft, plastic catheter
With a soft, plastic catheter (342) Vesicant chemotherapy should never be administered in the peripheral veins involving the hand or wrist. A person with breast cancer is to avoid injections in the affected extremity. A soft, plastic catheter should be used, not a butterfly needle.
The nurse is caring for a client is scheduled for chemotherapy followed by autologous stem cell transplant. Which of the following statements by the client indicates a need for further teaching? a. "I hope they find a bone marrow donor who matches." b. "The doctor will remove cells from my bone marrow before beginning chemotherapy." c. "I will receive chemotherapy until most of the cancer is gone, and then I will get my own stem cells back." d. "I will need to be in protective isolation for up to 3 months after treatment."
a. "I hope they find a bone marrow donor who matches."
a patient is to receive Bacille Calmette-Guerin (BCG), a nonspecific biologic response modifier. why would the patient receive this form of treatment? a. for cancer of the bladder b. for cancer of the breast c. for cancer of the lungs d. for skin cancer
a. for cancer of the bladder
Which of the following is a duty of the registered nurse first assistant? Select all that apply. a) Providing exposure at the operative field b) Suturing c) Maintaining hemostasis d) Specimen management e) Handling tissue
• Handling tissue • Suturing • Maintaining hemostasis • Providing exposure at the operative field Explanation: Handling tissue, suturing, maintaining hemostasis, and providing exposure at the operative field are responsibilities of the registered nurse first assistant. Specimen management is a duty of the circulating nurse.
A nurse is working as part of the surgical team in the semi-restricted area. Which of the following would be appropriate to wear? Select all that apply. a) Caps b) Street clothes c) Scrub clothes d) Shoe covers e) Masks
• Scrub clothes • Caps Explanation: Scrub clothes and caps are worn in the semi-restricted area. Street clothes are worn in the unrestricted area. Scrub clothes, caps, shoe covers, and masks are worn in the restricted area.
After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should assign highest priority to which intervention? Serving small portions of bland food Encouraging rhythmic breathing exercises Administering metoclopramide and dexamethasone as ordered Withholding fluids for the first 4 to 6 hours after chemotherapy administration
Administering metoclopramide and dexamethasone as ordered The nurse should assign highest priority to administering an antiemetic, such as metoclopramide, and an anti-inflammatory agent, such as dexamethasone, because it may reduce the severity of chemotherapy-induced nausea and vomiting. This intervention, in turn, helps prevent dehydration, a common complication of chemotherapy. Serving small portions of bland food, encouraging rhythmic breathing exercises, and withholding fluids for the first 4 to 6 hours are less likely to achieve this outcome.
The nurse identifies a nursing diagnosis of Imbalanced nutrition: less than body requirements for a terminally ill client who is near the end of life. Which of the following would the nurse expect to include in the client's plan of care? Suggestions that the family offer the client foods that are hot. Encouragement of the family to serve the client meat, especially beef. Advice for the family to have fruit juices readily available at the client's bedside. Arrangements for the client to eat meals while others are out of the home.
Advice for the family to have fruit juices readily available at the client's bedside. To promote nutrition in the terminally ill, the nurse would encourage the family to have fruit juices and milkshakes readily available at the bedside so that the client can access them frequently. Cool foods may be better tolerated than hot foods. Cheese, eggs, peanut butter, mild fish, chicken, and turkey are often better choices than meat such as beef that may taste bitter and unpleasant. Meals should be scheduled when family members are present to provide company and stimulation.
A client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing diagnosis is appropriate for this client? Anticipatory grieving Impaired swallowing Disturbed body image Chronic low self-esteem
Anticipatory grieving (368) Anticipatory grieving is an appropriate nursing diagnosis for this client because few clients with gallbladder cancer live more than 1 year after diagnosis. Impaired swallowing isn't associated with gallbladder cancer. Although surgery typically is done to remove the gallbladder and, possibly, a section of the liver, it isn't disfiguring and doesn't cause Disturbed body image. Chronic low self-esteem isn't an appropriate nursing diagnosis at this time because the diagnosis has just been made.
A patient who underwent abdominal surgery 3 hours ago has started to hemorrhage. The nurse would classify this type of hemorrhage has which of the following? a) Secondary b) Intermediary c) Primary d) Tertiary
Intermediary Correct Explanation: Intermediary hemorrhage occurs during the first few hours after surgery when the rise of blood pressure to its normal level dislodges insecure clots formed in untied vessels. Primary hemorrhage occurs at the time of surgery. Secondary hemorrhage may occur some time after surgery if a suture slips because a blood vessel was not securely tied, became infected, or was eroded by a drainage tube.
A client is diagnosed with metastatic adenocarcinoma of the stomach. The physician orders mitomycin and other chemotherapeutic agents for palliative treatment. How does mitomycin exert its cytotoxic effects? It inhibits ribonucleic acid (RNA) synthesis. It's cell cycle-phase specific. It inhibits protein synthesis. It inhibits deoxyribonucleic acid (DNA) synthesis.
It inhibits deoxyribonucleic acid (DNA) synthesis. Mitomycin (Mutamycin) exerts its cytotoxic effects by inhibiting DNA synthesis rather than RNA synthesis. It's cell cycle-phase nonspecific and doesn't inhibit protein synthesis.
What does the nurse understand is the rationale for administering allopurinol for a patient receiving chemotherapy? It stimulates the immune system against the tumor cells. It treats drug-related anemia. It prevents alopecia. It lowers serum and uric acid levels.
It lowers serum and uric acid levels. (345) Adequate hydration, diuresis, alkalinization of the acid crystals, and administration of allopurinol (Zyloprim) may be used to prevent renal toxicity.
The nurse is caring for a client undergoing an incisional biopsy. Which statement does the nurse understand to be true about an incisional biopsy? It is used to remove cancerous cells using a needle. It removes an entire lesion and the surrounding tissue. It removes a wedge of tissue for diagnosis. It treats cancer with lymph node involvement.
It removes a wedge of tissue for diagnosis. The three most common biopsy methods are excisional, incisional, and needle. In an incisional biopsy, a wedge of tissue is removed from the tumor and analyzed. In an excisional biopsy, the surgeon removes the tumor and the surrounding marginal tissues. Needle aspiration biopsy involves aspirating tissue fragments through a needle guided into the cancer cells.
A postoperative patient begins coughing forcefully when eating gelatin. The nurse notices an evisceration of the intestines. What should the nurse do first? a) Cover the intestines with sterile, moist dressings. b) Place the patient in low Fowler's position. c) Document the event. d) Notify the surgeon.
Place the patient in low Fowler's position. Correct Explanation: Placing the patient in low Fowler's position decreases further protrusion of the intestines. The nurse should cover the intestines with a sterile, moist dressing; notify the surgeon and document the event; but first and foremost the nurse should minimize further protrusion of the intestines.
During which step of cellular carcinogenesis do cellular changes exhibit increased malignant behavior? Promotion Initiation Prolongation Progression
Progression Progression is the third step of carcinogenesis, in which cells show a propensity to invade adjacent tissues and metastasize. During promotion, repeated exposure to promoting agents causes the expression of abnormal genetic information, even after long latency periods. During initiation, initiators such as chemicals, physical factors, and biologic agents escape normal enzymatic mechanisms and alter the genetic structure of cellular DNA. No stage of cellular carcinogenesis is termed prolongation.
Which of the following does a nurse have to assess during the bone marrow transplant (BMT) procedure? Psychological status Blood pressure status Urine gravity status Electrolyte levels
Psychological status
A client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis?
Red, open sores on the oral mucosa
Which is one level of hospice care covered under Medicare and Medicaid hospice benefits, includes a 5-day inpatient stay, and is provided occasionally to relive the family caregivers? Routine home care Respite care Continuous care General inpatient care
Respite care
When the nurse observes that the postoperative patient demonstrates a constant low level of oxygen saturation, although the patient's breathing appears normal, the nurse identifies that the patient may be suffering from which type of hypoxemia? a) Hypoxic b) Anemic c) Episodic d) Subacute
Subacute Correct Explanation: For subacute hypoxemia supplemental oxygen may be indicated. Hypoxic hypoxemia results from inadequate breathing. Episodic hypoxemia develops suddenly, and the patient may be at risk for myocardial ischemia, cerebral dysfunction, and cardiac arrest. Anemic hypoxemia results from blood loss during surgery.
A 36-year-old man is receiving three different chemotherapeutic agents for Hodgkin's disease. The nurse explains to the client that the three drugs are given over an extended period because:
The three drugs have a synergistic effect and act on the cancer cells with different mechanisms.
Nursing assessment findings reveal a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. The nurse recognizes the client is experiencing: a) Hyperthermia b) Wound infection c) Atelectasis d) Uncontrolled pain
Wound infection Correct Explanation: Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain.
Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that most support the nurse's analysis are: blood pressure of 150/100 mm Hg and pulse of 130 beats/minute. blood pressure of 150/100 mm Hg and pulse of 50 beats/minute. blood pressure of 80/40 mm Hg and pulse of 50 beats/minute. blood pressure of 80/40 mm Hg and pulse of 130 beats/minute.
blood pressure of 80/40 mm Hg and pulse of 130 beats/minute. The client had blood loss during the splenectomy and developed subsequent anemia. With a subnormal Hb level and vertigo when getting out of bed, the nurse is accurate in suspecting orthostasis. Orthostatic changes develop from hypovolemia and cause a drop in blood pressure (evidenced by a blood pressure of 80/40 mm Hg) and a compensatory rise in the heart rate (evidenced by a pulse of 130 beats/minute) when the client rises from a lying position.
The spouse of a terminally ill client is confused by the new terminology being used during discussions regarding the client's treatment. The nurse should explain that palliative care is: care that will reduce the client's physical discomfort and manage clinical symptoms. care that is provided at the very end of an illness to ease the dying process. an alternative therapy that uses massage and progressive relaxation for pain relief. offered to terminally ill clients who wish to remain in their homes in lieu of hospice care.
care that will reduce the client's physical discomfort and manage clinical symptoms.
A nurse assesses a client with a terminal illness and determines that the client is in denial about the condition. Which of the following would be most important for the nurse to do when developing the client's plan of care? Seek help from other health care team members to address the client's denial. Accept the client's denial of the situation. Explain to the client that denial of the situation is unhealthy. Correct the client's misconsceptions about the illness and treatment goals.
Accept the client's denial of the situation. When working with terminally ill clients, nurses need to understand that denial is often a useful coping mechanism that enables the client to gain temporary emotional distance from a situation that is too painful to think about.
The nurse is conducting a screening for familial predisposition to cancer. Which element should the nurse note as a possible indication of hereditary cancer syndrome? Onset of cancer after age 50 in family member A first cousin diagnosed with cancer A second cousin diagnosed with cancer An aunt and uncle diagnosed with cancer
An aunt and uncle diagnosed with cancer The hallmarks of hereditary cancer syndrome include cancer in two or more first-degree or second-degree relatives, early onset of cancer in family members younger than age 50, the same type of cancer in several family members, individual family members with more than one type of cancer, and a rare cancer in one or more family members.
A nurse is administering daunorubicin through a peripheral I.V. line when the client complains of burning at the insertion site. The nurse notes no blood return from the catheter and redness at the I.V. site. The client is most likely experiencing which complication?
Extravasation
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan? Administering aspirin if the temperature exceeds 102° F (38.8° C) Inspecting the skin for petechiae once every shift Providing for frequent rest periods Placing the client in strict isolation
Inspecting the skin for petechiae once every shift
On the second postoperative day, nursing assessment reveals that the client has a temperature of 103°F (39.5°C). The nurse recognizes that the client is most likely exhibiting a sign of: a) Lung atelectasis b) Urinary tract infection c) Wound infection d) The normal surgical stress response
Lung atelectasis Correct Explanation: Respiratory complications occur early in the postoperative period.
A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication? Urine output of 400 ml in 8 hours Serum potassium level of 2.6 mEq/L Blood pressure of 120/64 to 130/72 mm Hg Sodium level of 142 mEq/L
Serum potassium level of 2.6 mEq/L
A client, 66 years old, has just been diagnosed with multiple myeloma (a cancer of the plasma) and will be initiating chemotherapy. The nurse, in an outpatient clinic, reviews the medications the client has been taking at home. The medications include pantoprazole (Protonix) for gastroesophageal reflux disease (GERD) and an over-the-counter calcium supplement to prevent osteoporosis. The nurse does the following interventions: (Select all that apply.) instructs the client to discontinue calcium asks about nausea and vomiting restricts fluids to 1500 mL per day teaches the client to report abdominal or bone pain provides information about antidiarrheal medication
asks about nausea and vomiting teaches the client to report abdominal or bone pain instructs the client to discontinue calcium (382) The client with cancer is at risk for hypercalcemia from bone breakdown. The client should not take an over-the-counter calcium supplement that would increase blood levels of calcium. Signs and symptoms of hypercalcemia include nausea and vomiting. The client may also report abdominal or bone pain with cancer. The client should increase fluid intake to 2 to 4 L per day. Intake would have to be adjusted based on the client's other medical conditions. GERD would not negate an increase in fluid intake. The client most likely would have constipation with hypercalcemia, not diarrhea.
A client has cancer of the neck and is receiving external beam radiation therapy to the site. The client is experiencing trauma to the irradiated skin. The nurse does all of the following. (Select all that apply.) inspects for skin damage of the chest area assesses the client for any sun exposure uses cool water to wash the neck area applies an over-the-counter ointment to the skin avoids shaving the irradiated skin
assesses the client for any sun exposure avoids shaving the irradiated skin The client receiving external beam radiation therapy may experience trauma to the irradiated skin. To prevent further skin damage, the client is to avoid sun exposure and shaving the irradiated skin area. Other skin areas are not damaged, only the irradiated skin. Lukewarm water is to be used to bathe the area. Water of extreme temperature should be avoided. Many over-the-counter ointments contain metals and may cause additional skin damage.
A nurse is caring for a recently married, 29-year-old female client, who was diagnosed with acute lymphocytic leukemia. The client is preparing for an allogeneic bone marrow transplant. Which statement by the client demonstrates she understands the informed consent she gave about the diagnosis and treatment? "I should be able to finally start a family after I'm finished with the chemo." "I always had a good appetite. Even with chemo I shouldn't have to make any changes to my diet." "I'll have to remain in the hospital for about 3 months after my transplant." "I'll only need chemotherapy treatment before receiving my bone marrow
"I'll only need chemotherapy treatment before receiving my bone marrow transplant." (350) This client demonstrates understanding about treatment when she states that she'll need chemotherapy before receiving a bone marrow transplant. Most clients receive chemotherapy before undergoing bone marrow transplantation. Most women older than age 26 can't bear children after undergoing treatment because they experience the early onset of menopause. Clients who undergo chemotherapy or radiation must avoid all fresh fruits and vegetables, and all foods should be cooked to avoid bacterial contamination. Clients who undergo bone marrow transplantation typically remain hospitalized for 20 to 25 days.
A patient will be receiving radiation for 6 weeks for the treatment of breast cancer and asks the nurse why it takes so long. What is the best response by the nurse? "It allows time for you to cope with the treatment." "It will allow time for the repair of healthy tissue." "It will decrease the incidence of leukopenia and thrombocytopenia." "It is not really understood why you have to go for 6 weeks of treatment."
"It will allow time for the repair of healthy tissue." (340) In external-beam radiation therapy (EBRT), the total radiation dose is delivered over several weeks in daily doses called fractions. This allows healthy tissue to repair and achieves greater cell kill by exposing more cells to the radiation as they begin active cell division. Repeated radiation treatments over time (fractionated doses) also allow for the periphery of the tumor to be reoxygenated repeatedly, because tumors shrink from the outside inward. This increases the radiosensitivity of the tumor, thereby increasing tumor cell death (Kelvin, 2010).
A client with cancer is receiving chemotherapy and reports to the nurse that his mouth is painful and he has difficulty ingesting food. The nurse does which of the following: Asks the client to open his mouth to facilitate inspection of the oral mucosa Rinses the client's mouth with alcohol-based mouthwash every 2 hours Instructs the client to brush the teeth with a soft toothbrush Consults with the healthcare provider about use of nystatin (Mycostatin) Teaches the client to floss his teeth once every 24 hours
Asks the client to open his mouth to facilitate inspection of the oral mucosa Consults with the healthcare provider about use of nystatin (Mycostatin) Instructs the client to brush the teeth with a soft toothbrush (360-361) The description of the client's report is stomatitis following chemotherapy treatment. The nurse should assess the oral mucosa based on the client's report of pain and difficulty eating. The client is to use a soft toothbrush to minimize trauma to the mouth. Nystatin is a topical medication that may provide healing for the client's mouth. The client avoids alcohol-based mouthwashes as these are irritants. Flossing the teeth may cause additional trauma to the mouth.
A patient will be having an endoscopic procedure with a diagnostic biopsy. What type of biopsy does the nurse explain will remove an entire piece of suspicious tissue? Excisional biopsy Incisional biopsy Needle biopsy Punch biopsy
Excisional biopsy (335) Excisional biopsy is most frequently used for small, easily accessible tumors of the skin, breast, and upper or lower gastrointestinal and upper respiratory tracts. In many cases, the surgeon can remove the entire tumor as well as the surrounding marginal tissues. The removal of normal tissue beyond the tumor area decreases the possibility that residual microscopic malignant cells may lead to a recurrence of the tumor. Incisional biopsy is performed if the tumor mass is too large to be removed. In this case, a wedge of tissue from the tumor is removed for analysis. Needle biopsy is performed to sample suspicious masses that are easily and safely accessible, such as some masses in the breasts, thyroid, lung, liver, and kidney. A core needle biopsy uses a specially designed needle to obtain a small core of tissue that permits histologic analysis.
How does a nurse who has been providing home care to a terminally ill client know that the client's condition is beginning to deteriorate? apical pulse reaches 100 beats/minute skin appears red and flushed urine output increases facial muscles contract
Failing cardiac function is one of the first signs that a client's condition is worsening. At first, heart rate increases in a futile attempt to deliver oxygen to cells. The apical pulse rate may reach 100 or more beats/minute. In clients who are dying, the skin becomes pale or mottled, nail beds and lips may appear blue, and the client may feel cold. In clients who are dying, urine volume decreases, and the jaw and facial muscles relax.
A patient has been administered ketamine (Ketalar) for moderate sedation. What is the priority nursing intervention? a) Providing a quiet dark room b) Assessing for hallucinations c) Frequent monitoring of vital signs d) Administering oxygen
Frequent monitoring of vital signs Explanation: Vital signs must be monitored frequently to assess for respiratory depression and intervene quickly. Oxygen may need to be administered if respiratory depression occurs; therefore, monitoring vital signs is a higher priority nursing intervention. Providing a dark quiet room is appropriate after the procedure is completed and the patient is recovering. Hallucinations may be experienced as a side effect of the medication.
A nurse is working with a family of a deceased client and assisting them in working through their grief and mourning. Which of the following would be the priority to promote healthy accomodation of the loss by the family? Helping the family recognize the loss has occurred Assisting the family in expressing their feelings of loss Encouraging the family to remember the relationship they had with the client Urging them to give up their old attachments to the client
Helping the family recognize the loss has occurred Explanation: The priority in assisting the family to accommodate the loss of the client in a healthy way is to help them recognize the loss. Once this occurs, then the family can react to, experience, and express the feeling the of the pain of the loss; recollect and re-experience the deceased, the relationship, and associated feelings; and relinquish old attachments to the deceased.
A client is receiving the cell cycle-nonspecific alkylating agent thiotepa (Thioplex), 60 mg weekly for 4 weeks by bladder instillation as part of chemotherapy regimen to treat bladder cancer. The client asks the nurse how the drug works. How does thiotepa exert its therapeutic effects? It interferes with deoxyribonucleic acid (DNA) replication only. It interferes with ribonucleic acid (RNA) transcription only. It interferes with DNA replication and RNA transcription. It destroys the cell membrane, causing lysis.
It interferes with DNA replication and RNA transcription.
What does the nurse understand is the rationale for administering allopurinol for a patient receiving chemotherapy?
It lowers serum and uric acid levels.
The surgical client is at risk for injury related to positioning. Which of the following clinical manifestations exhibited by the client would indicate the goal was met of avoiding injury? a) Pulse oximetry 98% b) Peripheral pulses palpable c) Vital signs within normal limits for client d) Absence of itching
Peripheral pulses palpable Explanation: Surgical clients are at risk for pressure ulcers and damage to nerves and blood vessels as a result of awkward positioning required for surgical procedures. Palpable peripheral pulses indicate integrity of the blood vessels.
You are an oncology nurse caring for a client who is taking antineoplastic agents. What symptoms must you consider when monitoring this client? Symptoms of gout Symptoms of hypertension Symptoms of diarrhea Symptoms of anemia
Symptoms of gout (383) The nurse monitors the client being administered an antineoplastic agent for symptoms of gout, which include increased uric acid levels, joint pain, and edema. Administering antineoplastic agents does not cause hypertension, diarrhea, and anemia
a patient, age 67 years, is admitted for diagnostic studies to rule out cancer. the patient is caucasian, has been employed as a landscaper for 40 years, and has a 36 year history of smoking a pack of cigarettes a day. what significant risk factors does the nurse recognize this patient has? (select all that apply) a. age b. cigarette smoking c. occupation d. race e. martial status
a. age b. cigarette smoking c. occupation
what is the best way for the nurse to assess the nutritional status of a patient with cancer? a. weigh the patient daily b. monitor daily caloric intake c. observe for proper wound healing d. assess BUN and Cr levels
a. weigh the patient daily
A patient is administered succinylcholine and propofol (Diprivan) for induction of anesthesia. One hour after administration, the patient is demonstrating muscle rigidity with a heart rate of 180. What should the nurse do first? a) Administer dantrolene sodium (Dantrium). b) Obtain cooling blankets. c) Notify the surgical team. d) Document the assessment findings.
c) Notify the surgical team.
A client requires minor surgery for removal of a basal cell tumor. The anesthesiologist administers the anesthetic ketamine hydrochloride (Ketalar), 60 g I.V. After ketamine administration, the nurse should monitor the client for: a) extrapyramidal reactions and hiccups. b) respiratory depression. c) extrapyramidal reactions. d) hallucinations and respiratory depression. e) hallucinations. f) hiccups.
hallucinations and respiratory depression. Explanation: The nurse should monitor for hallucinations, which may follow administration of several of the injection anesthetics, including ketamine and the opioids; the reaction seems to be directly proportional to the infusion rate. Extrapyramidal manifestations are the most prominent adverse reactions to droperidol. Thiopental, etomidate, and propofol can produce airway reflex hyperactivity with hiccups, coughing, and muscle twitching and jerking. The barbiturates and propofol cause respiratory depression.
Following surgery for adenocarcinoma, the client learns the tumor stage is T3,N1,M0. What treatment mode will the nurse anticipate?
Adjuvant therapy is likely
Which statement by a client undergoing external radiation therapy indicates the need for further teaching? "I'm worried I'll expose my family members to radiation." A client without symptoms or complaints receives a diagnosis of prostate cancer after a routine physical. What factors contributed to this diagnosis? Select all that apply.
- risk factors - client history - tumor markers
A patient with renal failure is scheduled for a surgical procedure. When would surgery be contraindicated for this patient due to laboratory results? A blood urea nitrogen level of 42 mg/dL A creatine kinase level of 120 U/L A serum creatinine level of 0.9 mg/dL A urine creatinine level of 1.2 mg/dL
A blood urea nitrogen level of 42 mg/dL (7-20) A creatine kinase level of 120 U/L (22-198) A serum creatinine level of 0.9 mg/dL (0.6-1.2) A urine creatinine level of 1.2 mg/dL
Which is a sign or symptom of septic shock? Hypertension Warm, moist skin Altered mental status Increased urine output
AMS
A client with long-term breast cancer who was recently enrolled in a hospice program demonstrates signs and symptoms of clinical depression. Which action by the hospice nurse is appropriate? Educate the client that depression is expected. Perform a thorough pain assessment. Ask the client whether she is planning to hurt herself. Explain that antidepressants are not indicated for the client.
Perform a thorough pain assessment. An effective combined approach to clinical depression includes relief of physical symptoms such as pain. Clinical depression should not be accepted as an inevitable consequence of dying. Researchers have linked the psychological effects of cancer pain to suicidal thought and, less frequently, to carrying out a planned suicide. An effective combined approach to clinical depression includes relief of physical symptoms and pharmacologic intervention with tricyclic antidepressants.
Which of the following are true statements about effective radiation therapy? Select all that apply. Cells are least vulnerable during DNA synthesis. Slower-growing tissues at rest (muscle) are more radioresistant. Tumors that are well oxygenated are more sensitive to radiation. Tumors that are small in size and dividing rapidly are more sensitive.
Slower-growing tissues at rest (muscle) are more radioresistant. Tumors that are well oxygenated are more sensitive to radiation. Tumors that are small in size and dividing rapidly are more sensitive. Explanation: All of the statements are true except for A. Cells are most vulnerable during DNA synthesis and mitosis. Tissues that experience frequent cellular division are most sensitive to radiation.
A perioperative nurse is assigned to complete a preoperative assessment on a patient who is scheduled for surgery for kidney stones. The nurse knows that the surgery is scheduled the following day and would therefore be classified as:
Urgent
Which oncologic emergency involves the accumulation of fluid in the pericardial space? Cardiac tamponade Disseminated intravascular coagulation (DIC) Syndrome of inappropriate antidiuretic hormone release (SIADH) Tumor lysis syndrome
Cardiac tamponade Cardiac tamponade is an accumulation of fluid in the pericardial space. DIC is a complex disorder of coagulation and fibrinolysis that results in thrombosis and bleeding. SIADH is a result of the failure in the negative feedback mechanism that normally regulates the release of antidiuretic hormone (ADH). Tumor lysis syndrome is a rapidly developing oncologic emergency that results from the rapid release of intracellular contents as a result of radiation- or chemotherapy-induced cell destruction of large or rapidly growing cancers such as leukemia.
Nursing students are reviewing information about agents used for anesthesia. The students demonstrate understanding when they identify which of the following as an inhalation anesthetic? Halothane Fentanyl Succinylcholine Propofol
Halothane
When caring for an older client who is receiving external beam radiation, which is the key point for the nurse to incorporate into the plan of care?
Inspect the skin frequently
On postoperative day 2, a client requires care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing? Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing Covering the well-approximated wound edges with a dry dressing Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive Cleaning the wound with soap and water, then leaving it open to the air
Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing
Which type of surgery is used in an attempt to relieve complications of cancer? Palliative Prophylactic Reconstructive Salvage
Palliative surgery is performed to relieve complications of cancer. Prophylactic surgery involves removing nonvital tissues or organs that are likely to develop cancer. Reconstructive surgery may follow curative or radical surgery and is carried out in an attempt to improve function or to obtain a more desirable cosmetic effect. Salvage surgery is an additional treatment option that uses an extensive surgical approach to treat the local recurrence of a cancer after the use of a less extensive primary approach.
A nurse is caring for a client with a terminal illness. The client asks the nurse to help him end his own life to alleviate his suffering and that of his family. When responding to the client, the nurse integrates knowledge of which of the following? Participating in assisted suicide violates the Code of Ethics for Nurses. Nurses may administer medications prescribed by physicians to hasten end of life. A client has the right to make independent decisions about the timing of his or her death. Most states have enacted laws that allow for physician-assisted suicide.
Participating in assisted suicide violates the Code of Ethics for Nurses.
A postanesthesia care unit (PACU) nurse is preparing to discharge a patient home following ankle surgery. The patient keeps staring at the ceiling while being given discharge instructions. What action by the nurse is appropriate? a) Review the instructions with the patient and accompanying adult. b) Give the written instructions to the patient's 16-year-old child. c) Ask the patient, "Do you understand?" d) Continuously repeat the instructions until the patient restates them.
Review the instructions with the patient and accompanying adult. Correct Explanation: The effects of the anesthesia may impair the memory or concentration of the patient. It is important that the discharge instructions are covered with the patient and an accompanying adult. Giving the instructions to a 16-year-old is not appropriate. Repeating the instruction until the patient restates them does not ensure that the patient will remember them because of how anesthesia can impair the memory. Asking if the patient understands the instructions only elicits an yes or no answer but does not give insight on if the patient comprehending the instructions.
What evidence does the nurse understand indicates that a patient is ready for discharge from the recovery room or PACU? (Select all that apply.) The patient has been extubated but still has an oropharyngeal airway in. The patient is arousable but falls back to sleep rapidly. The patient has a blood pressure within 10 mm Hg of the baseline. The patient has sonorous respirations and occasionally requires chin lift. The patient rates pain a 9 out of 10 on a 0-10 scale after receiving morphine sulfate.
The patient is arousable but falls back to sleep rapidly. The patient has a blood pressure within 10 mm Hg of the baseline. The patient has sonorous respirations and occasionally requires chin lift. Explanation: A patient remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline.
A postanesthesia care unit (PACU) nurse is caring for a patient with the following assessment data: pale, cool, moist skin; thready pulse of 122; blood pressure 78/60; urine output of 25 mL/h; temperature 99.2°F. What interventions by the nurse are appropriate? Select all that apply. a) Administer blood products per orders. b) Raise the head of the bed 30 degrees. c) Apply a warming blanket. d) Apply oxygen per orders. e) Frequently monitor neurological status. f) Maintain a patent airway.
• Administer blood products per orders. • Apply oxygen per orders. • Frequently monitor neurological status. • Maintain a patent airway. Correct Explanation: The patient is demonstrating signs and symptoms of shock. The patient in shock may lose the ability to protect his or her airway. Frequently neurological assessment can provide information related to decrease oxygen to the brain. Administering the blood products may reverse the signs and symptoms of shock. There is an increased need for oxygen when in shock, so it is appropriate to apply oxygen. The head of the bed should not be elevated. The patient should be lying flat or in the Trendelenburg position. Applying a warming blanket when the patient is not hypothermic may cause vasodilation, which could further decrease blood pressure and perfusion to vital organs.