EXAM 1, 4th Semester
Which medication would the nurse expect to be prescribed for a client who has burrows with erythematous papules and vesicles with interdigital web crusting?
5% Permethrin lotion
While teaching the nursing student about delegation, the RN instructs the student to determine whether the delegation process is appropriate to the situation before delegating a task. Which right of delegation is the RN referring to?
Circumstance
Which action would the nurse take postoperatively when providing care for a client who has a permanent biliary drainage tube (T-tube) inserted to provide palliative care?
Cleanse the area around the insertion site to prevent skin breakdown
Which client in the postoperative unit would be a safety PRIORITY for the nurse to monitor for fluid volume overload?
Client with lymph node dissection
Applying the emergency severity index (ESI) criteria, which client condition would the nurse consider least severe?
Closed extremity trauma
Which type of fracture does the client admitted to the ER after a bomb blast who is given a yellow tag most likely have?
Compound Fracture (Open fracture)
Which potentially life threatening client condition found during the primary triage survey would necessitate priority nursing care?
Concussion
Which medication would the nurse anticipate incorporating into the plan of care to treat the client bitten by a snake that belongs to the class of North American pit vipers?
Crotalidae polyvalent immune fab (CroFab)
Assessment findings of a client who is admitted to the ER include cramping pain in the left lower quadrant, weakness, bloating, malaise, and a low grade fever. The nurse suspects which condition?
Diverticulitis
Which information would the nurse include when teaching a patient about radiation therapy for treating cancer?
Drink 3000 mL of fluid the day before and on the day of radiation therapy (Adequate hydration helps to prevent TLS)
Which type of burn or injury may cause a client to have a cervical spine injury?
Electrical burns
Which health care system focuses on palliative care?
Hospice
Which PRIORITY intervention would the nurse perform immediately for a client with a spinal cord injury?
Immobilize and stabilize the cervical spine
The nurse in the ER is caring for a 9 year old with a suspected spinal cord injury sustained while falling off a bicycle. Which INITIAL action should the nurse take?
Immobilizing the child's spine to limit additional injury
Which nursing action would have the HIGHEST priority when the nurse is moving a client with a neck and spinal cord injury during the assessment process?
Implementing the logrolling technique
A client is admitted with a head injury and has large amounts of clear, colorless urine draining from the urinary catheter. Which physiological response is possibly causing the increased urine output?
Inadequate anti diuretic hormone (ADH) secretion
Which instruction would the nurse include when teaching about hydrochlorothiazide given to a client diagnosed with a TIA related to hypertension?
Increase the intake of potassium rich foods.
Which condition may develop due to the effect of leukemia on WBCs?
Increased risk for infection
Which condition would the nurse suspect in a 6 year old child who was admitted with abdominal pain and guarding, nausea, anorexia, and pain with palpating of right lower quadrant.
Inflamed appendix
Which nursing intervention has the HIGHEST priority for implementation when caring for a client who has a suspected pelvic fracture as the result of a MVA?
Inspecting the genitalia
A client with a long history of alcohol abuse is admitted to the hospital with ascites and jaundice. A diagnosis of hepatic cirrhosis is made. Which is a nursing priority?
Institute fall prevention/safety measures
Which statement about the process of malignant transformation is correct?
Insulin and estrogen enhance the division of an initiated cell during the promotion phase.
The implementation of which maneuver would benefit a MVA client who is choking and may have a spinal cord injury?
Jaw-thrust
A patient receiving radiation for cancer treatment has cloudy urine, flank pain, muscle weakness, and vomiting. Which occurrence would the nurse suspect as the reason for these findings?
Large number of destroyed tumor cells (TLS)
A client with cancer of the cervix has an intracavity radioactive sealed implant in place. Which precaution would the nurse take to protect against excessive exposure to radiation?
Leaving used linens in the room until cleared by the Radiation Safety team
Which finding will the nurse expect during the assessment when a client with a history of chronic myelogenous leukemia and splenomegaly is admitted to the hospital?
Left upper quadrant tenderness
Which systemic side effect would the nurse monitor for in a client receiving combination chemo for the treatment of metastatic carcinoma?
Leukopenia
Which level trauma center provides basic trauma client stabilization and advanced life support before referring them to other trauma centers?
Level IV
The nurse would utilize the Glasgow Coma Scale on a trauma client to complete with assessment?
Level of consciousness
Which is the leading cause of cancer related deaths in North America?
Lung cancer
How can the nurse best manage a common side effect of chemo?
Providing meticulous oral hygiene
The nurse is caring for a client who has experienced a near drowning. For which potential danger would the nurse assess the client?
Pulmonary edema
A client on hospice care is receiving palliative treatment. Which is the goal of palliative care for this client?
Relieve the client's discomfort
Which outcome would the nurse teach a patient with end-stage ovarian cancer regarding the goal of palliative surgery?
Relieving symptoms or improved quality of life
Which nursing intervention is PRIORITY, after collaborating with the emergency response team, for a group of clients admitted to the ER after a radioactive explosion in a uranium mine?
Removing clients clothes and showering clients Immediately
A client is admitted with an acute onset of right lower quadrant pain at McBurney point, and appendicitis is suspected. For which clinical indicator would the nurse assess the client to determine if the pain is secondary to appendicitis?
Robound tenderness
When a client with blunt trauma to the nose is noted to have nasal swelling, ecchymosis around the eyes, and watery pink-tinged nasal drainage, which action will the nurse take?
Send a specimen of the fluid to the lab for analysis
The HCP informs a 22 year old patient with leukemia that the patient cannot receive the next round of chemo bc of low blood cell counts. If the pt admits to having difficulty remembering to take the meds as prescribed, which strategy would the nurse suggest to assist with compliance?
Set alarms on a mobile phone app
Which group of clients who were in a bus accident and admitted to the ER with injuries is considered urgent according to the three-tier triage system?
Severe abdominal pain
Which clinical finding would the nurse expect for a client with hypertensive emergency?
Severe pounding headache
Which role does shark cartilage play in the management of HIV and AIDS?
Shark cartilage is a complementary therapy
Which statement about four clients along with their conditions made by the student nurse indicates effective learning about the disaster triage tag system?
Sprain, Strains, Abrasions - Green Open Fractures, Renal colic - Yellow Airway Obstruction, Chest pain- Red Shock - Red High Cervical Spinal Cord Injury - Black
Which nursing intervention would the nurse perform immediately for the client with a head injury and a Glasgow Coma score of 9?
Stabilize the cervical spine
In which position would the nurse place a client who sustained a back injury?
Supine position while not allowing the spine to flex
The HCP instructs the nurse to manage fluid replacement therapy in a client with cancer. Which type of care is the client receiving?
Supportive care (Improve the clients quality of life)
Which nurse would be the most appropriate to reassign to assist in the operating room for emergency surgeries being performed on trauma victims?
Surgical suite staff development trainer
Which condition is a patient who is receiving paclitaxel for chemo treatments to treat multiple myeloma MOST at risk for?
TLS (Large numbers of tumor cells are destroyed rapidly)
How is the TNM classification of TisNoMx for a patient with lung cancer interpreted? SATA
*No metastasis *Carcinoma in situ *Presence of metastasis cannot be assessed PRIMARY TUMOR (T) -Tx : Cannot be assessed -To : No evidencce of primary tumor -Tis : Carcinoma in situ -T(1,2,3,4) Increasing size REGIONAL LYMPH NODES (N) -Nx : cannot be assessed -No : No lymph node metastasis -N(1,2,3) : Increasing involvement of lymph nodes DISTANT METASTASIS (M) -Mx : Presence cannot be assessed -Mo : No distant metastasis -M1 : Distant metastasis
Which information would the nurse include when conducting a community health education class on diet and cancer risk reduction? SATA
*Avoid beef and processed meats. *Increase consumption of whole grains. *Eat "colorful fruits and vegetables," including greens.
Which factor will the nurse include in teaching about the typical warning signs of cancer? SATA
*Axillary swelling *Persistent constipation *Sore throat present for 3 months
Which statement about benign and malignant tumors is correct? SATA
*Benign tumors grow by expansion. *Malignant tumors grow by invasion. *Overexpressed oncogenes may lead to the development of cancer.
When caring for a patient receiving cancer chemo, which sign related to thrombocytopenia would the nurse report to the HCP? SATA
*Bruises *Petechiae *Epistaxis
A client who had been receiving palliative care for cancer has deteriorated and now needs end of life care. The nurse identifies that which type of care will now be removed from the treatment plan? SATA
*Chemo *Blood transfusion *Radiation therapy
After reviewing a clients reports, the HCP suggests palliative care for the client. Which conditions would qualify the client for this type of care? SATA
*Chronic renal failure *Congestive heart failure *Chronic obstructive lung disease
Which clients are using complementary and/or alternative medicine (CAM) to treat their symptoms of emotional distress and psychiatric illness? SATA
*Client practices meditation to reduce anxiety in addition to outpatient counseling *Client uses massage, lavender, and chamomile to decrease stress and anxiety *Client with depression takes an omega 3 fatty acid supplement and an antidepressant
Which clients are using complementary and/or alternative medicine to treat their symptoms of emotional distress and psychiatric illness? SATA
*Client practices meditation to reduce anxiety in addition to outpatient counseling *Client uses massage, lavender, and chamomile to decrease stress and anxiety *Client with depression takes an omega 3 fatty acid supplement and an antidepressant
Which problems would the nurse plan to address when dealing with ethical issues specifically related to end of life care? SATA
*Clients may be unable to communicate effectively *All interventions for helping the clients seem futile *Predictions regarding health outcomes are not always accurate.
Which problem would the nurse rank as HIGH PRIORITY when planning care for a group of clients? SATA
*Complaints of chest pain following ambulation in the hallway *Decreased levels of consciousness after an automobile accident *Respiratory depression after narcotic pain medication administration
Which information would the nurse include when teaching a patient beginning chemo for leukemia on ways to prevent TLS? SATA
*Consume 3000 mL/day of fluids.
The nurse is caring for a client who sustained a GSW in a drive by shooting. The client is fearful of further harm from unwanted visitors. Which safety intervention will the nurse implement to prevent client and staff injury? SATA
*Contact hospital security *Activate security cameras *Lock doors into the facility
Which of the nurse's statements are true regarding delegation? SATA
*Delegation is a complex process *Delegation improves client care outcomes when used effectively
Which assessment finding of a client being related in the ER after a MVA indicates the need for immediate health care provider intervention? SATA
*Facial edema *Septal deviation *Clear nasal drainage *O2 Saturation 89% *Bilateral periorbital bruising
Which part of the clients body would the nurse assess to confirm a diagnosis of frostbite? SATA
*Fingers *Ear lobes
For which client condition would the nurse stabilize the cervical spine as the PRIORITY nursing intervention? SATA
*Flail Chest *Head Injuries *Facial Chemical Burns
For which client condition would the nurse stabilize the cervical spine as the PRIORITY nursing intervention? SATA
*Flail chest *Head injuries *Facial chemical burns
Which activity would the nurse recommend to a client who asks for advice about insomnia? SATA
*Follow the same bedtime ritual each night *Perform deep-breathing exercises
The patient reports a metallic taste to the nurse. Which disease-related consequence is the patient likely experiencing? SATA
*Food aversions *Reduced appetite
Which preliminary information will the nurse provide to a patient about genetic testing to determine cancer predisposition? SATA
*Genetic testing is expensive *The test is performed on blood
Which conditions of clients who have been exposed to cold temperatures in a snowstorm put them at risk of sustaining cold injuries? SATA
*Hypoglycemia *Opioid medication use *A heavy smoker for years
Which nursing action would the nurse implement during the primary survey of the emergency assessment process for a client? SATA
*Immobilizing the cervical spine *Preparing for chest tube insertion *Applying direct pressure to a wound
Which complication will likely cause thrombocytopenia in a patient with cancer? SATA
*Impaired immune function *Impaired platelet production *Impaired bone marrow function *Impaired blood-producing function
Which complication likely caused a patient with cancer to have anemia? SATA
*Impaired tissue oxygenation *Impaired blood-producing function
Which dietary modification can the nurse recommend to a patient for preventing cancer development? SATA
*Increasing broccoli intake *Consuming more dietary bran *Restricting alcohol consumption to less than two drinks per day
Which disease related consequence is often caused by cancer? SATA
*Infection *Decreased nutritional absorption
A client with positive family history of testicular cancer arrives at the hospital and reports testicular pain. The primary healthcare provider reviews the lab reports and makes a diagnosis of testicular cancer. After surgery, the client will undergo chemo. Which condition might occur in this client after chemo? SATA
*Infertility *Heart Disease *Metabolic syndrome
Which actions would the nurse implement when an older adult is brought to the ER after being found in the street without a coat during a snowstorm? SATA
*Obtain a rectal temperature *Assess the fingers for areas of frostbite *Determine client's level of consciousness *Ask for client identification
Which action would the nurse implement when a client develops an anaphylactic reaction? SATA
*Initially, apply oxygen at 90% to 100% per nasal cannula. *Call the Rapid Response Team and have the crash cart retrieved *Elevate the head of the bed to 45 degrees *Ensure emergency airway equipment is at the bedside.
The RN is caring for a client with epilepsy. Which tasks delegated by the RN to the members of the HC team indicate active delegation? SATA
*Instructing the LPN to monitor the vitals *Instructing the UAP to reposition the client *Instructing the UAP to place the oxygen mask
Which role does pharmacogenomics play in cancer treatment? SATA
*It can assist with side effect management during therapy. *It allows a more individualized approach to chemo. *It can determine the sensitivity to various therapeutic agents.
Which item would the nurse need when caring for a client undergoing treatment from an internal radiation implant that has become dislodged? SATA
*Lead-lined container *Long-handled forceps
Which feature can be found in a normal cell? SATA
*Low mitotic index *Tight adherence *Euploidy
Which is a common mode of transmission for cancer metastasis? SATA
*Lymphatic *Bloodborne *Extension into surrounding tissues
Which statement pertaining to cancer development is correct? SATA
*Mutated normal cells may become neoplastic cells. *Secondary prevention is screening for early detection. Primary prevention is prevention exposure to causes of cancer.
Which statement is true regarding delegation? SATA
*Open lines of communication must occur between delegator and delegatee. *Delegation occurs only when at least 2 people are involved in a mutual work situation *Delegation involves sharing activities with other appropriate authorities to accomplish the work
Which statements are true regarding delegation? SATA
*Open lines of communication must occur between delegator and delegatee. *Delegation occurs only when at least two people are involved in a mutual work situation.
Which statements are true regarding delegation? SATA
*Open lines of communication must occur between delegator and delegatee. *Delegation occurs only when at least two people are involved in a mutual work situation. *Delegation involves sharing activities with other health team members who have the authority to accomplish the work.
Which finding in the psychological assessment may be associated with disease-related consequences of cancer? SATA
*Pain *Suffering
Which emergency medical system (EMS) first responders can perform triage during mass casualty incidents? SATA
*Paramedics *Nurses appointed to a field team
Which initial nursing intervention is the MOST appropriate for a client who survived a fire in the hospital and is found to have neck trauma, dyspnea, gasping breathing, and is unable to speak? SATA
*Performing jaw-thrust maneuver *Preparing to assist in performing endotracheal intubation
Which methods qualify as alternative therapies for pain? Select all that apply. One, some, or all responses may be correct. SATA
*Prayer *Hypnosis *Aromatherapy *Guided imagery
Which parameters would the nurse consider for proper rapid baseline assessment using AVPU in a client with drug abuse? SATA
*Reaction to pain *Response to voice
The RN is planning to delegate various tasks. Which actions would the RN take when delegating tasks appropriately? SATA
*Select an experienced nurse as a delegatee *Ask open-ended questions to the delegatee *Provide constructive feedback to. The delegatee
The RN is planning to delegate various tasks. Which actions would the RN take when delegating tasks appropriately? SATA
*Select an experienced nurse s a delegatee *Ask open ended questions to the delegatee *Provide constructive feedback to the delegatee
The nurse teaches a student nurse about caring for patients with oncologic emergencies. Which condition identified by the student nurse indicates that teaching was effective? SATA
*Sepsis *Disseminated intravascular coagulation (DIC) *Syndrome of inappropriate anti diuretic hormone (SIADH)
Which potential life threatening conditions would be considered during the primary survey for a client admitted after a fire accident? SATA
*Shock *Inhalation injury *Direct cardiac injury
Which clinical indicator would the nurse expect to identify when assessing an individual with a spontaneous pneumothorax? SATA
*Shortness of breath *Unilateral chest pain
Which radiation therapy related information is important for the nurse to reinforce a patient who has. Just completed combination therapy? SATA
*Skin in the radiations path remains more sensitive to sunburn; therefore avoid direct skin exposure for 1 year after therapy. *Fatigue may last for months after therapy ends; therefore continue to utilize energy conservation measures and exercise regularly.
Which factor determines the type of cancer treatment a patient may receive? SATA
*Specific type of cancer *Patients general health *Evidence of cancer spread
Which action would be a PRIORITY for the nurse to implement when caring for a client with trauma? SATA
*Start a large-bore IV line *Immobilize any obvious deformities *Remove clothing to allow for an adequate exam
Which conditions are given a green tag according to triage disaster tag system? SATA
*Strains *Abrasions
A client sustains a fractured right femur after an automobile accident and is admitted to the hospitals ER. Which assessment would the nurse make? SATA
*Take the clients pedal pulse in the affected extremity *Instruct the client to wiggle the toes of the right foot *Ask the client if numbness or tingling is present in the right foot.
In which situation would the nurse consider family members as the primary source of information? SATA
*The client is an infant or a child *The client is brought in as an emergency *The client is critically ill and disoriented
Which cause would the nurse suspect for a patient with cancer who has a WBC count of 1200? SATA
*The patient may have leukemia *Cancer cells may have invaded the bone marrow (LOW and may be associated with leukemia or tumor cells invading the bone marrow.)
Which feature does a benign tumor cell have? SATA
*They have orderly growth patterns *They grow by hyper plastic expansion *They are encapsulated by fibrous connective tissue.
Which individuals would the ER charge nurse collaborate with during an actual disaster to organize nursing and ancillary services to meet the client needs? SATA
*Triage officer *Trauma program manager *Medical command physician
Which S/S will the nurse include when teaching a patient about cancer warning signs? SATA
*Unusual bleeding and discharge *Change in bowel and bladder habits *Nagging cough or a hoarse voice
Which action would the nurse correct after observing the student nursing caring for the skin of a client who recently underwent radiation therapy? SATA
*Using a washcloth for cleaning the radiated site *Drying the irradiated area with rubbing motions *Removing the ink marks that identify the location of the focused beam of radiation
The nurse assesses for which client symptoms that indicate hyperthermia? SATA
*Vasodilation *Dry and flushed skin *Decreased urinalysis output
The nurse assesses for which client symptoms that indicate hyperthermia? SATA
*Vasodilation *Dry and flushed skin *Decreased urinary output
Which assessment data would the nurse obtain for a woman who was sexually assaulted 2 hours ago? SATA
*Verbatim statements regarding the assault *S/S of physical trauma *S/S of emotional trauma *Availability of support systems *Level of anxiety and coping mechanisms
Which action would a nurse take to avoid complications in a client who has developed severe bone marrow depression after receiving chemo for cancer? SATA
*Wash hands before entering the clients room. *Advise use of a soft toothbrush for oral hygiene. *Report an elevation in temperature immediately.
Which instruction would the nurse provide a client with a leukopenia secondary to chemo?
"You should avoid large crowds and people with infections."
A breast feeding parent asks the nurse if the use of herbal medicines will increase breast milk supply. Which nursing response is most appropriate?
"You should speak to your HCP about this."
The RN is delegating work to 4 delegatees. Which delegatee has an established relationship with the delegator?
"Your way of doing is right; continue to do it in the same way."
The nurse is educating the caregivers of an elderly adult with advanced Parkinson's disease about continuing care. Which information would the nurse provide? SATA
*"Adult day care centers are ideal for clients whose caregivers have to be away from home during the day." *"Hospice care is a continuing care system that allows terminal clients to live at home with comfort, independence, and dignity." *"Nursing centers provide 24 hour custodial care to help residents achieve and maintain their highest level of functioning."
Which statements made by the nursing student demonstrate adequate knowledge about the etiology of hypothermia and administration of different treatments? SATA
*"Blood infusion causes hypothermia." *"Neuromuscular blocking agents causes hypothermia."
The nurse educator discusses pain management for patients with cancer pain and includes which statement? SATA
*"Cancer treatments can cause acute pain." *Most cancer pain is the result of tumor growth." *Most cancer pain is persistent."
Which statements indicate effective learning on ways to minimize heat radiation? SATA
*"I will apply an ice pack to the client." *"I will cover the client with dark clothes." *"I will instruct the client to lie in the fetal position."
Which statement about handling mass casualty disaster situations in the field made by the student nurse shows the need for further education? SATA
*"I will try to provide maximum care and save the critically ill clients tagged expectant." *"I will provide green tagged clients immediate care as compared to other categories."
Which statement indicates understanding after teaching a post radiation therapy client about proper skin care to the treatment area? SATA
*"I will wear loose fitting clothing over the area." *"I will avoid using adhesive bandages." *"I will avoid exposing the area to cold temperatures."
Which statement regarding an assessment technique for a patient with leukemia is valid? SATA
*"I'll ask the patient whether he or she feels fatigued." *"I'll observe the patients skin for color, petechiae, or ecchymosis." *"I'll ask the patient whether he or she has a history of infections and illnesses.
A patient diagnosed with leukemia has developed an infection. Which response would the nurse give the patient about the reason for the infection? SATA
*"Impaired immune function occurs most often in patients with leukemia." *"Impaired blood-producing functions occur most often in patients with leukemia."
Which statement indicates the need for further teaching about malignant cells? SATA
*"The cancer cells grow in the wrong place by hyper plastic expansion." *"The cancer cell does not respond to apoptotic signals because it contains fibronectin protein."
Which statement about IV administration of chemo is correct? SATA
*"Vesicant agents are very caustic to tissue if infiltration occurs." *"IV chemo is the preferred route of chemo in the treatment of cancer."
Which HCP would the nurse say work under active delegation? SATA
*A LPN administering oral medications as delegated by the RN *The UAP maintaining oral hygiene of the clients as delegated by the RN
Which characteristic must triage nurses employ when prioritizing care with any model? SATA
*A caring ethic *A systematic approach to care *Solid clinical decision making skills
Which characteristic must triage nurses employ when prioritizing care with any model? SATA
*A caring ethic *A systematic approach to care *Solid clinical decision-making skills
Which client condition would the triage nurse classify as needing immediate care? SATA
*Active hemorrhage *Substernal chest pain
Which emergency assessments are performed by the nurse in a primary survey for a client with injuries from a bomb blast? SATA
*Airway *Breathing *Circulation *Identify deformities
Which questions related to decision making for delegation are appropriate according to the delegation right of "right circumstance"? SATA
*Are the equipment and resources available to complete the task? *Does the delegatee have appropriate supervision to complete the task?
A patient asks if there are any drugs that help prevent the development of cancer. How will the nurse respond? SATA
*Aspirin reduces the risk for colon cancer. *Lycopene reduces the risk for prostate cancer. *Tamoxifen reduces the risk for breast cancer.
Which nursing action would be conducted during the primary survey airway assessment in the ER? SATA
*Assessing for edema *Checking for foreign bodies *Monitoring for respiratory distress
Which assessment would the triage nurse perform first for a client brought to the ER with a bone protruding from the right lower leg.
Pedal pulses
Which mechanism of injury might be the reason for a suspected spinal cord injury in a client with a direct injury to the vertebral column from a gunshot after a mass shooting?
Penetrating trauma
Which activity places a client at risk for hyperthermia?
Performing strenuous activity in high humidity
Which action would the nurse take when an older adult who was in a MVA exhibits a decreased LOC and serosanguineous drainage from the left ear?
Place a sterile pad over the external ear
Which action would the nurse take when planning room placement for a client with squamous cell carcinoma of the tongue that is to be treated with interstitially implanted Redon seeds?
Place the client in a private room
A group of bomb blast victims needs to be transported to the hospital immediately. Which staff members of an emergency unit are most appropriate to handle this situation?
Prehospital care providers
Which staff member would be the first to manage the care of victims from an accident at a nuclear power plant?
Prehospital care providers
When notified of a client en route to the ER after sustaining a GSW to the chest, which action is the nurses PRIORITY?
Prepare equipment for chest tube insertion
Which nursing action would the nurse implement immediately when providing care to a trauma client whose primary survey indicates a Glasgow score of 7?
Prepare for intubation
When preparing to admit a near drowning victim to the ER, which action by the nurse is PRIORITY?
Prepare the endotracheal intubation tray for insertion of an artificial airway
A 2 year old child is brought to the ER with fever, drooling, and agitation. The child is not coughing and. It's sitting upright and leaning forward. Which intervention is PRIORITY?
Procurement of crash cart and emergency airway management tools to be kept on hand during examination of the throat
Which screening guideline is recommended for the early detection of cancer?
Yearly fecal occult blood test for adults of all ages
Which information regarding palliative care as opposed to hospice care would the nurse provide during a home visit to a client with heart failure who asks about this option?
the focus of palliative care is to enhance you and your family's quality of life despite your heart failure
Which response would the nurse provide to a perimenopausal woman who asks about complementary treatment options for hot flashes?
"Try eating more soy rich foods such as yams, cherries, alfalfa sprouts, black beans, and soybeans."
Which response is best for a patient who is receiving chemo for stomach cancer and tells the nurse they have a metallic taste in the mouth.
"Unfortunately, it is a side effect of the chemo meds."
When assessing a client who is receiving palliative care, which question regarding spiritual health is correct?
"What is your source of spiritual strength during hard times?"
Which assessment by the student nurse indicates effective learning about the functions and utilization of trauma centers?
"Clients requiring stabilization with major injuries should be sent to a level III trauma center."
Which question would the nurse ask FIRST of the witnesses who accompanied a rescued drowning victim to the ER?
"How long were they under water?"
The RN teaches the student nurse about delegation. Which statement made by the student nurse indicates appropriate learning?
"LPNs can be expected to perform tasks with which they have experience."
The parent of a child with leukemia asks the nurse why irradiation of the spine and skull is necessary. Which is the most accurate response by the nurse?
"Leukemic cells may invade the nervous system, but the usual medications are ineffective in the brain."
Which explanation will the nurse provide to a client with cancer who develops pancytopenia during the course of chemo and asks the nurse why this has occurred?
"Noncancerous cells also are susceptible to the effects of chemo medications."
Which statement correctly describes oral chemo agents as compared to traditional IV agents?
"Oral chemo drugs are just as toxic as traditional IV chemo."
Which response by the nurse is most accurate when a patient with terminal cancer asks about the potential for chronic pain?
"Pain can be a major problem for those with terminal cancer."
The student nurse is describing palliative care to a clients family. Which statement made by the student nurse indicates a need for correction by the RN?
"Palliative care is the same as hospice care."
Which statement describes the mechanism by which chemo can cure and increase survival time in individuals with cancer?
"The killing effect on cancer cells is related to the ability to damage DNA and interfere with cell division."
In which order would the nurse perform the following interventions for a client with injuries from a MVA?
1. Control external bleeding. 2. Elevate the injured limb 3. Apply ice packs 4. Monitor for temperature elevation
In which order would the nurse perform the actions when inspecting the chest of a client with a suspected heart attack after a fire?
1. Inspect the chest for paradoxical chest movement 2. Palpate the sternum, clavicles, and ribs 3. Auscultate breath sounds and heart sounds 4. Evaluate the client for rib fractures, pulmonary contusion, blunt cardiac injury, and hemothorax. 5. Obtain a chest x-ray and 12-lead-ECG
Order to assess the airway of a patient with simultaneous spine stabilization.
1. Jaw-thrust maneuver 2. Remove or suction any foreign bodies 3. Insert oropharyngeal or nasopharyngeal airway or endotracheal tube or perform cricothyroidotomy. 4. Immobilize cervical spine using rigid cervical collar and cervical immobilization device
Which order would the nurse perform the interventions when inspecting posterior surfaces in a client admitted with injuries?
1. Logroll the client whenever movement is needed 2. Support the head of the client 3. Inspect the back for ecchymosis, abrasions, puncture, and cuts 4. Palpate the entire spine for misalignment, deformity, and pain
Which minimum length of time is recommended for victims of a large scale near drowning incident brought to the ER to be kept under observation in the hospital?
23 hours
Which of these clients in the ER would the nurse see first?
A client with ventricular fibrillation
According to the American Cancer Society (ACS), which factor has led. To health disparities between African Americans and White Americans?
Access to health care facilities
A client with a fractured femur is being prepared for surgery. The client develops a sudden onset of cyanosis, tachycardia, dyspnea, and restlessness. Which action would the nurse take first?
Administer oxygen by mask
Which emergency assessment has been performed on the client when an emergency management team is removing foreign bodies and performing cricothyroidotomy on a client post burn injury?
Airway with simultaneous cervical spine stabilization
Which causative agent is common to bitty hyperthermia and hypothermia
Alcohol
Which drug would the nurse administer to prevent acute kidney injury from TLS when caring for a patient beginning high dose chemo for the treatment of leukemia.
Allopurinol
A patient with cancer is experiencing fatigue and weakness. Which disorder could these symptoms be related to ?
Anemia
Which complication of pinworm infestation, although rare, would the nurse be aware of?
Appendicitis
Which cultural group adopts a combination of dietary, herbal, and other naturalistic therapies to prevent and treat illness?
Asian Indian
Which action is the priority when the pre operative nurse learns that a client is taking several herbal supplements?
Ask the client which herbs have been taken.
Which location would the nurse consider for triage of casualties when planning for a community disaster drill that will include a bombing in a shopping mall with hundreds of casualties?
At the scene of the disaster
Which tissue affected by chemo will the nurse consider when formulating a response to a client receiving cancer chemo who asks the nurse why an antibiotic was prescribed.
Bone marrow Immune system suppressed
The nurse is caring for a client admitted with peritonitis. Which finding in the medical record is most likely the cause?
Bowel Obstruction Causes: Bowel obstruction, appendicitis, external penetrating wound, peritoneal dialysis
Which type of emergency assessment is the nurse performing when the nurse uses the "AVPU" mnemonic to assess a group of clients admitted with NEURO injury after hiking at high altitude?
Disability A-Alert V-Voice P-Pain U-Unresponsive
Which condition will the nurse assess for when a patient states' "I've been using St. John's Wort to try and feel more like myself."?
Depression
Which clinical indicator suggests to the nurse that a client may be experiencing a complication of fractured ribs?
Diminished breath sounds on the affected side
Which assessment is a component of the primary survey?
Disability
Which type of emergency assessment is the nurse performing when the nurse reassess level of consciousness and mental status of a client who survived a fire?
Disability
Who is responsible for triaging the victims of a multiple MVA on a major interstate?
Emergency first resopnders
A client with chronic renal failure stops responding to the treatment. On examination, the primary HCP determines that the client is terminally ill. Which is the correct nursing intervention in this situation?
Encourage the family members to provide palliative care to the client
A client with advanced bone cancer is experiencing cachexia. The nurse reviews the nutritional components of palliative care with the clients family members. The nurse recognizes that the teaching is designed to achieve which outcome?
Enhance the quality of the client's life
The nurse is assessing a child receiving chemo for treatment of leukemia. Which side effect would the nurse anticipate?
Epistaxis
Which action would the nurse take FIRST when a client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures?
Establish an airway and stabilize the cervical spine
During the process of delegation, the delegator's behavior is noted to be observing and monitoring. What would be the relationship between the delegator and delegatee in this situation?
Established
Which care level would the nurse say is the difference between triage under usual conditions and triage under mass casualty conditions?
Expectant care
How is cancer-related cachexia defined?
Extreme body wasting and malnutrition
Which type of emergency assessment is being performed when the nurse is inserting a gastric tube and arranging for diagnostic studies for a client who sustained injuries after a bus accident?
Focused adjuncts
Which technique would the nurse recommend to a client who reports racing thoughts that are difficult to control in periods of stress?
Meditation
A client who has a long history of meds and alcohol abuse mentions taking ginkgo biloba. Which condition is the client taking ginkgo biloba to treat?
Memory impairment
Which action would the nurse take when caring for a client who has a possible skull fracture as a result of trauma?
Monitor the client for signs of brain injury
Which intervention would be a PRIORITY for the nurse to include in the plan of care for a client with a GSW who has severe hemiplegia associated with abnormal body posturing and fixed dilated pupils?
Monitoring respiratory rate
The nurse concludes that a client with a body temperature of 98.6 is experiencing which condition?
Normothermia
Which member of the inter-professional team in a palliative care setting serves as the client advocate, evaluating the physical, emotional, and spiritual needs of the client? 1. Nurse 2. Pharmacist 3. Music therapist 4. Primary health care provider
Nurse
Five victims of a shooting are identified as needing urgent care. What should the triage officer do first when these victims arrive in the emergency department?
TRIAGE THE VICTIMS The triage officer rapidly evaluates each person who presents to the hospital, even those who come in with triage tags in place. Client acuity is re-evaluated for appropriate disposition to the area within the ED or hospital best suited to meet the client's medical needs. The clients will need to be triaged before being sent to the operating room. The triage officer would not be responsible for conducting laboratory testing or notifying the next of kin of the victims.
Which activity performed by the community health nurse best reflects primary prevention of cancer?
Teaching a class on cancer prevention
Which behavior would the delegator adopt when communicating with the delegatee if the relationship between them is new, the delegatee has limited knowledge, and the delegator would not expect the relationship to be ongoing?
Telling
When delegating a task, the delegator says, "Please tell me how you are going to perform this procedure, and I will share my expectations regarding how we need to communicate with each other." Which explanation can be inferred about the delegatee?
The delegatee has willingness and ability, but the relationship is new.
How are malignant tumor cells that graded G1 characterized?
They closely resemble the cells from which they were produced.
The nurse recognizes that patients with cancer are at an increased risk for infection for which reason?
They have a decreased production of WBCs
Which oncologic emergency is a positive sign of the effectiveness of chemotherapy?
Tumor lysis syndrome (Characterized by the rapid destruction of a large number of cells)
Which assessment finding in a client reporting severe itching with redness and wheals on the uncovered parts of the legs after sleeping in an old bed supports the primary HCP prescribing antihistamines and topical corticosteroids?
Urticaria grouped in threes surrounded by vivid flare, transforming into a persistent lesion (Bedbugs)
During a mugging and robbery, a client sustained minor abrasions and contusions. Based on the assessment findings, which action would the nurse do FIRST?
Validate that anxiety is normal and have a family member stay with the client.
