iggy test 5

A client states that she rates her pain as a 5 on a 0-to-10 scale post-mastectomy. The provider has ordered morphine 4 mg for moderate pain every 4 hours. The morphine is supplied in a solution of 8 mg/mL. How many mL will the nurse administer? ____ mL

ANS: 0.5 mL 8x = 4 x = 0.5 mL

A nurse prepares to administer 12 mg/kg of 5-fluorouracil chemotherapy intravenously to a client who has colon cancer. The client weights 132 lb. How many milligrams should the nurse administer? (Record your answer using a whole number.) _____ mg

ANS: 720 mg 132 lb = 60 kg. 60 kg 12 mg/kg = 720 mg.

A nurse cares for a client who has a new colostomy. Which action should the nurse take? a. Empty the pouch frequently to remove excess gas collection. b. Change the ostomy pouch and wafer every morning. c. Allow the pouch to completely fill with stool prior to emptying it. d. Use surgical tape to secure the pouch and prevent leakage.

ANS: A The nurse should empty the new ostomy pouch frequently because of excess gas collection, and empty the pouch when it is one-third to one-half full of stool. The ostomy pouch does not need to be changed every morning. Ostomy wafers with paste should be used to secure and seal the ostomy appliance; surgical tape should not be used.

A client presents to the emergency department in sickle cell crisis. What intervention by the nurse takes priority? Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 331 a. Administer oxygen. b. Apply an oximetry probe. c. Give pain medication. d. Start an IV line.

ANS: A All actions are appropriate, but remembering the ABCs, oxygen would come first. The main problem in a sickle cell crisis is tissue and organ hypoxia, so providing oxygen helps halt the process

A nurse working with clients who experience alopecia knows that which is the best method of helping clients manage the psychosocial impact of this problem? a. Assisting the client to pre-plan for this event b. Reassuring the client that alopecia is temporary c. Teaching the client ways to protect the scalp d. Telling the client that there are worse side effects

ANS: A Alopecia does not occur for all clients who have cancer, but when it does, it can be devastating. The best action by the nurse is to teach the client about the possibility and to give the client multiple choices for preparing for this event. Not all clients will have the same reaction, but some possible actions the client can take are buying a wig ahead of time, buying attractive hats and scarves, and having a hairdresser modify a wig to look like the clients own hair. Teaching about scalp protection is important but does not address the psychosocial impact. Reassuring the client that hair loss is temporary and telling him or her that there are worse side effects are both patronizing and do not give the client tools to manage this condition.

A nurse caring for a client with sickle cell disease (SCD) reviews the clients laboratory work. Which finding should the nurse report to the provider? a. Creatinine: 2.9 mg/dL b. Hematocrit: 30% c. Sodium: 147 mEq/L d. White blood cell count: 12,000/mm3

ANS: A An elevated creatinine indicates kidney damage, which occurs in SCD. A hematocrit level of 30% is an expected finding, as is a slightly elevated white blood cell count. A sodium level of 147 mEq/L, although slightly high, is not concerning

The nurse working with oncology clients understands that which age-related change increases the older clients susceptibility to infection during chemotherapy? a. Decreased immune function b. Diminished nutritional stores c. Existing cognitive deficits d. Poor physical reserves

ANS: A As people age, there is an age-related decrease in immune function, causing the older adult to be more susceptible to infection than other clients. Not all older adults have diminished nutritional stores, cognitive dysfunction, or poor physical reserves

A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best? a. 0.45% normal saline b. 0.9% normal saline c. Dextrose 50% (D50) d. Lactated Ringers solution

ANS: A Because clients in sickle cell crisis are often dehydrated, the fluid of choice is a hypotonic solution such as 0.45% normal saline. 0.9% normal saline and lactated Ringers solution are isotonic. D50 is hypertonic and not used for hydration.

The nurse caring for oncology clients knows that which form of metastasis is the most common? a. Bloodborne b. Direct invasion c. Lymphatic spread d. Via bone marrow

ANS: A Bloodborne metastasis is the most common way for cancer to metastasize. Direct invasion and lymphatic spread are other methods. Bone marrow is not a medium in which cancer spreads, although cancer can occur in the bone marrow

A group of nursing students has entered a futuristic science contest in which they have developed a cure for cancer. Which treatment would most likely be the winning entry? a. Artificial fibronectin infusion to maintain tight adhesion of cells b. Chromosome repair kit to halt rapid division of cancer cells c. Synthetic enzyme transfusion to allow rapid cellular migration d. Telomerase therapy to maintain chromosomal immortality

ANS: A Cancer cells do not have sufficient fibronectin and so do not maintain tight adhesion with other cells. This is part of the mechanism of metastasis. Chromosome alterations in cancer cells (aneuploidy) consist of having too many, too few, or altered chromosome pairs. This does not necessarily lead to rapid cellular division. Rapid cellular migration is part of metastasis. Immortality is a characteristic of cancer cells due to too much telomerase.

The nurse is taking a history of a 68-year-old woman. What assessment findings would indicate a high risk for the development of breast cancer? (Select all that apply.) a. Age greater than 65 years b. Increased breast density c. Osteoporosis d. Multiparity e. Genetic factors

ANS: A, B, E The high risk factors for breast cancer are age greater than 65 with the risk increasing until age 80; an increase in breast density because of more glandular and connective tissue; and inherited mutations of BRCA1 and/or BRCA2 genes. Osteoporosis and multiparity are not risk factors for breast cancer. A high postmenopausal bone density and nulliparity are moderate and low increased risk factors, respectively.

A nurse in the oncology clinic is providing preoperative education to a client just diagnosed with cancer. The client has been scheduled for surgery in 3 days. What action by the nurse is best? a. Call the client at home the next day to review teaching. b. Give the client information about a cancer support group. c. Provide all the preoperative instructions in writing. d. Reassure the client that surgery will be over soon.

ANS: A Clients are often overwhelmed at a sudden diagnosis of cancer and may be more overwhelmed at the idea of a major operation so soon. This stress significantly impacts the clients ability to understand, retain, and recall information. The nurse should call the client at home the next day to review the teaching and to answer questions. The client may or may not be ready to investigate a support group, but this does not help with teaching. Giving information in writing is important (if the client can read it), but in itself will not be enough. Telling the client that surgery will be over soon is giving false reassurance and does nothing for teaching

A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking. When the client requests pain medication, what action by the nurse is best? a. Give the client pain medication if it is time for another dose. b. Instruct the client not to request pain medication too early. c. Request the provider leave a prescription for a placebo. d. Tell the client it is too early to have more pain medication

ANS: A Clients with sickle cell crisis often have severe pain that is managed with up to 48 hours of IV opioid analgesics. Even if the client is addicted and drug seeking, he or she is still in extreme pain. If the client can receive another dose of medication, the nurse should provide it. The other options are judgmental and do not address the clients pain. Giving placebos is unethical.

A nurse assesses a client who is prescribed 5-fluorouracil (5-FU) chemotherapy intravenously for the treatment of colon cancer. Which assessment finding should alert the nurse to contact the health care provider? a. White blood cell (WBC) count of 1500/mm3 b. Fatigue c. Nausea and diarrhea d. Mucositis and oral ulcers

ANS: A Common side effects of 5-FU include fatigue, leukopenia, diarrhea, mucositis and mouth ulcers, and peripheral neuropathy. However, the clients WBC count is very low (normal range is 5000 to 10,000/mm3), so the provider should be notified. He or she may want to delay chemotherapy by a day or two. Certainly the client is at high risk for infection. The other assessment findings are consistent with common side effects of 5-FU that would not need to be reported immediately.

A client asks the nurse if eating only preservative- and dye-free foods will decrease cancer risk. What response by the nurse is best? a. Maybe; preservatives, dyes, and preparation methods may be risk factors. b. No; research studies have never shown those things to cause cancer. c. There are other things you can do that will more effectively lower your risk. d. Yes; preservatives and dyes are well known to be carcinogens

ANS: A Dietary factors related to cancer development are poorly understood, although dietary practices are suspected to alter cancer risk. Suspected dietary risk factors include low fiber intake and a high intake of red meat or animal fat. Preservatives, preparation methods, and additives (dyes, flavorings, sweeteners) may have cancer- promoting effects. It is correct to say that other things can lower risk more effectively, but this does not give the client concrete information about how to do so, and also does not answer the clients question.

A client is placed on a medical regimen of doxorubicin (Adriamycin), cyclophosphamide (Cytoxan), and fluorouracil (5-FU) for breast cancer. Which side effect seen in the client should the nurse report to the provider immediately? a. Shortness of breath b. Nausea and vomiting c. Hair loss d. Mucositis

ANS: A Doxorubicin (Adriamycin) can cause cardiac problems with symptoms of extreme fatigue, shortness of breath, chronic cough, and edema. These need to be reported as soon as possible to the provider. Nausea, vomiting, hair loss, and mucositis are common problems associated with chemotherapy regimens.

A nurse works on an oncology unit and delegates personal hygiene to an unlicensed assistive personnel (UAP). What action by the UAP requires intervention from the nurse? a. Allowing a very tired client to skip oral hygiene and sleep b. Assisting clients with washing the perianal area every 12 hours c. Helping the client use a soft-bristled toothbrush for oral care d. Reminding the client to rinse the mouth with water or saline

ANS: A Even though clients may be tired, they still need to participate in hygiene to help prevent infection. The other options are all appropriate.

The nurse is caring for a client with leukemia who has the priority problem of fatigue. What action by the client best indicates that an important goal for this problem has been met? a. Doing activities of daily living (ADLs) using rest periods b. Helping plan a daily activity schedule c. Requesting a sleeping pill at night d. Telling visitors to leave when fatigued

ANS: A Fatigue is a common problem for clients with leukemia. This client is managing his or her own ADLs using rest periods, which indicates an understanding of fatigue and how to control it. Helping to plan an activity schedule is a lesser indicator. Requesting a sleeping pill does not help control fatigue during the day. Asking visitors to leave when tired is another lesser indicator. Managing ADLs using rest periods demonstrates the most comprehensive management strategy.

The nurse is teaching a 45-year-old woman about her fibrocystic breast condition. Which statement by the client indicates a lack of understanding? a. This condition will become malignant over time. b. I should refrain from using hormone replacement therapy. c. One cup of coffee in the morning should be enough for me. d. This condition makes it more difficult to examine my breasts.

ANS: A Fibrocystic breast condition does not increase a womans chance of developing breast cancer. Hormone replacement therapy is not indicated since the additional estrogen may aggravate the condition. Limiting caffeine intake may give relief for tender breasts. The fibrocystic changes to the breasts make it more difficult to examine the breasts because of fibrotic changes and lumps.

A client is receiving interleukins along with chemotherapy. What assessment by the nurse takes priority? a. Blood pressure b. Lung assessment c. Oral mucous membranes d. Skin integrity

ANS: A Interleukins can cause capillary leak syndrome and fluid shifting, leading to intravascular volume depletion. Although all assessments are important in caring for clients with cancer, blood pressure and other assessments of fluid status take priority

A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important? a. Assessing the IV site every hour b. Educating the client on side effects c. Monitoring the client for nausea d. Providing warm packs for comfort

ANS: A Intravenous chemotherapy can cause local tissue destruction if it extravasates into the surrounding tissues. Peripheral IV lines are more prone to this than centrally placed lines. The most important intervention is prevention, so the nurse should check hourly to ensure the IV site is patent, or frequently depending on facility policy. Education and monitoring for side effects such as nausea are important for all clients receiving chemotherapy. Warm packs may be helpful for comfort, but if the client reports that an IV site is painful, the nurse needs to assess further

A nurse assesses a client who is prescribed alosetron (Lotronex). Which assessment question should the nurse ask this client? a. Have you been experiencing any constipation? b. Are you eating a diet high in fiber and fluids? c. Do you have a history of high blood pressure? d. What vitamins and supplements are you taking?

ANS: A Ischemic colitis is a life-threatening complication of alosetron. The nurse should assess the client for constipation. The other questions do not identify complications related to alosetron.

A client has Crohns disease. What type of anemia is this client most at risk for developing? a. Folic acid deficiency b. Fanconis anemia c. Hemolytic anemia d. Vitamin B12 anemia

ANS: A Malabsorption syndromes such as Crohns disease leave a client prone to folic acid deficiency. Fanconis anemia, hemolytic anemia, and vitamin B12 anemia are not related to Crohns disease.

A woman diagnosed with breast cancer had these laboratory tests performed at an office visit: Alkaline phosphatase 125 U/L Total calcium 12 mg/dL Hematocrit 39% Hemoglobin 14 g/dL Which test results indicate to the nurse that some further diagnostics are needed? a. Elevated alkaline phosphatase and calcium suggests bone involvement. b. Only alkaline phosphatase is decreased, suggesting liver metastasis. c. Hematocrit and hemoglobin are decreased, indicating anemia. d. The elevated hematocrit and hemoglobin indicate dehydration.

ANS: A The alkaline phosphatase (normal value 30 to 120 U/L) and total calcium (normal value 9 to 10.5 mg/dL) levels are both elevated, suggesting bone metastasis. Both the hematocrit and hemoglobin are within normal limits for females.

A nurse reads on a hospitalized clients chart that the client is receiving teletherapy. What action by the nurse is best? a. Coordinate continuation of the therapy. b. Place the client on radiation precautions. c. No action by the nurse is needed at this time. d. Restrict visitors to only adults over age 18.

ANS: A The client needs to continue with radiation therapy, and the nurse can coordinate this with the appropriate department. The client is not radioactive, so radiation precautions and limiting visitors are not necessary.

After teaching a client who has a femoral hernia, the nurse assesses the clients understanding. Which statement indicates the client needs additional teaching related to the proper use of a truss? a. I will put on the truss before I go to bed each night. b. Ill put some powder under the truss to avoid skin irritation. c. The truss will help my hernia because I cant have surgery. d. If I have abdominal pain, Ill let my health care provider know right away

ANS: A The client should be instructed to apply the truss before arising, not before going to bed at night. The other statements show an accurate understanding of using a truss.

A nurse is caring for four clients with leukemia. After hand-off report, which client should the nurse see first? a. Client who had two bloody diarrhea stools this morning b. Client who has been premedicated for nausea prior to chemotherapy c. Client with a respiratory rate change from 18 to 22 breaths/min d. Client with an unchanged lesion to the lower right lateral malleolus

ANS: A The client who had two bloody diarrhea stools that morning may be hemorrhaging in the gastrointestinal (GI) tract and should be assessed first. The client with the change in respiratory rate may have an infection or worsening anemia and should be seen next. The other two clients are not a priority at this time.

A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL. What medication should the nurse prepare to administer? a. Epoetin alfa (Epogen) b. Filgrastim (Neupogen) c. Mesna (Mesnex) d. Oprelvekin (Neumega)

ANS: A The clients hemoglobin is low, so the nurse should prepare to administer epoetin alfa, a colony-stimulating factor that increases production of red blood cells. Filgrastim is for neutropenia. Mesna is used to decrease bladder toxicity from some chemotherapeutic agents. Oprelvekin is used to increase platelet coun

A client is discharged to home after a modified radical mastectomy with two drainage tubes. Which statement by the client would indicate that further teaching is needed? a. I am glad that these tubes will fall out at home when I finally shower. b. I should measure the drainage each day to make sure it is less than an ounce. c. I should be careful how I lie in bed so that I will not kink the tubing. d. If there is a foul odor from the drainage, I should contact my doctor.

ANS: A The drainage tubes (such as a Jackson-Pratt drain) lie just under the skin but need to be removed by the health care professional in about 1 to 3 weeks at an office visit. Drainage should be less than 25 mL in a days time. The client should be aware of her positioning to prevent kinking of the tubing. A foul odor from the drainage may indicate an infection; the doctor should be contacted immediately.

A nurse cares for a client who states, My husband is repulsed by my colostomy and refuses to be intimate with me. How should the nurse respond? a. Lets talk to the ostomy nurse to help you and your husband work through this. b. You could try to wear longer lingerie that will better hide the ostomy appliance. c. You should empty the pouch first so it will be less noticeable for your husband. d. If you are not careful, you can hurt the stoma if you engage in sexual activity.

ANS: A The nurse should collaborate with the ostomy nurse to help the client and her husband work through intimacy issues. The nurse should not minimize the clients concern about her husband with ways to hide the ostomy. The client will not hurt the stoma by engaging in sexual activity.

A nurse assesses clients at a community health center. Which client is at highest risk for the development of colorectal cancer? a. A 37-year-old who drinks eight cups of coffee daily b. A 44-year-old with irritable bowel syndrome (IBS) c. A 60-year-old lawyer who works 65 hours per week d. A 72-year-old who eats fast food frequently

ANS: D Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Coffee intake, IBS, and a heavy workload do not increase the risk for colon cancer

A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, The stool in my pouch is still liquid. How should the nurse respond? a. The stool will always be liquid with this type of colostomy. b. Eating additional fiber will bulk up your stool and decrease diarrhea. c. Your stool will become firmer over the next couple of weeks. d. This is abnormal. I will contact your health care provider.

ANS: A The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available to reabsorb the liquid from the stool. This finding is not abnormal. Liquid stool from an ascending colostomy will not become firmer with the addition of fiber to the clients diet or with the passage of time.

A client with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important? a. Assess the clients gait and balance. b. Ask the client about the ease of urine flow. c. Document the report completely. d. Inquire about the clients job risks

ANS: A This client has manifestations of spinal cord compression, which can be seen with prostate cancer. This may affect both gait and balance and urinary function. For client safety, assessing gait and balance is the priority. Documentation should be complete. The client may or may not have occupational risks for low back pain, but with his history of prostate cancer, this should not be where the nurse starts investigating

A client has been admitted after sustaining a humerus fracture that occurred when picking up the family cat. What test result would the nurse correlate to this condition? a. Bence-Jones protein in urine b. Epstein-Barr virus: positive c. Hemoglobin: 18 mg/dL d. Red blood cell count: 8.2/mm3

ANS: A This client has possible multiple myeloma. A positive Bence-Jones protein finding would correlate with this condition. The Epstein-Barr virus is a herpesvirus that causes infectious mononucleosis and some cancers. A hemoglobin of 18 mg/dL is slightly high for a male and somewhat high for a female; this can be caused by several conditions, and further information would be needed to correlate this value with a specific medical condition. A red blood cell count of 8.2/mm3 is also high, but again, more information would be needed to correlate this finding with a specific medical condition.

. A client in the emergency department reports difficulty breathing. The nurse assesses the clients appearance as depicted below: What action by the nurse is the priority? a. Assess blood pressure and pulse. b. Attach the client to a pulse oximeter. c. Have the client rate his or her pain. d. Start high-dose steroid therapy.

ANS: A This client has superior vena cava syndrome, in which venous return from the head, neck, and trunk is blocked. Decreased cardiac output can occur. The nurse should assess indicators of cardiac output, including blood pressure and pulse, as the priority. The other actions are also appropriate but are not the priority.

A client has frequent hospitalizations for leukemia and is worried about functioning as a parent to four small children. What action by the nurse would be most helpful? a. Assist the client to make sick day plans for household responsibilities. b. Determine if there are family members or friends who can help the client. c. Help the client inform friends and family that they will have to help out. d. Refer the client to a social worker in order to investigate respite child care

ANS: A While all options are reasonable choices, the best option is to help the client make sick day plans, as that is more comprehensive and inclusive than the other options, which focus on a single item.

A client has a platelet count of 9000/mm3. The nurse finds the client confused and mumbling. What action takes priority? a. Calling the Rapid Response Team b. Delegating taking a set of vital signs c. Instituting bleeding precautions d. Placing the client on bedrest

ANS: A With a platelet count this low, the client is at high risk of spontaneous bleeding. The most disastrous complication would be intracranial bleeding. The nurse needs to call the Rapid Response Team as this client has manifestations of a sudden neurologic change. The nurse should not delegate the vital signs as the client is no longer stable. Bleeding precautions will not address the immediate situation. Placing the client on bedrest or putting the client back into bed is important, but the critical action is to call for immediate medical attention.

A nurse is preparing to administer a blood transfusion to an older adult. Understanding age-related changes, what alterations in the usual protocol are necessary for the nurse to implement? (Select all that apply.) a. Assess vital signs more often. b. Hold other IV fluids running. c. Premedicate to prevent reactions. d. Transfuse smaller bags of blood. e. Transfuse each unit over 8 hours.

ANS: A, B The older adult needs vital signs monitored as often as every 15 minutes for the duration of the transfusion because changes may be the only indication of a transfusion-related problem. To prevent fluid overload, the nurse obtains a prescription to hold other running IV fluids during the transfusion. The other options are not warranted

A woman has been using acupuncture to treat the nausea and vomiting caused by the side effects of chemotherapy for breast cancer. Which conditions would cause the nurse to recommend against further use of acupuncture? (Select all that apply.) a. Lymphedema b. Bleeding tendencies c. Low white blood cell count d. Elevated serum calcium e. High platelet count

ANS: A, B, C Acupuncture could be unsafe for the client if there is poor drainage of the extremity with lymphedema or if there was a bleeding tendency and low white blood cell count. Coagulation would be compromised with a bleeding disorder, and the risk of infection would be high with the use of needles. An elevated serum calcium and high platelet count would not have any contraindication for acupuncture.

A client has mucositis. What actions by the nurse will improve the clients nutrition? (Select all that apply.) a. Assist with rinsing the mouth with saline frequently. b. Encourage the client to eat room-temperature foods. c. Give the client hot liquids to hold in the mouth. d. Provide local anesthetic medications to swish and spit. e. Remind the client to brush teeth gently after each meal.

ANS: A, B, D, E Mucositis can interfere with nutrition. The nurse can help with rinsing the mouth frequently with water or saline; encouraging the client to eat cool, slightly warm, or room-temperature foods; providing swish-and-spit anesthetics; and reminding the client to keep the mouth clean by brushing gently after each meal. Hot liquids would be painful for the client.

A clients family members are concerned that telling the client about a new finding of cancer will cause extreme emotional distress. They approach the nurse and ask if this can be kept from the client. What actions by the nurse are most appropriate? (Select all that apply.) a. Ask the family to describe their concerns more fully. b. Consult with a social worker, chaplain, or ethics committee. c. Explain the clients right to know and ask for their assistance. d. Have the unit manager take over the care of this client and family. e. Tell the family that this secret will not be kept from the client.

ANS: A, B, C The clients right of autonomy means that the client must be fully informed as to his or her diagnosis and treatment options. The nurse cannot ethically keep this information from the client. The nurse can ask the family to explain their concerns more fully so everyone understands the concerns. A social worker, chaplain, or ethics committee can become involved to assist the nurse, client, and family. The nurse should explain the clients right to know and ask the family how best to proceed. The nurse should not abdicate responsibility for this difficult situation by transferring care to another nurse. Simply telling the family that he or she will not keep this secret sets up an adversarial relationship. Explaining this fact along with the concept of autonomy would be acceptable, but this by itself is not

The nurse working with oncology clients understands that interacting factors affect cancer development. Which factors does this include? (Select all that apply.) a. Exposure to carcinogens b. Genetic predisposition c. Immune function d. Normal doubling time e. State of euploidy

ANS: A, B, C The three interacting factors needed for cancer development are exposure to carcinogens, genetic predisposition, and immune function

A nurse is providing community education on the seven warning signs of cancer. Which signs are included? (Select all that apply.) a. A sore that does not heal b. Changes in menstrual patterns c. Indigestion or trouble swallowing d. Near-daily abdominal pain e. Obvious change in a mole

ANS: A, B, C, E The seven warning signs for cancer can be remembered with the acronym CAUTION: changes in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious change in a wart or mole, and nagging cough or hoarseness. Abdominal pain is not a warning sign.

A client has thrombocytopenia. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply the clients shoes before getting the client out of bed. b. Assist the client with ambulation. c. Shave the client with a safety razor only. d. Use a lift sheet to move the client up in bed. e. Use the Waterpik on a low setting for oral care

ANS: A, B, D Clients with thrombocytopenia are at risk of significant bleeding even with minor injuries. The nurse instructs the UAP to put the clients shoes on before getting the client out of bed, assist with ambulation, shave the client with an electric razor, use a lift sheet when needed to reposition the client, and use a soft-bristled toothbrush for oral care

A student nurse is helping a registered nurse with a blood transfusion. Which actions by the student are most appropriate? (Select all that apply.) a. Hanging the blood product using normal saline and a filtered tubing set b. Taking a full set of vital signs prior to starting the blood transfusion c. Telling the client someone will remain at the bedside for the first 5 minutes d. Using gloves to start the clients IV if needed and to handle the blood product e. Verifying the clients identity, and checking blood compatibility and expiration time

ANS: A, B, D Correct actions prior to beginning a blood transfusion include hanging the product with saline and the correct filtered blood tubing, taking a full set of vital signs prior to starting, and using gloves. Someone stays with the client for the first 15 to 30 minutes of the transfusion. Two registered nurses must verify the clients identity and blood compatibility.

A nurse plans care for a client who is recovering from an inguinal hernia repair. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Encouraging ambulation three times a day b. Encouraging normal urination c. Encouraging deep breathing and coughing d. Providing ice bags and scrotal support e. Forcibly reducing the hernia

ANS: A, B, D Postoperative care for clients with an inguinal hernia includes all general postoperative care except coughing. The nurse should promote lung expansion by encouraging deep breathing and ambulation. The nurse should encourage normal urination, including allowing the client to stand, and should provide scrotal support and ice bags to prevent swelling. A hernia should never be forcibly reduced, and this procedure is not part of postoperative care.

A nurse plans care for a client who has chronic diarrhea. Which actions should the nurse include in this clients plan of care? (Select all that apply.) a. Using premoistened disposable wipes for perineal care b. Turning the client from right to left every 2 hours c. Using an antibacterial soap to clean after each stool d. Applying a barrier cream to the skin after cleaning e. Keeping broken skin areas open to air to promote healing

ANS: A, B, D The nurse should use premoistened disposable wipes instead of toilet paper for perineal care, or mild soap and warm water after each stool. Antibacterial soap would be too abrasive and damage good bacteria on the skin. The nurse should apply a thin layer of a medicated protective barrier after cleaning the skin. The client should be re-positioned frequently so that he or she is kept off the affected area, and open skin areas should be covered with DuoDerm or Tegaderm occlusive dressing to promote rapid healing.

A client has heparin-induced thrombocytopenia (HIT). The student nurse asks how this is treated. About what drugs does the nurse instructor teach? (Select all that apply.) a. Argatroban (Argatroban) b. Bivalirudin (Angiomax) c. Clopidogrel (Plavix) d. Lepirudin (Refludan) e. Methylprednisolone (Solu-Medrol)

ANS: A, B, D The standard drugs used to treat HIT are argatroban, bivalirudin, and lepirudin. The other drugs are not used. Clopidogrel is an antiplatelet agent used to reduce the likelihood of stroke or myocardial infarction. Methylprednisolone is a steroid used to reduce inflammation.

A nurse assesses a client with irritable bowel syndrome (IBS). Which questions should the nurse include in this clients assessment? (Select all that apply.) a. Which food types cause an exacerbation of symptoms? b. Where is your pain and what does it feel like? c. Have you lost a significant amount of weight lately? d. Are your stools soft, watery, and black in color? e. Do you experience nausea associated with defecation?

ANS: A, B, E The nurse should ask the client about factors that may cause exacerbations of symptoms, including food, stress, and anxiety. The nurse should also assess the location, intensity, and quality of the clients pain, and nausea associated with defecation or meals. Clients who have IBS do not usually lose weight and stools are not black in color.

A client on interferon therapy is reporting severe skin itching and irritation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Apply moisturizers to dry skin. b. Apply steroid creams to the skin. c. Bathe the client using mild soap. d. Help the client with a hot water bath. e. Teach the client to avoid sunlight.

ANS: A, C The nurse can delegate applying unscented moisturizer and using mild soap for bathing. Steroid creams are not used for this condition. Hot water will worsen the irritation. Client teaching is a nursing function.

After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the clients electronic medical record? (Select all that apply.) a. Peau dorange b. Dense breast tissue c. Nipple retraction d. Mobile mass at two oclock e. Nontender axillary nodes

ANS: A, C, D In the documentation of a breast mass, skin changes such as dimpling (peau dorange), nipple retraction, and whether the mass is fixed or movable are charted. The location of the mass should be stated by the face of a clock. Dense breast tissue and nontender axillary nodes are not abnormal assessment findings that may indicate breast cancer.

A client receiving chemotherapy has a white blood cell count of 1000/mm3. What actions by the nurse are most appropriate? (Select all that apply.) a. Assess all mucous membranes every 4 to 8 hours. b. Do not allow the client to eat meat or poultry. c. Listen to lung sounds and monitor for cough. d. Monitor the venous access device appearance with vital signs. e. Take and record vital signs every 4 to 8 hours.

ANS: A, C, D, E Depending on facility protocol, the nurse should assess this client for infection every 4 to 8 hours by assessing all mucous membranes, listening to lung sounds, monitoring for cough, monitoring the appearance of the venous access device, and recording vital signs. Eating meat and poultry is allowed.

A nurse working with clients with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crises. What factors should clients be taught to avoid? (Select all that apply.) a. Dehydration b. Exercise c. Extreme stress d. High altitudes e. Pregnancy

ANS: A, C, D, E Several factors cause red blood cells to sickle in SCD, including dehydration, extreme stress, high altitudes, and pregnancy. Strenuous exercise can also cause sickling, but not unless it is very vigorous.

A student studying leukemias learns the risk factors for developing this disorder. Which risk factors does this include? (Select all that apply.) a. Chemical exposure b. Genetically modified foods c. Ionizing radiation exposure d. Vaccinations e. Viral infections

ANS: A, C, E Chemical and ionizing radiation exposure and viral infections are known risk factors for developing leukemia. Eating genetically modified food and receiving vaccinations are not known risk factors.

A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which assessment findings should the nurse correlate with this diagnosis? (Select all that apply.) a. Serum potassium of 2.8 mEq/L b. Loss of 15 pounds without dieting c. Abdominal pain in upper quadrants d. Low-pitched bowel sounds e. Serum sodium of 121 mEq/L

ANS: A, C, E Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic (normal range is 3.5 to 5.0 mEq/L) and hyponatremic (normal range is 136 to 145 mEq/L). Abdominal pain across the upper quadrants is associated with small bowel obstruction. Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched sounds may be noted with small bowel obstructions

A nurse inserts a nasogastric (NG) tube for an adult client who has a bowel obstruction. Which actions does the nurse perform correctly? (Select all that apply.) a. Performs hand hygiene and positions the client in high-Fowlers position, with pillows behind the head and shoulders b. Instructs the client to extend the neck against the pillow once the NG tube has reached the oropharynx c. Checks for correct placement by checking the pH of the fluid aspirated from the tube d. Secures the NG tube by taping it to the clients nose and pinning the end to the pillowcase e. Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent

ANS: A, C, E The clients head should be flexed forward once the NG tube has reached the oropharynx. The NG tube should be secured to the clients gown, not to the pillowcase, because it could become dislodged easily. All the other actions are appropriate.

A student nurse is learning about blood transfusion compatibilities. What information does this include? (Select all that apply.) a. Donor blood type A can donate to recipient blood type AB. b. Donor blood type B can donate to recipient blood type O. c. Donor blood type AB can donate to anyone. d. Donor blood type O can donate to anyone. e. Donor blood type A can donate to recipient blood type B.

ANS: A, D Blood type A can be donated to people who have blood types A or AB. Blood type O can be given to anyone. Blood type B can be donated to people who have blood types B or AB. Blood type AB can only go to recipients with blood type AB.

The nurse is formulating a teaching plan according to evidence-based breast cancer screening guidelines for a 50-year-old woman with low risk factors. Which diagnostic methods should be included in the plan? (Select all that apply.) a. Annual mammogram b. Magnetic resonance imaging (MRI) c. Breast ultrasound d. Breast self-awareness e. Clinical breast examination

ANS: A, D, E Guidelines recommend a screening annual mammogram for women ages 40 years and older, breast self- awareness, and a clinical breast examination. An MRI is recommended if there are known high risk factors. A breast ultrasound is used if there are problems discovered with the initial screening or dense breast tissue.

The nursing student learning about cancer development remembers characteristics of normal cells. Which characteristics does this include? (Select all that apply.) a. Differentiated function b. Large nucleus-to-cytoplasm ratio c. Loose adherence d. Nonmigratory e. Specific morphology

ANS: A, D, E Normal cells have the characteristics of differentiated function, nonmigratory, specific morphology, a smaller nucleus-to-cytoplasm ratio, tight adherence, and orderly and well-regulated growth

A nurse cares for a client who has a nasogastric (NG) tube. Which actions should the nurse take? (Select all that apply.) a. Assess for proper placement of the tube every 4 hours. b. Flush the tube with water every hour to ensure patency. c. Secure the NG tube to the clients upper lip. d. Disconnect suction when auscultating bowel peristalsis. e. Monitor the clients skin around the tube site for irritation.

ANS: A, D, E The nurse should assess for proper placement, tube patency, and output every 4 hours. The nurse should also monitor the skin around the tube for irritation and secure the tube to the clients nose. When auscultating bowel sounds for peristalsis, the nurse should disconnect suction.

A client with sickle cell disease (SCD) takes hydroxyurea (Droxia). The client presents to the clinic reporting an increase in fatigue. What laboratory result should the nurse report immediately? a. Hematocrit: 25% b. Hemoglobin: 9.2 mg/dL c. Potassium: 3.2 mEq/L d. White blood cell count: 38,000/mm3

ANS: Although individuals with SCD often have elevated white blood cell (WBC) counts, this extreme elevation could indicate leukemia, a complication of taking hydroxyurea. The nurse should report this finding immediately. Alternatively, it could indicate infection, a serious problem for clients with SCD. Hematocrit and hemoglobin levels are normally low in people with SCD. The potassium level, while slightly low, is not as worrisome as the WBCs

A client has a platelet count of 9800/mm3. What action by the nurse is most appropriate? a. Assess the client for calf pain, warmth, and redness. b. Instruct the client to call for help to get out of bed. c. Obtain cultures as per the facilitys standing policy. d. Place the client on protective isolation precautions.

ANS: B A client with a platelet count this low is at high risk for serious bleeding episodes. To prevent injury, the client should be instructed to call for help prior to getting out of bed. Calf pain, warmth, and redness might indicate a deep vein thrombosis, not associated with low platelets. Cultures and isolation relate to low white cell counts.

A nurse assesses a client who is recovering from a hemorrhoidectomy that was done the day before. The nurse notes that the client has lower abdominal distention accompanied by dullness to percussion over the distended area. Which action should the nurse take? a. Assess the clients heart rate and blood pressure. b. Determine when the client last voided. c. Ask if the client is experiencing flatus. d. Auscultate all quadrants of the clients abdomen.

ANS: B Assessment findings indicate that the client may have an over-full bladder. In the immediate postoperative period, the client may experience difficulty voiding due to urinary retention. The nurse should assess when the client last voided. The clients vital signs may be checked after the nurse determines the clients last void. Asking about flatus and auscultating bowel sounds are not related to a hemorrhoidectomy

After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the clients understanding. Which menu selection indicates that the client correctly understands the dietary teaching? a. Ham sandwich on white bread, cup of applesauce, glass of diet cola b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice c. Grilled cheese sandwich, small banana, cup of hot tea with lemon d. Baked tilapia, fresh green beans, cup of coffee with low-fat milk

ANS: B Clients with IBS are advised to eat a high-fiber diet (30 to 40 g/day), with 8 to 10 cups of liquid daily. Chicken with brown rice, broccoli, and apple juice has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants.

A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client should the nurse see first? a. Client with a blood pressure of 180/98 mm Hg b. Client who reports shortness of breath c. Client who reports calf tenderness and swelling d. Client with a swollen and painful left great toe

ANS: B Clients with polycythemia vera often have clotting abnormalities due to the hyperviscous blood with sluggish flow. The client reporting shortness of breath may have a pulmonary embolism and should be seen first. The client with a swollen calf may have a deep vein thrombosis and should be seen next. High blood pressure and gout symptoms are common findings with this disorder.

The student nurse learning about cellular regulation understands that which process occurs during the S phase of the cell cycle? a. Actual division (mitosis) b. Doubling of DNA c. Growing extra membrane d. No reproductive activity

ANS: B During the S phase, the cell must double its DNA content through DNA synthesis. Actual division, or mitosis, occurs during the M phase. Growing extra membrane occurs in the G1 phase. During the G0 phase, the cell is working but is not involved in any reproductive activity.

A client with cancer has anorexia and mucositis, and is losing weight. The clients family members continually bring favorite foods to the client and are distressed when the client wont eat them. What action by the nurse is best? a. Explain the pathophysiologic reasons behind the client not eating. b. Help the family show other ways to demonstrate love and caring. c. Suggest foods and liquids the client might be willing to try to eat. d. Tell the family the client isnt able to eat now no matter what they bring

ANS: B Families often become distressed when their loved ones wont eat. Providing food is a universal sign of caring, and to some people the refusal to eat signifies worsening of the condition. The best option for the nurse is to help the family find other ways to demonstrate caring and love, because with treatment-related anorexia and mucositis, the client is not likely to eat anything right now. Explaining the rationale for the problem is a good idea but does not suggest to the family anything that they can do for the client. Simply telling the family the client is not able to eat does not give them useful information and is dismissive of their concerns.

A nurse is preparing to administer a blood transfusion. What action is most important? a. Correctly identifying client using two identifiers b. Ensuring informed consent is obtained if required c. Hanging the blood product with Ringers lactate d. Staying with the client for the entire transfusion

ANS: B If the facility requires informed consent for transfusions, this action is most important because it precedes the other actions taken during the transfusion. Correctly identifying the client and blood product is a National Patient Safety Goal, and is the most important action after obtaining informed consent. Ringers lactate is not used to transfuse blood. The nurse does not need to stay with the client for the duration of the transfusion.

A client is concerned about the risk of lymphedema after a mastectomy. Which response by the nurse is best? a. You do not need to worry about lymphedema since you did not have radiation therapy. b. A risk factor for lymphedema is infection, so wear gloves when gardening outside. c. Numbness, tingling, and swelling are common sensations after a mastectomy. d. The risk for lymphedema is a real threat and can be very self-limiting.

ANS: B Infection can create lymphedema; therefore, the client needs to be cautious with activities using the affected arm, such as gardening. Radiation therapy is just one of the factors that could cause lymphedema. Other risk factors include obesity and the presence of axillary disease. The symptoms of lymphedema are heaviness, aching, fatigue, numbness, tingling, and swelling, and are not common after the surgery. Women with lymphedema live fulfilling lives.

A nurse cares for a middle-aged male client who has irritable bowel syndrome (IBS). The client states, I have changed my diet and take bulk-forming laxatives, but my symptoms have not gotten better. I heard about a drug called Amitiza. Do you think it might help? How should the nurse respond? a. This drug is still in the research phase and is not available for public use yet. b. Unfortunately, lubiprostone is approved only for use in women. c. Lubiprostone works well. I will recommend this prescription to your provider. d. This drug should not be used with bulk-forming laxatives.

ANS: B Lubiprostone (Amitiza) is a new drug for IBS with constipation that works by simulating receptors in the intestines to increase fluid and promote bowel transit time. Lubiprostone is currently approved only for use in women. Trials with increased numbers of male participants are needed prior to Food and Drug Administration approval for men.

The family of a neutropenic client reports the client is not acting right. What action by the nurse is the priority? a. Ask the client about pain. b. Assess the client for infection. c. Delegate taking a set of vital signs. d. Look at todays laboratory results.

ANS: B Neutropenic clients often do not have classic manifestations of infection, but infection is the most common cause of death in neutropenic clients. The nurse should assess for infection. The nurse should assess for pain but this is not the priority. The nurse should take the clients vital signs instead of delegating them since the client has had a change in status. Laboratory results may be inconclusive.

After receiving the hand-off report, which client should the oncology nurse see first? a. Client who is afebrile with a heart rate of 108 beats/min b. Older client on chemotherapy with mental status changes c. Client who is neutropenic and in protective isolation d. Client scheduled for radiation therapy today

ANS: B Older clients often do not exhibit classic signs of infection, and often mental status changes are the first observation. Clients on chemotherapy who become neutropenic also often do not exhibit classic signs of infection. The nurse should assess the older client first. The other clients can be seen afterward

An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the clients lower abdomen. Which action should the nurse take first? a. Measure the clients abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the clients hemoglobin and hematocrit. d. Obtain the clients complete health history.

ANS: B On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present, because this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or obtaining a complete health history is not appropriate at this time. Laboratory test results can be checked after assessment for abdominal guarding or rigidity.

A client has received a dose of ondansetron (Zofran) for nausea. What action by the nurse is most important? a. Assess the client for a headache. b. Assist the client in getting out of bed. c. Instruct the client to reduce salt intake. d. Weigh the client daily before the client eats

ANS: B Ondansetron side effects include postural hypotension, vertigo, and bradycardia, all of which increase the clients risk for injury. The nurse should assist the client when getting out of bed. Headache and fluid retention are not side effects of this drug

A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate? a. Are you getting adequate rest and sleep each day? b. It is normal to be fatigued even for years afterward. c. This is not normal and Ill let the provider know. d. Try adding more vitamins B and C to your diet.

ANS: B Regardless of the cause, radiation-induced fatigue can be debilitating and may last for months or years after treatment has ended. Rest and adequate nutrition can affect fatigue, but it is most important that the client understands this is normal.

A client admitted for sickle cell crisis is distraught after learning her child also has the disease. What response by the nurse is best? a. Both you and the father are equally responsible for passing it on. b. I can see you are upset. I can stay here with you a while if you like. c. Its not your fault; there is no way to know who will have this disease. d. There are many good treatments for sickle cell disease these days.

ANS: B The best response is for the nurse to offer self, a therapeutic communication technique that uses presence. Attempting to assign blame to both parents will not help the client feel better. There is genetic testing available, so it is inaccurate to state there is no way to know who will have the disease. Stating that good treatments exist belittles the clients feelings.

A nurse cares for a client who is recovering from a hemorrhoidectomy. The client states, I need to have a bowel movement. Which action should the nurse take? a. Obtain a bedside commode for the client to use. b. Stay with the client while providing privacy. c. Make sure the call light is in reach to signal completion. d. Gather supplies to collect a stool sample for the laboratory.

ANS: B The first bowel movement after hemorrhoidectomy can be painful enough to induce syncope. The nurse should stay with the client. The nurse should instruct clients who are discharged the same day to have someone nearby when they have their first postoperative bowel movement. Making sure the call light is within reach is an important nursing action too, but it does not take priority over client safety. Obtaining a bedside commode and taking a stool sample are not needed in this situation

A 68-year-old male client is embarrassed about having bilateral breast enlargement. Which statement by the nurse is the most appropriate? a. Breast cancer in men is quite rare. b. It is good that you came to be carefully evaluated. c. Gynecomastia usually comes from overeating. d. When you get older, the male breast always enlarges

ANS: B The most appropriate statement is the one that is supportive of the client. A breast mass should be carefully evaluated for breast cancer, even if it is not common. Gynecomastia as a symptom can be related to antiandrogen agents, aging, obesity, estrogen excess, or lack of androgens

A nurse cares for a client newly diagnosed with colon cancer who has become withdrawn from family members. Which action should the nurse take? a. Contact the provider and recommend a psychiatric consult for the client. b. Encourage the client to verbalize feelings about the diagnosis. c. Provide education about new treatment options with successful outcomes. d. Ask family and friends to visit the client and provide emotional support.

ANS: B The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric consult is not appropriate for the client. The nurse should not brush aside the clients feelings with discussions related to cancer prognosis and treatment. The nurse should not assume that the client desires family or friends to visit or provide emotional support.

A client tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate? a. Avoid getting salt water on the radiation site. b. Do not expose the radiation area to direct sunlight. c. Have a wonderful time and enjoy your vacation! d. Remember you should not drink alcohol for a year

ANS: B The skin overlying the radiation site is extremely sensitive to sunlight after radiation therapy has been completed. The nurse should inform the client to avoid sun exposure to this area. This advice continues for 1 year after treatment has been completed. The other statements are not appropriate.

The nurse is taking the history of a client who is scheduled for breast augmentation surgery. The client reveals that she took two aspirin this morning for a headache. Which action by nurse is best? a. Take the clients vital signs and record them in the chart. b. Notify the surgeon about the aspirin ingestion by the client. c. Warn the client that health insurance may not pay for the procedure. d. Teach the client about avoiding twisting above the waist after the operation.

ANS: B The surgeon must be notified immediately since the aspirin could cause increased bleeding during the procedure. Vital signs should be recorded and postoperative teaching should be completed in the preoperative time frame, but these are not the priority since the procedure may be rescheduled. The warning about the clients health insurance is not appropriate at this time

A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important? a. Documenting the events in the clients medical record b. Double-checking the client and blood product identification c. Placing the client on strict bedrest until the pain subsides d. Reviewing the clients medical record for known allergies

ANS: B This client had a hemolytic transfusion reaction, most commonly caused by blood type or Rh incompatibility. The nurse should double-check all identifying information for both the client and blood type. Documentation occurs after the client is stable. Bedrest may or may not be needed. Allergies to medications or environmental items is not related.

A client has a serum ferritin level of 8 ng/mL and microcytic red blood cells. What action by the nurse is best? a. Encourage high-protein foods. b. Perform a Hemoccult test on the clients stools. c. Offer frequent oral care. d. Prepare to administer cobalamin (vitamin B12).

ANS: B This client has laboratory findings indicative of iron deficiency anemia. The most common cause of this disorder is blood loss, often from the GI tract. The nurse should perform a Hemoccult test on the clients stools. High-protein foods may help the condition, but dietary interventions take time to work. That still does not determine the cause. Frequent oral care is not related. Cobalamin injections are for pernicious anemia

A client is having a catheter placed in the femoral artery to deliver yttrium-90 beads into a liver tumor. What action by the nurse is most important? a. Assessing the clients abdomen beforehand b. Ensuring that informed consent is on the chart c. Marking the clients bilateral pedal pulses d. Reviewing client teaching done previously

ANS: B This is an invasive procedure requiring informed consent. The nurse should ensure that consent is on the chart. The other actions are also appropriate but not the priority

After teaching a client who is recovering from a colon resection, the nurse assesses the clients understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.) a. I must change the ostomy appliance daily and as needed. b. I will use warm water and a soft washcloth to clean around the stoma. c. I might start bicycling and swimming again once my incision has healed. d. Cutting the flange will help it fit snugly around the stoma to avoid skin breakdown. e. I will check the stoma regularly to make sure that it stays a deep red color. f. I must avoid dairy products to reduce gas and odor in the pouch.

ANS: B, C, D The ostomy appliance should be changed as needed when the adhesive begins to decrease, placing the appliance at risk of leaking. Changing the appliance daily can cause skin breakdown as the adhesive will still be secured to the clients skin. The client should avoid using soap to clean around the stoma because it might prevent effective adhesion of the ostomy appliance. The client should use warm water and a soft washcloth instead. The tissue of the stoma is very fragile, and scant bleeding may occur when the stoma is cleaned. The flange should be cut to fit snugly around the stoma to reduce contact between excretions and the clients skin. Exercise (other than some contact sports) is important for clients with an ostomy. The stoma should remain a soft pink color. A deep red or purple hue indicates ischemia and should be reported to the surgeon right away. Yogurt and buttermilk can help reduce gas in the pouch, so the client need not avoid dairy products.

The student nurse caring for clients who have cancer understands that the general consequences of cancer include which client problems? (Select all that apply.) a. Clotting abnormalities from thrombocythemia b. Increased risk of infection from white blood cell deficits c. Nutritional deficits such as early satiety and cachexia d. Potential for reduced gas exchange e. Various motor and sensory deficits

ANS: B, C, D, E The general consequences of cancer include reduced immunity and blood-producing functions, altered GI structure and function, decreased respiratory function, and motor and sensory deficits. Clotting problems often occur due to thrombocytopenia (not enough platelets), not thrombocythemia (too many platelets)

A client has Hodgkins lymphoma, Ann Arbor stage Ib. For what manifestations should the nurse assess the client? (Select all that apply.) a. Headaches b. Night sweats c. Persistent fever d. Urinary frequency e. Weight loss

ANS: B, C, E In this stage, the disease is located in a single lymph node region or a single nonlymph node site. The client displays night sweats, persistent fever, and weight loss. Headache and urinary problems are not related.

A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse most likely to engage? (Select all that apply.) a. Demonstrating breast self-examination methods to women b. Instructing people on the use of chemoprevention c. Providing vaccinations against certain cancers d. Screening teenage girls for cervical cancer e. Teaching teens the dangers of tanning booths

ANS: B, C, E Primary prevention aims to prevent the occurrence of a disease or disorder, in this case cancer. Secondary prevention includes screening and early diagnosis. Primary prevention activities include teaching people about chemoprevention, providing approved vaccinations to prevent cancer, and teaching teens the dangers of tanning beds. Breast examinations and screening for cervical cancer are secondary prevention methods.

A client with chronic anemia has had many blood transfusions. What medications does the nurse anticipate teaching the client about adding to the regimen? (Select all that apply.) a. Azacitidine (Vidaza) b. Darbepoetin alfa (Aranesp) c. Decitabine (Dacogen) d. Epoetin alfa (Epogen) e. Methylprednisolone (Solu-Medrol)

ANS: B, D Darbepoetin alfa and epoetin alfa are both red blood cell colony-stimulating factors that will help increase the production of red blood cells. Azacitidine and decitabine are used for myelodysplastic syndromes. Methylprednisolone is a steroid and would not be used for this problem

A nurse prepares a client for a colonoscopy scheduled for tomorrow. The client states, My doctor told me that the fecal occult blood test was negative for colon cancer. I dont think I need the colonoscopy and would like to cancel it. How should the nurse respond? a. Your doctor should not have given you that information prior to the colonoscopy. b. The colonoscopy is required due to the high percentage of false negatives with the blood test. c. A negative fecal occult blood test does not rule out the possibility of colon cancer. d. I will contact your doctor so that you can discuss your concerns about the procedure.

ANS: C A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed so the entire colon can be visualized and a tissue sample taken for biopsy. The client may want to speak with the provider, but the nurse should address the clients concerns prior to contacting the provider.

A nurse is caring for a young male client with lymphoma who is to begin treatment. What teaching topic is a priority? a. Genetic testing b. Infection prevention c. Sperm banking d. Treatment options

ANS: C All teaching topics are important to the client with lymphoma, but for a young male, sperm banking is of particular concern if the client is going to have radiation to the lower abdomen or pelvis.

The nursing instructor explains the difference between normal cells and benign tumor cells. What information does the instructor provide about these cells? a. Benign tumors grow through invasion of other tissue. b. Benign tumors have lost their cellular regulation from contact inhibition. c. Growing in the wrong place or time is typical of benign tumors. d. The loss of characteristics of the parent cells is called anaplasia.

ANS: C Benign tumors are basically normal cells growing in the wrong place or at the wrong time. Benign cells grow through hyperplasia, not invasion. Benign tumor cells retain contact inhibition. Anaplasia is a characteristic of cancer cells.

A nurse teaches a client who is recovering from a colon resection. Which statement should the nurse include in this clients plan of care? a. You may experience nausea and vomiting for the first few weeks. b. Carbonated beverages can help decrease acid reflux from anastomosis sites. c. Take a stool softener to promote softer stools for ease of defecation. d. You may return to your normal workout schedule, including weight lifting.

ANS: C Clients recovering from a colon resection should take a stool softener as prescribed to keep stools a soft consistency for ease of passage. Nausea and vomiting are symptoms of intestinal obstruction and perforation and should be reported to the provider immediately. The client should be advised to avoid gas-producing foods and carbonated beverages, and avoid lifting heavy objects or straining on defecation.

A client has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? a. Apply ice packs to the clients legs. b. Elevate the clients legs on pillows. c. Keep the lower extremities warm. d. Place elastic bandage wraps on the clients legs

ANS: C During a sickle cell crisis, the tissue distal to the occlusion has decreased blood flow and ischemia, leading to pain. Due to decreased blood flow, the clients legs will be cool or cold. The UAP can attempt to keep the clients legs warm. Ice and elevation will further decrease perfusion. Elastic bandage wraps are not indicated and may constrict perfusion in the legs

A client has just returned from a right radical mastectomy. Which action by the unlicensed assistive personnel (UAP) would the nurse consider unsafe? a. Checking the amount of urine in the urine catheter collection bag b. Elevating the right arm on a pillow c. Taking the blood pressure on the right arm d. Encouraging the client to squeeze a rolled washcloth

ANS: C Health care professionals need to avoid the arm on the side of the surgery for blood pressure measurement, injections, or blood draws. Since lymph nodes are removed, lymph drainage would be compromised. The pressure from the blood pressure cuff could promote swelling. Infection could occur with injections and blood draws. Checking urine output, elevation of the affected arm on a pillow, and encouraging beginning exercises are all safe postoperative interventions.

Which finding in a female client by the nurse would receive the highest priority of further diagnostics? a. Tender moveable masses throughout the breast tissue b. A 3-cm firm, defined mobile mass in the lower quadrant of the breast c. Nontender immobile mass in the upper outer quadrant of the breast d. Small, painful mass under warm reddened skin

ANS: C Malignant lesions are hard, nontender, and usually located in the upper outer quadrant of the breast and would be the priority for further diagnostic study. The other lesions are benign breast disorders. The tender moveable masses throughout the breast tissue could be a fibrocystic breast condition. A firm, defined mobile mass in the lower quadrant of the breast is a fibroadenoma, and a painful mass under warm reddened skin could be a local abscess or ductal ectasia.

With a history of breast cancer in the family, a 48-year-old female client is interested in learning about the modifiable risk factors for breast cancer. After the nurse explains this information, which statement made by the client indicates that more teaching is needed? a. I am fortunate that I breast-fed each of my three children for 12 months. b. It looks as though I need to start working out at the gym more often. c. I am glad that we can still have wine with every evening meal. d. When I have menopausal symptoms, I must avoid hormone replacement therapy.

ANS: C Modifiable risk factors can help prevent breast cancer. The client should lessen alcohol intake and not have wine 7 days a week. Breast-feeding, regular exercise, and avoiding hormone replacement are also strategies for breast cancer prevention.

A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client? a. Eat low-fiber and low-residual foods. b. White rice and bread are easier to digest. c. Add vegetables such as broccoli and cauliflower to your new diet. d. Foods high in animal fat help to protect the intestinal mucosa.

ANS: C The client should be taught to modify his or her diet to decrease animal fat and refined carbohydrates. The client should also increase high-fiber foods and Brassica vegetables, including broccoli and cauliflower, which help to protect the intestinal mucosa from colon cancer.

A nurse cares for a client with colon cancer who has a new colostomy. The client states, I think it would be helpful to talk with someone who has had a similar experience. How should the nurse respond? a. I have a good friend with a colostomy who would be willing to talk with you. b. The enterostomal therapist will be able to answer all of your questions. c. I will make a referral to the United Ostomy Associations of America. d. Youll find that most people with colostomies dont want to talk about them.

ANS: C Nurses need to become familiar with community-based resources to better assist clients. The local chapter of the United Ostomy Associations of America has resources for clients and their families, including Ostomates (specially trained visitors who also have ostomies). The nurse should not suggest that the client speak with a personal contact of the nurse. Although the enterostomal therapist is an expert in ostomy care, talking with him or her is not the same as talking with someone who actually has had a colostomy. The nurse should not brush aside the clients request by saying that most people with colostomies do not want to talk about them. Many people are willing to share their ostomy experience in the hope of helping others

What comfort measure can only be performed by a nurse, as opposed to an unlicensed assistive personnel (UAP), for a client who returned from a left modified radical mastectomy 4 hours ago? a. Placing the head of bed at 30 degrees b. Elevating the left arm on a pillow c. Administering morphine for pain at a 4 on a 0-to-10 scale d. Supporting the left arm while initially ambulating the client

ANS: C Only the nurse is authorized to administer medications, but the UAP could inform the nurse about the rating of pain by the client. The UAP could position the bed to 30 degrees and elevate the clients arm on a pillow to facilitate lymphatic fluid drainage return. The clients arm should be supported while walking at first but then allowed to hang straight by the side. The UAP could support the arm while walking the client.

A nurse is caring for a client who is about to receive a bone marrow transplant. To best help the client cope with the long recovery period, what action by the nurse is best? a. Arrange a visitation schedule among friends and family. b. Explain that this process is difficult but must be endured. c. Help the client find things to hope for each day of recovery. d. Provide plenty of diversionary activities for this time.

ANS: C Providing hope is an essential nursing function during treatment for any disease process, but especially during the recovery period after bone marrow transplantation, which can take up to 3 weeks. The nurse can help the client look ahead to the recovery period and identify things to hope for during this time. Visitors are important to clients, but may pose an infection risk. Telling the client the recovery period must be endured does not acknowledge his or her feelings. Diversionary activities are important, but not as important as instilling hope.

A client is receiving rituximab (Rituxan) and asks how it works. What response by the nurse is best? a. It causes rapid lysis of the cancer cell membranes. b. It destroys the enzymes needed to create cancer cells. c. It prevents the start of cell division in the cancer cells. d. It sensitizes certain cancer cells to chemotherapy.

ANS: C Rituxan prevents the initiation of cancer cell division. The other statements are not accurate.

A client is admitted with superior vena cava syndrome. What action by the nurse is most appropriate? a. Administer a dose of allopurinol (Aloprim). b. Assess the clients serum potassium level. c. Gently inquire about advance directives. d. Prepare the client for emergency surgery.

ANS: C Superior vena cava syndrome is often a late-stage manifestation. After the client is stabilized and comfortable, the nurse should initiate a conversation about advance directives. Allopurinol is used for tumor lysis syndrome. Potassium levels are important in tumor lysis syndrome, in which cell destruction leads to large quantities of potassium being released into the bloodstream. Surgery is rarely done for superior vena cava syndrome.

A 35-year-old woman is diagnosed with stage III breast cancer. She seems to be extremely anxious. What action by the nurse is best? a. Encourage the client to search the Internet for information tonight. b. Ask the client if sexuality has been a problem with her partner. c. Explore the idea of a referral to a breast cancer support group. d. Assess whether there has been any mental illness in her past.

ANS: C Support for the diagnosis would be best with a referral to a breast cancer support group. The Internet may be a good source of information, but the day of diagnosis would be too soon. The nurse could assess the frequency and satisfaction of sexual relations but should not assume that there is a problem in that area. Assessment of mental illness is not an appropriate action.

Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients should the nurse assess first? a. Client with dry, itchy, peeling skin b. Client with a serum calcium of 9.2 mg/dL c. Client with a serum potassium of 2.8 mEq/L d. Client with a weight gain of 0.5 pound (1.1 kg) in 1 day

ANS: C TKIs can cause electrolyte imbalances. This potassium level is very low, so the nurse should assess this client first. Dry, itchy, peeling skin can be a problem in clients receiving biologic response modifiers, and the nurse should assess that client next because of the potential for discomfort and infection. This calcium level is normal. TKIs can also cause weight gain, but the client with the low potassium level is more critical

A client is starting hormonal therapy with tamoxifen (Nolvadex) to lower the risk for breast cancer. What information needs to be explained by the nurse regarding the action of this drug? a. It blocks the release of luteinizing hormone. b. It interferes with cancer cell division. c. It selectively blocks estrogen in the breast. d. It inhibits DNA synthesis in rapidly dividing cells

ANS: C Tamoxifen (Nolvadex) reduces the estrogen available to breast tumors to stop or prevent growth. This drug does not block the release of luteinizing hormone to prevent the ovaries from producing estrogen; leuprolide (Lupron) does this. Chemotherapy agents such as ixabepilone (Ixempra) interfere with cancer cell division, and doxorubicin (Adriamycin) inhibits DNA synthesis in susceptible cells.

A client has thrombocytopenia. What client statement indicates the client understands self-management of this condition? a. I brush and use dental floss every day. b. I chew hard candy for my dry mouth. c. I usually put ice on bumps or bruises. d. Nonslip socks are best when I walk.

ANS: C The client should be taught to apply ice to areas of minor trauma. Flossing is not recommended. Hard foods should be avoided. The client should wear well-fitting shoes when ambulating.

The nurse is examining a womans breast and notes multiple small mobile lumps. Which question would be the most appropriate for the nurse to ask? a. When was your last mammogram at the clinic? b. How many cans of caffeinated soda do you drink in a day? c. Do the small lumps seem to change with your menstrual period? d. Do you have a first-degree relative who has breast cancer?

ANS: C The most appropriate question would be one that relates to benign lesions that usually change in response to hormonal changes within a menstrual cycle. Reduction of caffeine in the diet has been shown to give relief in fibrocystic breast conditions, but research has not found that it has a significant impact. Questions related to the clients last mammogram or breast cancer history are not related to the nurses assessment.

A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action should the nurse take? a. Ask if the client is experiencing pain in the right shoulder. b. Perform a rectal examination and assess for polyps. c. Contact the provider and recommend computed tomography. d. Administer a laxative to increase bowel movement activity.

ANS: C The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative of partial obstruction caused by the tumor. The nurse should contact the provider with these results and recommend a computed tomography scan for further diagnostic testing. This assessment finding is not associated with right shoulder pain; peritonitis and cholecystitis are associated with referred pain to the right shoulder. The registered nurse is not qualified to complete a rectal examination for polyps, and laxatives would not help this client.

A client has been treated for a deep vein thrombus and today presents to the clinic with petechiae. Laboratory results show a platelet count of 42,000/mm3. The nurse reviews the clients medication list to determine if the client is taking which drug? a. Enoxaparin (Lovenox) b. Salicylates (aspirin) c. Unfractionated heparin d. Warfarin (Coumadin)

ANS: C This client has manifestations of heparin-induced thrombocytopenia. Enoxaparin, salicylates, and warfarin do not cause this condition.

A nurse has taught a client about dietary changes that can reduce the chances of developing cancer. What statement by the client indicates the nurse needs to provide additional teaching? a. Foods high in vitamin A and vitamin C are important. b. Ill have to cut down on the amount of bacon I eat. c. Im so glad I dont have to give up my juicy steaks. d. Vegetables, fruit, and high-fiber grains are important.

ANS: C To decrease the risk of developing cancer, one should cut down on the consumption of red meats and animal fat. The other statements are correct.

A nurse assesses a male client with an abdominal hernia. Which abdominal hernias are correctly paired with their physiologic processes? (Select all that apply.) a. Indirect inguinal hernia An enlarged plug of fat eventually pulls the peritoneum and often the bladder into a sac b. Femoral hernia A peritoneum sac pushes downward and may descend into the scrotum c. Direct inguinal hernia A peritoneum sac passes through a weak point in the abdominal wall d. Ventral hernia Results from inadequate healing of an incision e. Incarcerated hernia Contents of the hernia sac cannot be reduced back into the abdominal cavity

ANS: C, D, E A direct inguinal hernia occurs when a peritoneum sac passes through a weak point in the abdominal wall. A ventral hernia results from inadequate healing of an incision. An incarcerated hernia cannot be reduced or placed back into the abdominal cavity. An indirect inguinal hernia is a sac formed from the peritoneum that contains a portion of the intestine and pushes downward at an angle into the inguinal canal. An indirect inguinal hernia often descends into the scrotum. A femoral hernia protrudes through the femoral ring and, as the clot enlarges, pulls the peritoneum and often the urinary bladder into the sac.

A client has received a bone marrow transplant and is waiting for engraftment. What actions by the nurse are most appropriate? (Select all that apply.) a. Not allowing any visitors until engraftment b. Limiting the protein in the clients diet c. Placing the client in protective precautions d. Teaching visitors appropriate hand hygiene e. Telling visitors not to bring live flowers or plants

ANS: C, D, E The client waiting for engraftment after bone marrow transplant has no white cells to protect him or her against infection. The client is on protective precautions and visitors are taught hand hygiene. No fresh flowers or plants are allowed due to the standing water in the vase or container that may harbor organisms. Limiting protein is not a healthy option and will not promote engraftment.

A client has a platelet count of 25,000/mm3. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist with oral hygiene using a firm toothbrush. b. Give the client an enema if he or she is constipated. c. Help the client choose soft foods from the menu. d. Shave the male client with an electric razor. e. Use a lift sheet when needed to re-position the client.

ANS: C, D, E This client has thrombocytopenia and requires bleeding precautions. These include oral hygiene with a soft- bristled toothbrush or swabs, avoiding rectal trauma, eating soft foods, shaving with an electric razor, and using a lift sheet to re-position the client.

A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next? a. Administer intravenous opioid medications. b. Position the client with knees to chest. c. Insert a nasogastric tube for decompression. d. Assess the clients bowel sounds.

ANS: D A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds. The nurse should not medicate the client until the provider has been notified of the change in his or her condition. The nurse may help the client to the knee-chest position for comfort, but this is not the priority action. The nurse need not insert a nasogastric tube for decompression

During dressing changes, the nurse assesses a client who has had breast reconstruction. Which finding would cause the nurse to take immediate action? a. Slightly reddened incisional area b. Blood pressure of 128/75 mm Hg c. Temperature of 99 F (37.2 C) d. Dusky color of the flap

ANS: D A dusky color of the breast flap could indicate poor tissue perfusion and a decreased capillary refill. The nurse should notify the surgeon to preserve the tissue. It is normal to have a slightly reddened incision as the skin heals. The blood pressure is within normal limits and the temperature is slightly elevated but should be monitored.

A nurse is assessing a client with glioblastoma. What assessment is most important? a. Abdominal palpation b. Abdominal percussion c. Lung auscultation d. Neurologic examination

ANS: D A glioblastoma arises in the brain. The most important assessment for this client is the neurologic examination

A nurse is assessing a female client who is taking progestins. What assessment finding requires the nurse to notify the provider immediately? a. Irregular menses b. Edema in the lower extremities c. Ongoing breast tenderness d. Red, warm, swollen calf

ANS: D All clients receiving progestin therapy are at risk for thromboembolism. A red, warm, swollen calf is a manifestation of deep vein thrombosis and should be reported to the provider. Irregular menses, edema in the lower extremities, and breast tenderness are common side effects of the therapy.

A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority? a. Helping clients adjust to their appearance b. Reassuring clients that this change is temporary c. Referring clients to a reputable wig shop d. Teaching measures to prevent scalp injury

ANS: D All of the actions are appropriate for clients with alopecia. However, the priority is client safety, so the nurse should first teach ways to prevent scalp injury.

An emergency room nurse cares for a client who has been shot in the abdomen and is hemorrhaging heavily. Which action should the nurse take first? a. Send a blood sample for a type and crossmatch. b. Insert a large intravenous line for fluid resuscitation. c. Obtain the heart rate and blood pressure. d. Assess and maintain a patent airway.

ANS: D All of the options are important nursing actions in the care of a trauma client. However, airway always comes first. The client must have a patent airway, or other interventions will not be helpful.

A client is diagnosed with a fibrocystic breast condition while in the hospital and is experiencing breast discomfort. What comfort measure would the nurse delegate to the unlicensed assistive personnel (UAP)? a. Aid in the draining of the cysts by needle aspiration. b. Teach the client to wear a supportive bra to bed. c. Administer diuretics to decrease breast swelling. d. Obtain a cold pack to temporarily relieve the pain.

ANS: D All of the options would be comfort measures for a client with a fibrocystic breast condition. The UAP can obtain the cold or heat therapy. Only the nurse should aid the health care provider with a needle aspiration, teach, and administer medications

A client with multiple myeloma demonstrates worsening bone density on diagnostic scans. About what drug does the nurse plan to teach this client? a. Bortezomib (Velcade) b. Dexamethasone (Decadron) c. Thalidomide (Thalomid) d. Zoledronic acid (Zometa)

ANS: D All the options are drugs used to treat multiple myeloma, but the drug used specifically for bone manifestations is zoledronic acid (Zometa), which is a bisphosphonate. This drug class inhibits bone resorption and is used to treat osteoporosis as well.

A student nurse asks the nursing instructor what apoptosis means. What response by the instructor is best? a. Growth by cells enlarging b. Having the normal number of chromosomes c. Inhibition of cell growth d. Programmed cell death

ANS: D Apoptosis is programmed cell death. With this characteristic, organs and tissues function with cells that are at their peak of performance. Growth by cells enlarging is hyperplasia. Having the normal number of chromosomes is euploidy. Inhibition of cell growth is contact inhibition

The nurse has taught a client with cancer ways to prevent infection. What statement by the client indicates that more teaching is needed? a. I should take my temperature daily and when I dont feel well. b. I will wash my toothbrush in the dishwasher once a week. c. I wont let anyone share any of my personal items or dishes. d. Its alright for me to keep my pets and change the litter box.

ANS: D Clients should wash their hands after touching their pets and should not empty or scoop the cat litter box. The other statements are appropriate for self-management.

A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the clients oral chemotherapy medications. What action by the nurse is most appropriate? a. Crush the medications if the client cannot swallow them. b. Give one medication at a time with a full glass of water. c. No special precautions are needed for these medications. d. Wear personal protective equipment when handling the medications

ANS: D During the administration of oral chemotherapy agents, nurses must take the same precautions that are used when administering IV chemotherapy. This includes using personal protective equipment. These medications cannot be crushed, split, or chewed. Giving one at a time is not needed.

A nursing student is struggling to understand the process of graft-versus-host disease. What explanation by the nurse instructor is best? a. Because of immunosuppression, the donor cells take over. b. Its like a transfusion reaction because no perfect matches exist. c. The clients cells are fighting donor cells for dominance. d. The donors cells are actually attacking the clients cells.

ANS: D Graft versus host disease is an autoimmune-type process in which the donor cells recognize the clients cells as foreign and begin attacking them. The other answers are not accurate.

A nursing student is caring for a client with leukemia. The student asks why the client is still at risk for infection when the clients white blood cell count (WBC) is high. What response by the registered nurse is best? a. If the WBCs are high, there already is an infection present. b. The client is in a blast crisis and has too many WBCs. c. There must be a mistake; the WBCs should be very low. d. Those WBCs are abnormal and dont provide protection.

ANS: D In leukemia, the WBCs are abnormal and do not provide protection to the client against infection. The other statements are not accurate.

A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads in the clients chart that the cancer classification is TISN0M0. What does the nurse conclude about this clients cancer? a. The primary site of the cancer cannot be determined. b. Regional lymph nodes could not be assessed. c. There are multiple lymph nodes involved already. d. There are no distant metastases noted in the report.

ANS: D TIS stands for carcinoma in situ; N0 stands for no regional lymph node metastasis; and M0 stands for no distant metastasis

A 37-year-old Nigerian woman is at high risk for breast cancer and is considering a prophylactic mastectomy and oophorectomy. What action by the nurse is most appropriate? a. Discourage this surgery since the woman is still of childbearing age. b. Reassure the client that reconstructive surgery is as easy as breast augmentation. c. Inform the client that this surgery removes all mammary tissue and cancer risk. d. Include support people, such as the male partner, in the decision making.

ANS: D The cultural aspects of decision making need to be considered. In the Nigerian culture, the man often makes the decisions for care of the female. Women with a high risk for breast cancer can consider prophylactic surgery. If reconstructive surgery is considered, the procedure is more complex and will have more complications compared to a breast augmentation. There is a small risk that breast cancer can still develop in the remaining mammary tissue

A nurse cares for a client who has a family history of colon cancer. The client states, My father and my brother had colon cancer. What is the chance that I will get cancer? How should the nurse respond? a. If you eat a low-fat and low-fiber diet, your chances decrease significantly. b. You are safe. This is an autosomal dominant disorder that skips generations. c. Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer. d. You should have a colonoscopy more frequently to identify abnormal polyps early.

ANS: D The nurse should encourage the client to have frequent colonoscopies to identify abnormal polyps and cancerous cells early. The abnormal gene associated with colon cancer is an autosomal dominant gene mutation that does not skip a generation and places the client at high risk for cancer. Changing the clients diet, preemptive chemotherapy, and removal of polyps will decrease the clients risk but will not prevent cancer. However, a client at risk for colon cancer should eat a low-fat and high-fiber diet.

The nurse assesses a clients oral cavity and makes the discovery shown in the photo below: What action by the nurse is most appropriate? a. Encourage the client to have genetic testing. b. Instruct the client on high-fiber foods. c. Place the client in protective precautions. d. Teach the client about cobalamin therapy.

ANS: D This condition is known as glossitis, and is characteristic of B12 anemia. If the anemia is a pernicious anemia, it is treated with cobalamin. Genetic testing is not a priority for this condition. The client does not need highfiber foods or protective precautions.

A new nurse has been assigned a client who is in the hospital to receive iodine-131 treatment. Which action by the nurse is best? a. Ensure the client is placed in protective isolation. b. Hand off a pregnant client to another nurse. c. No special action is necessary to care for this client. d. Read the policy on handling radioactive excreta

ANS: D This type of radioisotope is excreted in body fluids and excreta (urine and feces) and should not be handled directly. The nurse should read the facilitys policy for handling and disposing of this type of waste. The other actions are not warranted

. A nurse is preparing to hang a blood transfusion. Which action is most important? a. Documenting the transfusion b. Placing the client on NPO status c. Placing the client in isolation d. Putting on a pair of gloves

ANS: D To prevent bloodborne illness, the nurse should don a pair of gloves prior to hanging the blood. Documentation is important but not the priority at this point. NPO status and isolation are not needed.

Which statement about carcinogenesis is accurate? a. An initiated cell will always become clinical cancer. b. Cancer becomes a health problem once it is 1 cm in size. c. Normal hormones and proteins do not promote cancer growth. d. Tumor cells need to develop their own blood supply.

ANS: D Tumors need to develop their own blood supply through a process called angiogenesis. An initiated cell needs a promoter to continue its malignant path. Normal hormones and proteins in the body can act as promoters. A 1-cm tumor is a detectable size, but other events have to occur for it to become a health problem.

A client with autoimmune idiopathic thrombocytopenic purpura (ITP) has had a splenectomy and returned to the surgical unit 2 hours ago. The nurse assesses the client and finds the abdominal dressing saturated with blood. What action is most important? a. Preparing to administer a blood transfusion b. Reinforcing the dressing and documenting findings c. Removing the dressing and assessing the surgical site d. Taking a set of vital signs and notifying the surgeon

ANS: D While some bloody drainage on a new surgical dressing is expected, a saturated dressing is not. This client is already at high risk of bleeding due to the ITP. The nurse should assess vital signs for shock and notify the surgeon immediately. The client may or may not need a transfusion. Reinforcing the dressing is an appropriate action, but the nurse needs to do more than document afterward. Removing the dressing increases the risk of infection; plus, it is not needed since the nurse knows where the bleeding is coming from.

A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (Select all that apply.) a. Chemo gloves b. Facemask c. Isolation gown d. N95 respirator e. Shoe covers

NS: A, B, C The Occupational Safety and Health Administration (OSHA) and the Oncology Nurses Society have developed safety guidelines for those preparing or administering IV chemotherapy. These include double gloves (or chemo gloves), a facemask, and a gown. An N95 respirator and shoe covers are not required