Med Surg 2 Exam 3 Practice Questions

A patient has a diagnosis of multiple myeloma and the nurse is preparing health education in preparation for discharge from the hospital. What action should the nurse promote? A) Daily performance of weight-bearing exercise to prevent muscle atrophy B) Close monitoring of urine output and kidney function C) Daily administration of warfarin (Coumadin) as ordered D) Safe use of supplementary oxygen in the home setting

Ans: B Feedback: Renal function must be monitored closely in the patient with multiple myeloma. Excessive weight- bearing can cause pathologic fractures. There is no direct indication for anticoagulation or supplementary oxygen.

A nurse is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system. The nurses most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurses best response to this assessment finding? A) Document the presence of normal bile output. B) Irrigate the drainage system with normal saline as ordered. C) Aspirate a sample of the drainage for culture. D) Promptly report this assessment finding to the primary care provider.

Ans: A Feedback: Bile is usually a dark green or brownish-yellow color, so this would constitute an expected assessment finding, with no other action necessary.

A nurse practitioner has provided care for three different patients with chronic pharyngitis over the past several months. Which patients are at greatest risk for developing chronic pharyngitis? A) Patients who are habitual users of alcohol and tobacco B) Patients who are habitual users of caffeine and other stimulants C) Patients who eat a diet high in spicy foods D) Patients who have gastrointestinal reflux disease (GERD)

Ans: A Feedback: Chronic pharyngitis is common in adults who live and work in dusty surroundings, use the voice to excess, suffer from chronic chough, and habitually use alcohol and tobacco. Caffeine and spicy foods have not been linked to chronic pharyngitis. GERD is not a noted risk factor.

The perioperative nurse is writing a care plan for a patient who has returned from surgery 2 hours prior. Which measure should the nurse implement to most decrease the patients risk of developing pulmonary emboli (PE)? A) Early ambulation B) Increased dietary intake of protein C) Maintaining the patient in a supine position D) Administering aspirin with warfarin

Ans: A Feedback: For patients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stocking are general preventive measures. The patient does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The patient should not be maintained in one position, but frequently repositioned, unless contraindicated by the surgical procedure. Aspirin should never be administered with warfarin because it will increase the patients risk for bleeding.

A group of nurses have attended an inservice on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurses risk of acquiring hepatitis C in the workplace? A) Disposing of sharps appropriately and not recapping needles B) Performing meticulous hand hygiene at the appropriate moments in care C) Adhering to the recommended schedule of immunizations D) Wearing an N95 mask when providing care for patients on airborne precautions

Ans: A Feedback: HCV is bloodborne. Consequently, prevention of needlestick injuries is paramount. Hand hygiene, immunizations and appropriate use of masks are important aspects of overall infection control, but these actions do not directly mitigate the risk of HCV.

The nurse is caring for a patient whose recent unexplained weight loss and history of smoking have prompted diagnostic testing for cancer. What symptom is most closely associated with the early stages of laryngeal cancer? A) Hoarseness B) Dyspnea C) Dysphagia D) Frequent nosebleeds

Ans: A Feedback: Hoarseness is an early symptom of laryngeal cancer. Dyspnea, dysphagia, and lumps are later signs of laryngeal cancer. Alopecia is not associated with a diagnosis of laryngeal cancer.

An oncology nurse is caring for a patient with multiple myeloma who is experiencing bone destruction. When reviewing the patients most recent blood tests, the nurse should anticipate what imbalance? A) Hypercalcemia B) Hyperproteinemia C) Elevated serum viscosity D) Elevated RBC count

Ans: A Feedback: Hypercalcemia may result when bone destruction occurs due to the disease process. Elevated serum viscosity occurs because plasma cells excrete excess immunoglobulin. RBC count will be decreased. Hyperproteinemia would not be present.

A patient with a liver mass is undergoing a percutaneous liver biopsy. What action should the nurse perform when assisting with this procedure? A) Position the patient on the right side with a pillow under the costal margin after the procedure. B) Administer 1 unit of albumin 90 minutes before the procedure as ordered. C) Administer at least 1 unit of packed red blood cells as ordered the day before the scheduled procedure. D) Confirm that the patients electrolyte levels have been assessed prior to the procedure.

Ans: A Feedback: Immediately after a percutaneous liver biopsy, assist the patient to turn onto the right side and place a pillow under the costal margin. Prior administration of albumin or PRBCs is unnecessary. Coagulation tests should be performed, but electrolyte analysis is not necessary.

A nurse is caring for a patient who has a diagnosis of acute leukemia. What assessment most directly addresses the most common cause of death among patients with leukemia? A) Monitoring for infection B) Monitoring nutritional status C) Monitor electrolyte levels D) Monitoring liver function

Ans: A Feedback: In patients with acute leukemia, death typically occurs from infection or bleeding. Compromised nutrition, electrolyte imbalances, and impaired liver function are all plausible, but none is among the most common causes of death in this patient population.

The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis of lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the clients oxygen saturation rapidly dropping. The patient complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include what? A) Diminished or absent breath sounds on the affected side B) Paradoxical chest wall movement with respirations C) Sudden loss of consciousness D) Muffled heart sounds

Ans: A Feedback: In the case of a simple pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Sudden loss of consciousness does not typically occur. Muffled or distant heart sounds occur in pericardial tamponade.

A patient with a diagnosis of acute myeloid leukemia (AML) is being treated with induction therapy on the oncology unit. What nursing action should be prioritized in the patients care plan? A) Protective isolation and vigilant use of standard precautions B) Provision of a high-calorie, low-texture diet and appropriate oral hygiene C) Including the family in planning the patients activities of daily living D) Monitoring and treating the patients pain

Ans: A Feedback: Induction therapy causes neutropenia and a severe risk of infection. This risk must be addressed directly in order to ensure the patients survival. For this reason, infection control would be prioritized over nutritional interventions, family care, and pain, even though each of these are important aspects of nursing care.

A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patients current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? A) Two to 3 soft bowel movements daily B) Significant increase in appetite and food intake C) Absence of nausea and vomiting D) Absence of blood or mucus in stool

Ans: A Feedback: Lactulose (Cephulac) is administered to reduce serum ammonia levels. Two or three soft stools per day are desirable; this indicates that lactulose is performing as intended. Lactulose does not address the patients appetite, symptoms of nausea and vomiting, or the development of blood and mucus in the stool.

An oncology nurse is providing health education for a patient who has recently been diagnosed with leukemia. What should the nurse explain about commonalities between all of the different subtypes of leukemia? A) The different leukemias all involve unregulated proliferation of white blood cells. B) The different leukemias all have unregulated proliferation of red blood cells and decreased bone marrow function. C) The different leukemias all result in a decrease in the production of white blood cells. D) The different leukemias all involve the development of cancer in the lymphatic system.

Ans: A Feedback: Leukemia commonly involves unregulated proliferation of white blood cells. Decreased production of red blood cells is associated with anemias. Decreased production of white blood cells is associated with leukopenia. The leukemias are not characterized by their involvement with the lymphatic system

A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this patients presentation? A) How many alcoholic drinks do you typically consume in a week? B) To the best of your knowledge, are your immunizations up to date? C) Have you ever worked in an occupation where you might have been exposed to toxins? D) Has anyone in your family ever experienced symptoms similar to yours?

Ans: A Feedback: Signs or symptoms of hepatic dysfunction indicate a need to assess for alcohol use. Immunization status, occupational risks, and family history are also relevant considerations, but alcohol use is a more common etiologic factor in liver disease.

The nurse is caring for a patient at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis? A) Incentive spirometry B) Intermittent positive-pressure breathing (IPPB) C) Positive end-expiratory pressure (PEEP) D) Bronchoscopy

Ans: A Feedback: Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung-volume expansion maneuvers (deep breathing exercises, incentive spirometry), and coughing, serve as the first- line measures to minimize or treat atelectasis by improving ventilation. In patients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as positive end-expiratory pressure (PEEP), continuous or intermittent positive-pressure breathing (IPPB), or bronchoscopy may be used.

A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease? A) Asterixis B) Constructional apraxia C) Fetor hepaticus D) Palmar erythema

Ans: A Feedback: The nurse will document that a patient exhibiting a flapping tremor of the hands is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the inability to reproduce a simple figure. Fetor hepaticus is a sweet, slightly fecal odor to the breath and not associated with a motor disturbance. Skin changes associated with liver dysfunction may include palmar erythema, which is a reddening of the palms, but is not a flapping tremor.

A 55-year-old female patient with hepatocellular carcinoma (HCC) is undergoing radiofrequency ablation. The nurse should recognize what goal of this treatment? A) Destruction of the patients liver tumor B) Restoration of portal vein patency C) Destruction of a liver abscess D) Reversal of metastasis

Ans: A Feedback: Using radiofrequency ablation, a tumor up to 5 cm in size can be destroyed in one treatment session. This technique does not address circulatory function or abscess formation. It does not allow for the reversal of metastasis.

The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition? A) Pneumothorax B) Anxiety C) Acute bronchitis D) Aspiration

Ans: A Feedback: If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The patient is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms are not definitive of pneumothorax, but because of the patients recent trauma they are inconsistent with anxiety, bronchitis, or aspiration.

A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply. A) Immunization B) Use of standard precautions C) Consumption of a vitamin-rich diet D) Annual vitamin K injections E) Annual vitamin B12 injections

Ans: A, B Feedback: People who are at high risk, including nurses and other health care personnel exposed to blood or blood products, should receive active immunization. The consistent use of standard precautions is also highly beneficial. Vitamin supplementation is unrelated to an individuals risk of HBV.

A patients physician has ordered a liver panel in response to the patients development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply. A) Alanine aminotransferase (ALT) B) C-reactive protein (CRP) C) Gamma-glutamyl transferase (GGT) D) Aspartate aminotransferase (AST) E) B-type natriuretic peptide (BNP)

Ans: A, C, D Feedback: Liver function testing includes GGT, ALT, and AST. CRP addresses the presence of generalized inflammation and BNP is relevant to heart failure; neither is included in a liver panel.

An oncology nurse recognizes a patients risk for fluid imbalance while the patient is undergoing treatment for leukemia. What relevant assessments should the nurse include in the patients plan of care? Select all that apply. A) Monitoring the patients electrolyte levels B) Monitoring the patients hepatic function C) Measuring the patients weight on a daily basis D) Measuring and recording the patients intake and output E) Auscultating the patients lungs frequently

Ans: A, C, D, E Feedback: Assessments that relate to fluid balance include monitoring the patients electrolytes, auscultating the patients chest for adventitious sounds, weighing the patient daily, and closely monitoring intake and output. Liver function is not directly relevant to the patients fluid status in most cases.

A patient with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what nursing intervention should the nurse perform? A) Keep patient NPO until the results of test are known. B) Keep patient NPO until the patients gag reflex returns. C) Administer analgesia until post-procedure tenderness is relieved. D) Give the patient a cold beverage to promote swallowing ability.

Ans: B Feedback: After the examination, fluids are not given until the patients gag reflex returns. Lozenges and gargles may be used to relieve throat discomfort if the patients physical condition and mental status permit. The result of the test is known immediately. Food and fluids are contraindicated until the gag reflex returns.

An older adult patient is undergoing diagnostic testing for chronic lymphocytic leukemia (CLL). What assessment finding is certain to be present if the patient has CLL? A) Increased numbers of blast cells B) Increased lymphocyte levels C) Intractable bone pain D) Thrombocytopenia with no evidence of bleeding

Ans: B Feedback: An increased lymphocyte count (lymphocytosis) is always present in patients with CLL. Each of the other listed symptoms may or may not be present, and none is definitive for CLL.

The nurse recognizes that aspiration is a potential complication of a laryngectomy. How should the nurse best manage this risk? A) Facilitate total parenteral nutrition (TPN). B) Keep a complete suction setup at the bedside. C) Feed the patient several small meals daily. D) Refer the patient for occupational therapy.

Ans: B Feedback: Due to the risk for aspiration, the nurse keeps a suction setup available in the hospital and instructs the family to do so at home for use if needed. TPN is not indicated and small meals do not necessarily reduce the risk of aspiration. Physical therapists do not address swallowing ability.

A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this patients plan of care? A) Measurement of abdominal girth and body weight B) Assessment for variceal bleeding C) Assessment for signs and symptoms of jaundice D) Monitoring of results of liver function testing

Ans: B Feedback: Esophageal varices are a major cause of mortality in patients with uncompensated cirrhosis. Consequently, this should be a focus of the nurses assessments and should be prioritized over the other listed assessments, even though each should be performed.

An adult patient has presented to the health clinic with a complaint of a firm, painless cervical lymph node. The patient denies any recent infectious diseases. What is the nurses most appropriate response to the patients complaint? A) Call 911. B) Promptly refer the patient for medical assessment. C) Facilitate a radiograph of the patients neck and have the results forwarded to the patients primary care provider. D) Encourage the patient to track the size of the lymph node and seek care in 1 week.

Ans: B Feedback: Hodgkin lymphoma usually begins as an enlargement of one or more lymph nodes on one side of the neck. The individual nodes are painless and firm but not hard. Prompt medical assessment is necessary if a patient has this presentation. However, there is no acute need to call 911. Delaying care for 1 week could have serious consequences and x-rays are not among the common diagnostic tests.

A nurse is caring for a patient with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate? A) Watery, blood-streaked diarrhea B) Orange and foamy urine C) Increased abdominal girth D) Decreased cognition

Ans: B Feedback: If the bile duct is obstructed, the bile will be reabsorbed into the blood and carried throughout the entire body. It is excreted in the urine, which becomes deep orange and foamy. Bloody diarrhea, ascites, and cognitive changes are not associated with obstructive jaundice.

A nursing student is caring for a patient with acute myeloid leukemia who is preparing to undergo induction therapy. In preparing a plan of care for this patient, the student should assign the highest priority to which nursing diagnoses? A) Activity Intolerance B) Risk for Infection C) Acute Confusion D)Risk for Spiritual Distress

Ans: B Feedback: Induction therapy places the patient at risk for infection, thus this is the priority nursing diagnosis. During the time of induction therapy, the patient is very ill, with bacterial, fungal, and occasional viral infections; bleeding and severe mucositis, which causes diarrhea; and marked decline in the ability to maintain adequate nutrition. Supportive care consists of administering blood products and promptly treating infections. Immobility, confusion, and spiritual distress are possible, but infection is the patients most acute physiologic threat.

A nurse practitioner is assessing a patient who has a fever, malaise, and a white blood cell count that is elevated. Which of the following principles should guide the nurses management of the patients care? A) There is a need for the patient to be assessed for lymphoma. B) Infection is the most likely cause of the patients change in health status. C) The patient is exhibiting signs and symptoms of leukemia. D) The patient should undergo diagnostic testing for multiple myeloma.

Ans: B Feedback: Leukocytosis is most often the result of infection. It is only considered pathologic (and suggestive of leukemia) if it is persistent and extreme. Multiple myeloma and lymphoma are not likely causes of this constellation of symptoms.

A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurses most recent assessment reveals subtle changes in the patients cognition and behavior. What is the nurses most appropriate response? A) Ensure that the patients sodium intake does not exceed recommended levels. B) Report this finding to the primary care provider due to the possibility of hepatic encephalopathy. C) Inform the primary care provider that the patient should be assessed for alcoholic hepatitis. D) Implement interventions aimed at ensuring a calm and therapeutic care environment.

Ans: B Feedback: Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the patients mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly. This change in status is likely unrelated to sodium intake and would not signal the onset of hepatitis. A supportive care environment is beneficial, but does not address the patients physiologic deterioration.

An adult patients abnormal complete blood count (CBC) and physical assessment have prompted the primary care provider to order a diagnostic workup for Hodgkin lymphoma. The presence of what assessment finding is considered diagnostic of the disease? A) Schwann cells B) Reed-Sternberg cells C) Lewy bodies D) Loops of Henle

Ans: B Feedback: The malignant cell of Hodgkin lymphoma is the Reed-Sternberg cell, a gigantic tumor cell that is morphologically unique and thought to be of immature lymphoid origin. It is the pathologic hallmark and essential diagnostic criterion. Schwann cells exist in the peripheral nervous system and Lewy bodies are markers of Parkinson disease. Loops of Henle exist in nephrons.

The nurse is providing care for a patient who has just been admitted to the postsurgical unit following a laryngectomy. What assessment should the nurse prioritize? A) The patients swallowing ability B) The patients airway potency C) The patients carotid pulses D) Signs and symptoms of infection

Ans: B Feedback: The patient with a laryngectomy is a risk for airway occlusion and respiratory distress. As in all nursing situations, assessment of the airway is a priority over other potential complications and assessment parameters.

A nurse is caring for a patient who has been diagnosed with leukemia. The nurses most recent assessment reveals the presence of ecchymoseson the patients sacral area and petechiae in her forearms. In addition to informing the patients primary care provider, the nurse should perform what action? A) Initiate measures to prevent venous thromboembolism (VTE). B) Check the patients most recent platelet level. C) Place the patient on protective isolation. D) Ambulate the patient to promote circulatory function.

Ans: B Feedback: The patients signs are suggestive of thrombocytopenia, thus the nurse should check the patients most recent platelet level. VTE is not a risk and this does not constitute a need for isolation. Ambulation and activity may be contraindicated due to the risk of bleeding.

A patient with a history of injection drug use has been diagnosed with hepatitis C. When collaborating with the care team to plan this patients treatment, the nurse should anticipate what intervention? A) Administration of immune globulins B) A regimen of antiviral medications C) Rest and watchful waiting D) Administration of fresh-frozen plasma (FFP)

Ans: B Feedback: There is no benefit from rest, diet, or vitamin supplements in HCV treatment. Studies have demonstrated that a combination of two antiviral agents, Peg-interferon and ribavirin (Rebetol), is effective in producing improvement in patients with hepatitis C and in treating relapses. Immune globulins and FFP are not indicated.

A patient has just been diagnosed with squamous cell carcinoma of the neck. While the nurse is doing health education, the patient asks, Does this kind of cancer tend to spread to other parts of the body? What is the nurses best response? A) In many cases, this type of cancer spreads to other parts of the body. B) This cancer usually does not spread to distant sites in the body. C) You will have to speak to your oncologist about that. D) Squamous cell carcinoma is nothing to be concerned about, so try to focus on your health.

Ans: B Feedback: The incidence of distant metastasis with squamous cell carcinoma of the head and neck (including larynx cancer) is relatively low. The patients prognosis is determined by the oncologist, but the patient has asked a general question and it would be inappropriate to refuse a response. The nurse must not downplay the patients concerns.

A patient has been admitted to the critical care unit with a diagnosis of toxic hepatitis. When planning the patients care, the nurse should be aware of what potential clinical course of this health problem? Place the following events in the correct sequence. 1. Fever rises. 2. Hematemesis. 3. Clotting abnormalities. 4. Vascular collapse. 5. Coma. A) 1, 2, 5, 4, 3 B) 1, 2, 3, 4, 5 C) 2, 3, 1, 4, 5 D) 3, 1, 2, 5, 4

Ans: B Feedback: Recovery from acute toxic hepatitis is rapid if the hepatotoxin is identified early and removed or if exposure to the agent has been limited. Recovery is unlikely if there is a prolonged period between exposure and onset of symptoms. There are no effective antidotes. The fever rises; the patient becomes toxic and prostrated. Vomiting may be persistent, with the emesis containing blood. Clotting abnormalities may be severe, and hemorrhages may appear under the skin. The severe GI symptoms may lead to vascular collapse. Delirium, coma, and seizures develop, and within a few days the patient may die of fulminant hepatic failure unless he or she receives a liver transplant.

The nurse is performing an assessment on a patient who has been diagnosed with cancer of the larynx. Part of the nurses assessment addresses the patients general state of nutrition. Which laboratory values would be assessed when determining the nutritional status of the patient? Select all that apply. A) White blood cell count B) Protein level C) Albumin level D) Platelet count E) Glucose level

Ans: B,C,E Feedback: The nurse also assesses the patients general state of nutrition, including height and weight and body mass index, and reviews laboratory values that assist in determining the patients nutritional status (albumin, protein, glucose, and electrolyte levels). The white blood cell count and the platelet count would not normally assist in determining the patients nutritional status.

The nurse is performing preoperative teaching with a patient who has cancer of the larynx. After completing patient teaching, what would be most important for the nurse to do? A) Give the patient his or her cell phone number. B) Refer the patient to a social worker or psychologist. C) Provide the patient with audiovisual materials about the surgery. D) Reassure the patient and family that everything will be alright.

Ans: C Feedback Informational materials (written and audiovisual) about the surgery are given to the patient and family for review and reinforcement. The nurse never gives personal contact information to the patient. Nothing in the scenario indicates that a referral to a social worker or psychologist is necessary. False reassurance must always be avoided.

A nurse has entered the room of a patient with cirrhosis and found the patient on the floor. The patient states that she fell when transferring to the commode. The patients vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurses most appropriate action? A) Remove the patients commode and supply a bedpan. B) Complete an incident report and submit it to the unit supervisor. C) Have the patient assessed by the physician due to the risk of internal bleeding. D) Perform a focused abdominal assessment in order to rule out injury.

Ans: C Feedback: A fall would necessitate thorough medical assessment due to the patients risk of bleeding. The nurses abdominal assessment is an appropriate action, but is not wholly sufficient to rule out internal injury. Medical assessment is a priority over removing the commode or filling out an incident report, even though these actions are appropriate.

An emergency department nurse is triaging a 77-year-old man who presents with uncharacteristic fatigue as well as back and rib pain. The patient denies any recent injuries. The nurse should recognize the need for this patient to be assessed for what health problem? A) Hodgkin disease B) Non-Hodgkin lymphoma C) Multiple myeloma D) Acute thrombocythemia

Ans: C Feedback: Back pain, which is often a presenting symptom in multiple myeloma, should be closely investigated in older patients. The lymphomas and bleeding disorders do not typically present with the primary symptom of back pain or rib pain.

A nurse is planning the care of a patient who has been admitted to the medical unit with a diagnosis of multiple myeloma. In the patients care plan, the nurse has identified a diagnosis of Risk for Injury. What pathophysiologic effect of multiple myeloma most contributes to this risk? A) Labyrinthitis B) Left ventricular hypertrophy C) Decreased bone density D) Hypercoagulation

Ans: C Feedback: Clients with multiple myeloma are at risk for pathologic bone fractures secondary to diffuse osteoporosis and osteolytic lesions. Labyrinthitis is uncharacteristic, and patients do not normally experience hypercoagulation or cardiac hypertrophy.

The nurse is planning the care of a patient who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis? A) Anxiety related to diagnosis of cancer B) Altered nutrition related to swallowing difficulties C) Ineffective airway clearance related to airway alterations D) Impaired verbal communication related to removal of the larynx

Ans: C Feedback: Each of the listed diagnoses is valid, but ineffective airway clearance is the priority nursing diagnosis for all conditions.

After receiving a diagnosis of acute lymphocytic leukemia, a patient is visibly distraught, stating, I have no idea where to go from here. How should the nurse prepare to meet this patients psychosocial needs? A) Assess the patients previous experience with the health care system. B) Reassure the patient that treatment will be challenging but successful. C) Assess the patients specific needs for education and support. D) Identify the patients plan of medical care.

Ans: C Feedback: In order to meets the patients needs, the nurse must first identify the specific nature of these needs. According to the nursing process, assessment must precede interventions. The plan of medical care is important, but not central to the provision of support. The patients previous health care is not a primary consideration, and the nurse cannot assure the patient of successful treatment.

A previously healthy adults sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the patient has been admitted to the intensive care unit. The nurse should be aware that the treatment of choice for this patient is what? A) IV administration of immune globulins B) Transfusion of packed red blood cells and fresh-frozen plasma (FFP) C) Liver transplantation D) Lobectomy

Ans: C Feedback: Liver transplantation carries the highest potential for the resolution of fulminant hepatic failure. This is preferred over other interventions, such as pharmacologic treatments, transfusions, and surgery.

A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem? A) Assessment of blood pressure and assessment for headaches and visual changes B) Assessments for signs and symptoms of venous thromboembolism C) Daily weights and abdominal girth measurement D) Blood glucose monitoring q4h

Ans: C Feedback: Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Assessments related to ascites are daily weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE.

A nurse is caring for a patient with hepatic encephalopathy. The nurses assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4

Ans: C Feedback: Patients in the third stage of hepatic encephalopathy exhibit the following symptoms: stuporous, difficult to arouse, sleeps most of the time, exhibits marked confusion, incoherent in speech, asterixis, increased deep tendon reflexes, rigidity of extremities, marked EEG abnormalities. Patients in stages 1 and 2 exhibit clinical symptoms that are not as advanced as found in stage 3, and patients in stage 4 are comatose. In stage 4, there is an absence of asterixis, absence of deep tendon reflexes, flaccidity of extremities, and EEG abnormalities.

A patient with liver disease has developed jaundice; the nurse is collaborating with the patient to develop a nutritional plan. The nurse should prioritize which of the following in the patients plan? A) Increased potassium intake B) Fluid restriction to 2 L per day C) Reduction in sodium intake D) High-protein, low-fat diet

Ans: C Feedback: Patients with ascites require a sharp reduction in sodium intake. Potassium intake should not be correspondingly increased. There is no need for fluid restriction or increased protein intake.

Diagnostic testing has revealed that a patients hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this patients plan of care will focus on what intervention? A) Cryosurgery B) Liver transplantation C) Lobectomy D) Laser hyperthermia

Ans: C Feedback: Surgical resection is the treatment of choice when HCC is confined to one lobe of the liver and the function of the remaining liver is considered adequate for postoperative recovery. Removal of a lobe of the liver (lobectomy) is the most common surgical procedure for excising a liver tumor. While cryosurgery and liver transplantation are other surgical options for management of liver cancer, these procedures are not performed at the same frequency as a lobectomy. Laser hyperthermia is a nonsurgical treatment for liver cancer.

A young adult patient has received the news that her treatment for Hodgkin lymphoma has been deemed successful and that no further treatment is necessary at this time. The care team should ensure that the patient receives regular health assessments in the future due to the risk of what complication? A) Iron-deficiency anemia B) Hemophilia C) Hematologic cancers D) Genitourinary cancers

Ans: C Feedback: Survivors of Hodgkin lymphoma have a high risk of second cancers, with hematologic cancers being the most common. There is no consequent risk of anemia or hemophilia, and hematologic cancers are much more common than GU cancers.

A 77-year-old male is admitted to a unit with a suspected diagnosis of acute myeloid leukemia (AML). When planning this patients care, the nurse should be aware of what epidemiologic fact? A) Early diagnosis is associated with good outcomes. B) Five-year survival for older adults is approximately 50%. C) Five-year survival for patients over 75 years old is less than 2%. D) Survival rates are wholly dependent on the patients pre-illness level of health.

Ans: C Feedback: The 5-year survival rate for patients with AML who are 50 years of age or younger is 43%; it drops to 19% for those between 50 and 64 years, and drops to1.6% for those older than 75 years. Early diagnosis is beneficial, but is nonetheless not associated with good outcomes or high survival rates. Preillness health is significant, but not the most important variable.

The nurse has noted the emergence of a significant amount of fresh blood at the drain site of a patient who is postoperative day 1 following total laryngectomy. How should the nurse respond to this development? A)Remove the patients drain and apply pressure with a sterile gauze. B) Assess the patient, reposition the patient supine, and apply wall suction to the drain. C) Rapidly assess the patient and notify the surgeon about the patients bleeding. D) Administer a STAT dose of vitamin K to aid coagulation.

Ans: C Feedback: The nurse promptly notifies the surgeon of any active bleeding, which can occur at a variety of sites, including the surgical site, drains, and trachea. The drain should not be removed or connected to suction. Supine positioning would exacerbate the bleeding. Vitamin K would not be administered without an order.

The clinical nurse educator is presenting health promotion education to a patient who will be treated for non-Hodgkin lymphoma on an outpatient basis. The nurse should recommend which of the following actions? A) Avoiding direct sun exposure in excess of 15 minutes daily B) Avoiding grapefruit juice and fresh grapefruit C) Avoiding highly crowded public places D) Using an electric shaver rather than a razor

Ans: C Feedback: The risk of infection is significant for these patients, not only from treatment-related myelosuppression but also from the defective immune response that results from the disease itself. Limiting infection exposure is thus necessary. The need to avoid grapefruit is dependent on the patients medication regimen. Sun exposure and the use of razors are not necessarily contraindicated.

A patient has just been diagnosed with lung cancer. After the physician discusses treatment options and leaves the room, the patient asks the nurse how the treatment is decided upon. What would be the nurses best response? A) The type of treatment depends on the patients age and health status. B) The type of treatment depends on what the patient wants when given the options. C) The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patients health status. D) The type of treatment depends on the discussion between the patient and the physician of which treatment is best.

Ans: C Feedback: Treatment of lung cancer depends on the cell type, the stage of the disease, and the patients physiologic status (particularly cardiac and pulmonary status). Treatment does not depend solely on the patients age or the patients preference between the different treatment modes. The decision about treatment does not primarily depend on a discussion between the patient and the physician of which treatment is best, though this discussion will take place.

A nurse is caring for a patient with severe hemolytic jaundice. Laboratory tests show free bilirubin to be 24 mg/dL. For what complication is this patient at risk? A) Chronic jaundice B) Pigment stones in portal circulation C) Central nervous system damage D) Hepatomegaly

Ans: C Feedback: Prolonged jaundice, even if mild, predisposes to the formation of pigment stones in the gallbladder, and extremely severe jaundice (levels of free bilirubin exceeding 20 to 25 mg/dL) poses a risk for CNS damage. There are not specific risks of hepatomegaly or chronic jaundice resulting from high bilirubin.

The nurse is caring for a 46-year-old patient recently diagnosed with the early stages of lung cancer. The nurse is aware that the preferred method of treating patients with nonsmall cell tumors is what? A) Chemotherapy B) Radiation C) Surgical resection D) Bronchoscopic opening of the airway

Ans: C Feedback: Surgical resection is the preferred method of treating patients with localized nonsmall cell tumors with no evidence of metastatic spread and adequate cardiopulmonary function. The other listed treatment options may be considered, but surgery is preferred.

The nurse is creating a care plan for a patient who is status post-total laryngectomy. Much of the plan consists of a long-term postoperative communication plan for alaryngeal communication. What form of alaryngeal communication will likely be chosen? A) Esophageal speech B) Electric larynx C) Tracheoesophageal puncture D) American Sign Language (ASL)

Ans: C Feedback: Tracheoesophageal puncture is simple and has few complications. It is associated with high phonation success, good phonation quality, and steady long-term results. As a result, it is preferred over esophageal speech, and electric larynx or ASL.

A patients total laryngectomy has created a need for alaryngeal speech which will be achieved through the use of tracheoesophageal puncture. What action should the nurse describe to the patient when teaching him about this process? A) Training on how to perform controlled belching B) Use of an electronically enhanced artificial pharynx C) Insertion of a specialized nasogastric tube D) Fitting for a voice prosthesis

Ans: D Feedback In patients receiving transesophageal puncture, a valve is placed in the tracheal stoma to divert air into the esophagus and out the mouth. Once the puncture is surgically created and has healed, a voice prosthesis (Blom-Singer) is fitted over the puncture site. A nasogastric tube and belching are not required. An artificial pharynx is not used.

The nurse is caring for a patient who is postoperative day 2 following a total laryngectomy for supraglottic cancer. The nurse should prioritize what assessment? A) Assessment of body image B) Assessment of jugular venous pressure C) Assessment of carotid pulse D) Assessment of swallowing ability

Ans: D Feedback: A common postoperative complication from this type of surgery is difficulty in swallowing, which creates a potential for aspiration. Cardiovascular complications are less likely at this stage of recovery. The patients body image should be assessed, but dysphagia has the potential to affect the patients airway, and is a consequent priority.

A nurse is caring for patient whose diagnosis of multiple myeloma is being treated with bortezomib. The nurse should assess for what adverse effect of this treatment? A) Stomatitis B) Nephropathy C) Cognitive changes D) Peripheral neuropathy

Ans: D Feedback: A significant toxicity associated with the use of bortezomib for multiple myeloma is peripheral neuropathy. Stomatitis, cognitive changes, and nephropathy are not noted to be adverse effects of this medication.

Diagnostic testing has resulted in a diagnosis of acute myeloid leukemia (AML) in an adult patient who is otherwise healthy. The patient and the care team have collaborated and the patient will soon begin induction therapy. The nurse should prepare the patient for which of the following? A) Daily treatment with targeted therapy medications B) Radiation therapy on a daily basis C) Hematopoietic stem cell transplantation D) An aggressive course of chemotherapy

Ans: D Feedback: Attempts are made to achieve remission of AML by the aggressive administration of chemotherapy, called induction therapy, which usually requires hospitalization for several weeks. Induction therapy is not synonymous with radiation, stem cell transplantation, or targeted therapies.

A clinic patient is being treated for polycythemia vera and the nurse is providing health education. What practice should the nurse recommend in order to prevent the complications of this health problem? A) Avoiding natural sources of vitamin K Avoiding altitudes of 1500 feet (457 meters) B)C) Performing active range of motion exercises daily D) Avoiding tight and restrictive clothing on the legs

Ans: D Feedback: Because of the risk of DVT, patients with polycythemia vera should avoid tight and restrictive clothing. There is no need to avoid foods with vitamin K or to avoid higher altitudes. Activity levels should be maintained, but there is no specific need for ROM exercises.

A patient with liver cancer is being discharged home with a biliary drainage system in place. The nurse should teach the patients family how to safely perform which of the following actions? A) Aspirating bile from the catheter using a syringe B) Removing the catheter when output is 15 mL in 24 hours C) Instilling antibiotics into the catheter D) Assessing the patency of the drainage catheter

Ans: D Feedback: Families should be taught to provide basic catheter care, including assessment of patency. Antibiotics are not instilled into the catheter and aspiration using a syringe is contraindicated. The family would not independently remove the catheter; this would be done by a member of the care team when deemed necessary.

A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at this restaurant and have never received the hepatitis A vaccine? A) The hepatitis A vaccine B) Albumin infusion C) The hepatitis A and B vaccines D) An immune globulin injection

Ans: D Feedback: For people who have not been previously vaccinated, hepatitis A can be prevented by the intramuscular administration of immune globulin during the incubation period, if given within 2 weeks of exposure. Administration of the hepatitis A vaccine will not protect the patient exposed to hepatitis A, as protection will take a few weeks to develop after the first dose of the vaccine. The hepatitis B vaccine provides protection again the hepatitis B virus, but plays no role in protection for the patient exposed to hepatitis A. Albumin confers no therapeutic benefit.

A 35-year-old male is admitted to the hospital complaining of severe headaches, vomiting, and testicular pain. His blood work shows reduced numbers of platelets, leukocytes, and erythrocytes, with a high proportion of immature cells. The nurse caring for this patient suspects a diagnosis of what? A) AML B) CML C) MDS D) ALL

Ans: D Feedback: In acute lymphocytic leukemia (ALL), manifestations of leukemic cell infiltration into other organs are more common than with other forms of leukemia, and include pain from an enlarged liver or spleen, as well as bone pain. The central nervous system is frequently a site for leukemic cells; thus, patients may exhibit headache and vomiting because of meningeal involvement. Other extranodal sites include the testes and breasts. This particular presentation is not closely associated with acute myeloid leukemia (AML), chronic myeloid leukemia (CML), or myelodysplastic syndromes (MDS).

A patient has completed the full course of treatment for acute lymphocytic leukemia and has failed to respond appreciably. When preparing for the patients subsequent care, the nurse should perform what action? A) Arrange a meeting between the patients family and the hospital chaplain. B) Assess the factors underlying the patients failure to adhere to the treatment regimen. C) Encourage the patient to vigorously pursue complementary and alternative medicine (CAM). D) Identify the patients specific wishes around end-of-life care.

Ans: D Feedback: Should the patient not respond to therapy, it is important to identify and respect the patients choices about treatment, including measures to prolong life and other end-of-life measures. The patient may or may not be open to pursuing CAM. Unsuccessful treatment is not necessarily the result of failure to adhere to the treatment plan. Assessment should precede meetings with a chaplain, which may or may not be beneficial to the patient and congruent with the familys belief system.

A nurse is performing an admission assessment for an 81-year-old patient who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what finding? A) Similar liver size and texture as in younger adults B) A nonpalpable liver C) A slightly enlarged liver with palpably hard edges D) A slightly decreased size of the liver

Ans: D Feedback: The most common age-related change in the liver is a decrease in size and weight. The liver is usually still palpable, however, and is not expected to have hardened edges.

A nurse is amending a patients plan of care in light of the fact that the patient has recently developed ascites. What should the nurse include in this patients care plan? A) Mobilization with assistance at least 4 times daily B) Administration of beta-adrenergic blockers as ordered C) Vitamin B12 injections as ordered D) Administration of diuretics as ordered

Ans: D Feedback: Use of diuretics along with sodium restriction is successful in 90% of patients with ascites. Beta- blockers are not used to treat ascites and bed rest is often more beneficial than increased mobility. Vitamin B12 injections are not necessary.

A 54-year-old man has just been diagnosed with small cell lung cancer. The patient asks the nurse why the doctor is not offering surgery as a treatment for his cancer. What fact about lung cancer treatment should inform the nurses response? A) The cells in small cell cancer of the lung are not large enough to visualize in surgery. B) Small cell lung cancer is self-limiting in many patients and surgery should be delayed. C) Patients with small cell lung cancer are not normally stable enough to survive surgery. D) Small cell cancer of the lung grows rapidly and metastasizes early and extensively.

Ans: D Feedback: Surgery is primarily used for NSCLCs, because small cell cancer of the lung grows rapidly and metastasizes early and extensively. Difficult visualization and a patients medical instability are not the limiting factors. Lung cancer is not a self-limiting disease.

A clinic nurse is working with a patient who has a long-standing diagnosis of polycythemia vera. How can the nurse best gauge the course of the patients disease? A) Document the color of the patients palms and face during each visit. B) Follow the patients erythrocyte sedimentation rate over time. C) Document the patients response to erythropoietin injections. D) Follow the trends of the patients hematocrit.

Ans: D Feedback: The course of polycythemia vera can be best ascertained by monitoring the patients hematocrit, which should remain below 45%. Erythropoietin injections would exacerbate the condition. Skin tone should be observed, but is a subjective assessment finding. The patients ESR is not relevant to the course of the disease.