Med Surg Test #2

A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). The nurse will include which information in the patients teaching plan?

Hospitalization will be required for several weeks after the stem cell transplant procedure is performed.

During a routine health examination, a 40-year-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next?

Obtain more information from the patient about the family history.

A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching?

The patients visitors bring in some fresh peaches from home.

The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider?

White blood cell (WBC) count of 2700/L

When performing a skin assessment, the nurse notes several angiomas on the chest of an older patient. Which action should the nurse take next?

assess the patient for evidence of liver disease

A patient in the dermatology clinic is scheduled for removal of a 15-mm multicolored and irregular mole from the upper back. The nurse should prepare the patient for which type of biopsy?

incisional biopsy

Which abnormality on the skin of an older patient is the priority to discuss immediately with the health care provider?

petechiae present on the chest & abdomen

A patient in the dermatology clinic has a thin, scaly erythematous plaque on the right cheek. Which action should the nurse take?

prepare the patient for a biopsy

A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next?

rising body temperature

The nurse should include which food choice when providing dietary teaching for a patient scheduled to receive external beam radiation for abdominal cancer?

roasted chicken

The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider?

separation of the proximal wound incisional pain

The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement, if made by the patient, indicates that teaching was effective?

the biopsy will help decide the treatment for my enlarged prostate

The nurse instructs a patient about application of corticosteroid cream to an area of contact dermatitis on the right leg. Which patient action indicates that further teaching is needed?

the patient applies a thick layer of the cream to the affected skin.

The nurse working in the dermatology clinic assesses a young adult female patient who is taking isotretinoin (Accutane) to treat severe cystic acne. Which assessment finding is most indicative of a need for further questioning of the patient?

the patient recently had an intrauterine device removed

The nurse is caring for a patient with colon cancer who is scheduled for external radiation therapy to the abdomen. Which information obtained by the nurse would indicate a need for patient teaching?

the patient swims a mile 3 days a week

The nurse is interviewing a patient with contact dermatitis. Which finding indicates a need for patient teaching?

the patient uses Neosporin ointment on minor cuts or abrasions

A patient has the following risk factors for melanoma. Which risk factor should the nurse assign as the priority focus of patient teaching?

the patient uses a tanning booth throughout the winter

After receiving a change-of-shift report, which patient should the nurse assess first?

the patient who has been receiving chemotherapy & has a temperature of 102 F

The nurse should plan to use a wet-to-dry dressing for which patient?

a patient who has a wound w/ purulent drainage & dry brown areas

The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in therapy with the health care provider?

increase in carcinoembryonic antigen (CEA)

A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurses highest priority?

maintaining the patients blood glucose within a normal range.

A patient with an open leg wound has a white blood cell (WBC) count of 13, 500/L and a band count of 11%. What action should the nurse take first?

obtain wound cultures

A teenaged male patient who wrestles in high school is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis?

papular, wheal-like lesions w/ white deposits on the hair shaft

During assessment of the patients skin, the nurse observes a similar pattern of small, raised lesions on the left and right upper back areas. Which term should the nurse use to document these lesions?

symmetric

The nurse assesses a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which assessment data should be reported to the surgeon immediately?

the skin around the incision is pale & cold when palpated

A patient who has an infected abdominal wound develops a temperature of 104 F (40 C). All the following interventions are included in the patients plan of care. In which order should the nurse perform the following actions?

- administer IV antibiotics - administer acetaminophen (tylenol) - sponge patient w/ cool water - perform wet-to-dry dressing change.

Which activities can the nurse working in the outpatient clinic delegate to a licensed practical/vocational nurse (LPN/LVN) (select all that apply)?

- administer patch testing to a patient w/ allergic dermatitis - apply a sterile dressing after the health care provider excises a mole

A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan (select all that apply)?

- cook food thoroughly before eating - avoid public transportation such as buses - talk to the oncologist before having any dental work done.

A nurse is teaching a patient with contact dermatitis of the arms and legs about ways to decrease pruritus. Which information should the nurse include in the teaching plan (select all that apply)?

- cool, wet cloths or dressings can be used to reduce itching. - take cool or tepid baths several times daily to decrease itching - use of an OTC antihistamine can reduce scratching

The nurse at the clinic is interviewing a 64-year-old woman who is 5 feet, 3 inches tall and weighs 125 pounds (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk (select all that apply)?

- pap testing - sunscreen use - mammography - colorectal screening

The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first?

24-year-old patient who received neck radiation and has blood oozing from the neck

There is one opening in the schedule at the dermatology clinic, and 4 patients are seeking appointments today. Which patient will the nurse schedule for the available opening?

38 yr old w/ a 7mm nevus on the face that has recently become darker

The nurse assesses a patients surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate?

Document the assessment.

During the teaching session for a patient who has a new diagnosis of acute leukemia the patient is restless and is looking away, never making eye contact. After teaching about the complications associated with chemotherapy, the patient asks the nurse to repeat all of the information. Based on this assessment, which nursing diagnosis is most appropriate for the patient?

Risk for ineffective health maintenance related to anxiety about new leukemia diagnosis

The nurse is caring for a patient with left-sided lung cancer. Which finding would be most important for the nurse to report to the health care provider?

Serum sodium 126 mEq/L

A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure ulcer?

Stage III

Which action should the nurse take when caring for a patient who is receiving chemotherapy and complains of problems with concentration?

Suggest use of a daily planner and encourage adequate rest and sleep

When caring for a patient who is pancytopenic, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene?

The UAP assists the patient to use dental floss after eating

The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention?

The UAP stands by the patients bed for 30 minutes talking with the patient

The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)?

The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer.

The nurse teaches a patient with cancer of the liver about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective?

blueberry yogurt

A patient is undergoing psoralen plus ultraviolet A light (PUVA) therapy for treatment of psoriasis. What action should the nurse take to prevent adverse effects from this procedure?

have the patient use protective eyewear while receiving PUVA

A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is being cared for at home by his mother. To prevent further tissue damage, what instructions are most important for the nurse to teach the mother?

change the patients position at least every 2 hrs.

A dark-skinned patient has been admitted to the hospital with chronic heart failure. How would the nurse best assess this patient for cyanosis?

check the lips & oral mucous membranes

A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8 F (38.7 C). Which action by the nurse is most appropriate?

check the patient oral temperature again in 4 hours

The health care provider diagnoses impetigo in a patient who has crusty vesicopustular lesions on the lower face. Which instructions should the nurse include in the teaching plan?

clean the infected areas w/ soap & water

The nurse is caring for a patient who smokes 2 packs/day. To reduce the patients risk of lung cancer, which action by the nurse is best?

discuss the risks associated w/ cigarettes during every patient encounter

The nurse is caring for a patient diagnosed with furunculosis. Which nursing action could the nurse delegate to unlicensed assistive personnel (UAP)?

cleaning the skin w/ antimicrobial soap

The nurse notes darker skin pigmentation in the skinfolds of a middle-aged patient who has a body mass index of 40 kg/m2. What is the nurses best action?

ask the patient about type 2 diabetes or if there is a family history of it

A patient has been assigned the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers. Which nursing action will be most effective in improving oral intake?

apply the ordered anesthetic gel to oral lesions before meals

The nurse notes the presence of white lesions that resemble milk curds in the back of a patients throat. Which question by the nurse is appropriate at this time?

are you taking any medications at present?

A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action is most appropriate?

Avoid giving the patient foods that are strongly disliked.

A patient with rheumatoid arthritis has been taking corticosteroids for 11 months. Which nursing action is most likely to detect early signs of infection in this patient?

ask about fatigue or feeling of malaise.

The nurse is caring for a patient who has been diagnosed with stage I cancer of the colon. When assessing the need for psychologic support, which question by the nurse will provide the most information?

Can you tell me what has been helpful to you in the past when coping with stressful events?

A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective?

I can buy some aloe vera gel to use on the area

Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient?

IL-2 enhances the immunologic response to tumor cells

An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hour in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider?

Patient has audible crackles to the midline posterior chest

A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. Which action, if taken by the nurse, is most appropriate?

administer prescribed antimetics 1 hr before the treatments

The nurse will perform which action when doing a wet-to-dry dressing change on a patients stage III sacral pressure ulcer?

administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change.

External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation?

clean the perianal area carefully after every bowel movement

A patient who has ovarian cancer is crying and tells the nurse, My husband rarely visits. He just doesnt care. The husband indicates to the nurse that he never knows what to say to help his wife. Which nursing diagnosis is most appropriate for the nurse to add to the plan of care?

dysfunctional family processes related to effect of illness on family members

A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is most appropriate?

elevate the ankle above the heart level.

A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to maintain the patients self-esteem?

encourage the patient to purchase a wig or hat & wear it once hair loss begins.

A patient with Hodgkins lymphoma who is undergoing external radiation therapy tells the nurse, I am so tired I can hardly get out of bed in the morning. Which intervention should the nurse add to the plan of care?

establish time to take a short walk almost every day

The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect?

hematuria

When taking the health history of an older adult, the nurse discovers that the patient has worked in the landscaping business for 40 years. The nurse will plan to teach the patient about how to self-assess for which clinical manifestations (select all that apply)?

- erythema - actinic keratosis

The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider?

Crackles heard at the lower scapular border

After change-of-shift report on the oncology unit, which patient should the nurse assess first?

Patient who is neutropenic and has a temperature of 100.5 F (38.1 C)

A patient who has severe refractory psoriasis on the face, neck, and extremities is socially withdrawn because of the appearance of the lesions. Which action should the nurse take first?

ask the patient to describe the impact of psoriasis on quality of life

A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first?

assess for sensation & strength in the legs

When assessing a new patient at the outpatient clinic, the nurse notes dry, scaly skin; thin hair; and thick, brittle nails. What is the nurses best action?

consult w/ the health care provider about the need for further diagnostic testing

The nurse prepares to obtain a culture from a patient who has a possible fungal infection on the foot. Which items should the nurse gather for this procedure?

cotton-tipped applicators

A patients 4 3-cm leg wound has a 0.4 cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound?

hydrocolloid dressing (DuoDerm)

The home health nurse cares for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment?

i rarely have the energy to get out of bed

The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective?

i will need to have follow-up examinations for many years after i have treatment before i can be considered cured.

A patient with atopic dermatitis has a new prescription for pimecrolimus (Elidel). After teaching the patient about the medication, which statement by the patient indicates that further teaching is needed?

if the medication burns when i apply it, i will wipe it off & call the doctor.

Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative pressure wound therapy?

low serum albumin level

A patient who is scheduled for a right breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct?

malignant tumors may spread to other tissues or organs

A 38-year-old female patient states that she is using topical fluorouracil to treat actinic keratoses on her face. Which additional assessment information will be most important for the nurse to obtain?

method of birth control used by the patient

A nurse develops a teaching plan for a patient diagnosed with basal cell carcinoma (BCC). Which information should the nurse include in the teaching plan?

minimizing sun exposure will reduce risk for future BCC

The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patients ankle. How should the nurse determine if the lesion is related to intradermal bleeding?

press firmly on the lesion

A patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. How would the nurse document this wound?

red wound

Which integumentary assessment data from an older patient admitted with bacterial pneumonia is of most concern for the nurse?

reports a history of allergic rashes

A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient?

rinse the mouth before & after each meal & at bedtime w/ a saline solution

The nurse assesses a patient with non-Hodgkins lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse?

shortness of breath

The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take?

stop the infusion if swelling is observed at the site.

A patient with an enlarging, irregular mole that is 7 mm in diameter is scheduled for outpatient treatment. The nurse should plan to prepare the patient for which procedure?

surgical excision

When examining an older patient in the home, the home health nurse notices irregular patterns of bruising at different stages of healing on the patients body. Which action should the nurse take first?

talk with the patient alone & ask about what caused the bruising

An older adult patient with a squamous cell carcinoma (SCC) on the lower arm has a Mohs procedure in the dermatology clinic. Which nursing action will be included in the postoperative plan of care?

teach about the use of cold packs to reduce bruising & swelling

A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is most appropriate?

the cancer involves only the cervix

After the home health nurse teaches a patients family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed?

the family member dries the wound using a hair dryer set on a low setting

A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care?

the new nurse cleans the ulcer w/ a sterile dressing soaked in half-strength peroxide.

When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing?

the patient takes insulin daily.

A patient who has severe pain associated with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching regarding pain management has been effective?

the patient takes opioids around the clock on a regular schedule & uses additional doses when breakthrough pain occurs.

A patient reports chronic itching of the ankles and continuously scratches the area. Which assessment finding will the nurse expect?

thickening of the skin around the ankles

A patient with atopic dermatitis has been using a high-potency topical corticosteroid ointment for several weeks. The nurse should assess for which adverse effect?

thinning of the affected skin

Which information should the nurse include when teaching patients about decreasing the risk for sun damage to the skin?

try to stay out of the sun between the hours of 10am & 2pm (regular time)

A patient with a large stomach tumor that is attached to the liver is scheduled to have a debulking procedure. Which information should the nurse teach the patient about the outcome of this procedure?

tumor size will decrease & this will improve the effects of other therapy.

Which information should the nurse include when teaching a patient who has just received a prescription for ciprofloxacin (Cipro) to treat a urinary tract infection?

use a sunscreen w/ a high SPF when exposed to the sun

Which information will the nurse include when teaching an older patient about skin care?

use warm water & a moisturizing soap when bathing

What is the best method to prevent the spread of infection when the nurse is changing the dressing over a wound infected with Staphylococcus aureus?

wash hands & properly dispose of soiled dressings

A widowed mother of four school-age children is hospitalized with metastatic ovarian cancer. The patient is crying and tells the nurse that she does not know what will happen to her children when she dies. Which response by the nurse is most appropriate?

why dont we talk about the options you have for the care of your children?

The health care provider prescribes topical 5-FU for a patient with actinic keratosis on the left cheek. The nurse should include which statement in the patients instructions?

your cheek area will be painful & develop eroded areas that will take weeks to heal