principles week 5
After receiving a report that a tumor biopsy is benign, a client demonstrates understanding by making which of the following statements to the nurse?
'I'm going to need chemotherapy and radiation treatments.' Correct Answer: 'The tumor did not spread to other parts of my body.' Principle: Malignant neoplasms invade other areas (metastasis) and branch off while benign tumors do not metastasize
Which of the following clients has clinical manifestations that suggest an impaired immune system?
A client with a history of recurrent pneumonia Principle: Immunodeficiency is marked by frequent infections that could be severe, infection from organisms that do not typically cause a problem, poor treatment response and chronic diarrhea
The nurse is caring for a client with AIDS and pneumocystic jiroveci pneumonia (PCP). Which of the following pathological processes best explains the occurrence of PCP?
A decrease in the number of CD4 cells Principle: The reduction in T cells increases the risk for opportunistic infections
A client who had a stem cell transplant 4 weeks ago, now presents with fever of 100.4 degrees Fahrenheit, severe abdominal cramping and diarrhea, and an itchy, red skin rash. The nurse is aware that the probable reason for the client's symptoms is which of the following? Answer Options *
Acute graft versus host disease. Principle: Graft versus host disease could present as a blistering skin rash, diffuse inflammation to the gastrointestinal tract with massive diarrhea, or hepatomegaly
The nurse determines the client has extravasation of a chemotherapeutic agent. Which of the following nursing interventions would follow. Select all that apply.
Administer the prescribed antidote. Perform a neurovascular assessment to the affected extremity. Aspirate for residual medication from site. Principle: Following an extravasation, neurovascular assessments of the affected extremity should be performe
When caring for a client with stomatitis, which of the following interventions does the nurse recommend to the client?
Advise client with stomatitis to avoid mouthwashes that contain alcohol or tobacco because they dry the mucosa, use a soft toothbrush, avoid rough, hot or spicy foods, and remove dentures unless eating
When caring for a client receiving radiation therapy for breast cancer, the nurse observes signs of moist desquamation in the skin folds near the radiation site. The nurse expects which of the following treatments in the care of this client's skin.
Application of prescribed ointment and cover with non-adhesive pad. Principle: Treat wet desquamation by leaving blisters intact and notifying primary care provider, avoid frequent washing of area because of increased irritation, obtain an order for a cream or ointment and use a nonadhesive pad over the area
The nurse demonstrates knowledge of primary prevention measures when educating clients on which of the following teaching points? Select all that apply.
Apply sunscreen protection (SPF) that provides an SPF 15 or higher. Use latex condoms correctly and consistently. Principle: Educate on avoiding carcinogens (smoking), limiting alcohol and caloric intake and increasing activity level, using sunscreen with a minimum SPF of 15, limiting sun exposure and using condoms
When providing self-care instructions to a client with human immunodeficiency virus (HIV), the nurse includes which of the following symptoms that should be reported promptly to the health care provider.
Being immunocompromised reduces the clinical manifestations of infection so a temp greater than 100.4 for an hour is significant and should be reported ; P
The nurse has just completed the administration of the client's first round of chemotherapy for treatment of Burkitt lymphoma. The nurse closely monitors for which clinical indicators of tumor lysis syndrome? Select all that apply.
Bradycardia. Hyperphosphatemia. Tented T waves. Principle: Clinical manifestations of tumor lysis syndrome include hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia; bradydysrhythmias, wide QRS complexes, tented T waves, tetany, seizures and flank pain
When administering an intravenous (IV) chemotherapeutic agent to a client through a peripheral site, which of the following signs indicate possible extravasation to the nurse? Select all that apply.
Burning discomfort at the site. Resistance is met while flushing the IV catheter. Principle: Suspect an increase risk for extravasation if resisitance is met while flusing intravenous catheter, blood return is absent or there is burning pain or swelling to the site
The nurse recommends which of the following screening tests for cancer when educating clients on the importance of early detection? Select all that apply.
Colonoscopy every 10 years starting at age 50. Fecal occult blood test annually starting at age 50. Principle: Screen for cancer; annual mammogram starting at age 40, colonoscopy at age 50 every 10 years, annual fecal occult blood test at age 50, prostate specific antigen at age 50, pap test every 3 years
The nurse would expect to observe which of the following laboratory findings in a client with symptomatic human immunodeficiency virus (HIV) infection?
Decreased production of T-helper cells. Principle: CD4 cells (helper T cells) stimulate the immune system and help to destroy organisms
The nurse is providing discharge instructions to a client who has a peripherally inserted central catheter (PICC) line for chemotherapy. Which of the following reportable signs of infection does the nurse review with the client prior to discharge? Select all that apply
Drainage or leakage around insertion site. Chills and night sweats. Tenderness or discomfort around insertion site. Principle: Redness, swelling, tenderness, purulent drainage, fever and chills, and an elevated white blood cell count are classic signs of infection
The nurse is caring for a client with an urinary tract infection. Which of the following laboratory abnormalities would most likely be present on this client's complete blood count? Answer Options *
Elevated neutrophils Principle: An increase in neutrophils indicates a bacterial infection while an increase in lymphoctyes indicate a viral infection (although lymphocytes are also elevated in some bacterial infections as well)
The nurse receives report on a 72 year old client who fractured their left tibia two days ago. What nursing intervention is a priority?
Encourage cough and deep breathing exercises. Principle: Reduce the risk for infection with elderly; drink plenty of fluids unless contraindicated, use lotion, assessing for signs of skin breakdown, change incontinence pads frequently, void after intercourse, pneumococcal and influenza vaccine, cough and deep breathing exercies, sit up while eating
When caring for a client with human immunodeficiency virus (HIV), the nurse recognizes which of the following factors may contribute to the client's increased risk for opportunistic infections?
Having a protein deficiency. Principle: Protein deficiency increases the risk of infection
When performing a comprehensive pain assessment, the nurse asks which of the following questions to determine the client's subjective perception of pain?
How would you describe the pain?' Principle: A comprehensive pain assessment includes duration (includes when it started), type (incudes intensity, associated factors, influencing factors (what makes it better or worse), location
When providing discharge instructions to a client undergoing treatment for cancer, the nurse includes which of the following reportable symptoms of hypercalcemia? Select all that apply.
Increase in lethargy. Fatigue and weakness. Increased thirst and urination. Principle: Hypercalcemia is an oncologic emergency and is marked by a progressive change in level of consciousness, hyporeflexia, ileus, constipation, polyuria and polydipsia
The nurse is preparing to discharge a client receiving corticosteroid therapy. Which of the instructions should be included in the discharge teaching?
Instruct on factors that increase the risk for infection; excess alcohol consumption, poor nutrition, smoking, glucocorticosteroids, and diabetes mellitus
he nurse is caring for a client with colon cancer and receives an order to draw a CEA. Which of the following is the most likely reason the physician ordered the test?
It will help to evaluate treatment response Principle: Tumor markers (for example, CEA, CA 125) are monitored to help determine the effectiveness of chemotherapy
The nurse is preparing to receive a client from surgery after having a radioactive device implanted. What equipment must be kept at the bedside? Answer Options *
Keep a lead container in the room in case a radioactive device dislodges
The nurse administers subcutaneous filgrastim (Neupogen) to a client. Which laboratory value does the nurse monitor to evaluate this drug's effectiveness? Answer Options *
Leukocyte count. Principle: Colony-stimulating factors stimulate red blood cell production decreasing the need for blood transfusions (erythropoietin) or stimulate neutrophil production to decrease the risk for infection (neupogen).
The nurse administers methotrexate to a client with rheumatoid arthritis (RA). Which other medication does the nurse expect to be part of this client's treatment? Answer Options *
Methotrexate contributes to folic acid deficiency and results in cell death (is typically prescribed with folic acid)
The nurse is caring for a client receiving brachytherapy for prostate cancer. Which of the following safety precautions should the nurse follow? Select all that apply.
Minimize time in client's room when providing care. Utilize radiation dosimeter when in client's room. Principle: Radiation safety precautions (brachytherapy) include limiting time with client, wearing dosimeter badges, keeping pregnant staff or visitors and children out of room, limiting visits to 30 minutes and keeping 6 feet away from the radiation source
A client's breast biopsy report shows a 7 centimeter (cm) tumor with lymph node involvement. The nurse understands this client's treatment will be mainly based on which of the following
Node involvement Principle: Staging of a tumor is done to communicate the size of the tumor, if lymph nodes are involved, and if there is metastasis
The nurse is caring for a client with a urinary tract infection and is receiving sulfamethoxazole trimethroprim. The final culture report shows that the bacteria is resistant to the medication sulfamethoxazole trimethroprim (bactrim). Which of the following interventions should the nurse perform next?
Notify the physician of the drug resistance Principle: Notify the provider if a culture and sensitivity reveals that the organism is resistant to the prescribed antibiotic
When administering chemotherapy medications to a client, the nurse understands the need to instruct the client that there is an increased risk for which of the following?
Opportunistic infections. Principle: Mylosuppression, induced by chemotherapy, results in pancytopenia and increases the risk for infection, bleeding and fatigue
When administering chemotherapy agents to a client, the nurse is on alert for which of the following signs of extravasation?
Pain at infusion site. Principle: Extravasation of a vesicant could result in tissue necrosis so never use the hand or wrist and prevent extravasation by confirming patency of intravenous device
The nurse demonstrates knowledge of nonpharmacological pain management strategies when assisting the client with which of the following? Select all that apply.
Positioning. Therapeutic touch. Guided imagery. Principle: Provide non-pharmacological pain management strategies such as physical modalities, mind-body methods, biologic and energy based therapies
When creating a plan of care for a client who has tumor lysis syndrome, the nurse focuses on which of the following goals?
Preventing renal failure and achieving electrolyte balance is a priority in the setting of tumor lysis syndrome
A client receiving chemotherapeutic agents has a decreased appetite and complains of being bothered by the smell of foods. Which of the following nursing interventions will help improve the client's oral intake? Select all that apply.
Provide small, frequent meals. Assure proper pain management. Assist with oral hygiene. Principle: Improve oral intake in the setting of nausea by serving cold foods since they are less odorous, encourage oral hygiene, provide small frequent meals, and make sure pain is managed
While caring for a client receiving chemotherapeutic agents, the nurse receives an order for odansetron (Zofran). The nurse understands the action of this medication is to do which of the following?
Relieve nausea and vomiting. Principle: Seratonin receptor blockers (ondansetron, granisetron), dopaminergic receptor blockers (metoclopramide, prochlorperazine), bland foods, and small, frequent meals are used to decrease nausea and vomiting
The nurse is caring for a client with myasthenic crisis on a ventilator. Which of the following interventions best demonstrates the nurses knowledge of primary prevention? Answer Options *
Repositioning the client every 2 hours Principle: Reduce the risk for infection with elderly; drink plenty of fluids unless contraindicated, use lotion, assessing for signs of skin breakdown, change incontinence pads frequently, void after intercourse
Which of the following clinical signs would cause the nurse to suspect thrombocytopenia in a client undergoing chemotherapy treatment? Select all that apply. Answer Options *
Scattered ecchymosis. Petechiae. Principle: Common signs of thrombocytopenia include petechiae and ecchymosis
When caring for a client with metastatic cancer of the right lung, the nurse is alert for which early indicator of superior vena cava syndrome?
Signs of superior vena cava syndrome include increased dypsnea, facial and neck edema, jugular vein distention, visual disturbances, and headache
The nurse understands that a client receiving chemotherapy could develop hemorrhagic cystitis. To prevent this complication the nurse prepares to administer which of the following?
Some chemotherapy agents could induce hemorrhagic cystitis which could lead to a life-threatening hemorrhage so protect the bladder with intravenous hydration and diuresis
During morning rounds the nurse notes that a client is scheduled for a CT scan of the head with contrast. The client is scheduled to receive metformin (Glucophage). Which of the following interventions is the most appropriate?
Speak to the prescriber prior to administering the medication. Principle: Metformin should be stopped 48 hours before and after the administration of iodinated contrast medium
During administration of an intravenous antibiotic to a client, the nurse observes signs of a Type I hypersensitivity reaction. What action does the nurse take next? Answer Options *
Stop the intravenous antibiotic infusion. Principle: Monitor for hypersensitivity reactions which could be acute (withing 15-30 minutes) or delayed (several courses after the medication) and stop the medication immediately
A client returns from abdominal surgery with a patient-controlled anesthesia (PCA) pump. The client's spouse questions the need for so much medication. Which of the following is the nurse's best response?
The PCA pump will help relieve pain so ambulation and cough and deep breathing exercises are tolerated.' Principle: Provide patient controlled analgesia to help reduce complicatons related to pain
Insert foley catheter. Position client by using log-roll technique. Principle: Prevent dislodgement of intracavitary low dose radiation by maintaining the client on bedrest, in a private room, provide low-residue foods, give antidiarrheal agents to prevent bowel movements, log-roll to prevent dislodgement of device, and insert a foley
The client is receiving intracavitary radiation. Which of the following nursing interventions will help prevent dislodgement of the implant? Select all that apply.
The laboratory calls the nurse to report an older adult male client's white blood cell count is 900/mm3. Which of the following teaching points is most important for the nurse to tell this client? Select all that apply.
Use an electric razor for shaving. Avoid large crowds in public places. Principle: Reduce the risk for infection by implementing neutropenic precautions (WBC less than 1,000/mm3), avoiding rectal or vaginal procedures, using electric razors, avoid using stagnant water, and reduce exposure to sources of infection
The nurse is caring for a client with a fever, sore throat and swollen cervical lymph nodes. The complete blood count shows a normal neutrophil count and an elevated lymphocyte count. Which of the following microorganisms is the most likely etiology for the client's symptoms?
Virus Principle: An increase in neutrophils indicates a bacterial infection while an increase in lymphoctyes indicate a viral infection (although lymphocytes are also elevated in some bacterial infections as well)
A client with human immunodeficiency virus (HIV) has developed Kaposi sarcoma. The nurse recognizes this complication is increased due to which causative factor?
Weakened immune system. Principle: Cancer develops when the immune system fails to recognize and destroy abnormal cells
When caring for a client who underwent bone marrow transplantation, the nurse knows that the client is at risk for which early major complication? Select all that apply.
hemmorage Sepsis and bleeding are major complications following bone marrow transplantation until new marrrow engraftment occurs