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1

The nurse understands that the type of precautions needed for children receiving chemotherapy is based on which actions of chemotherapeutic agents?

a. Gastrointestinal upset
b. Bone marrow suppression
c. Decreased creatinine level
d. Alopecia


ANS: B

Bone marrow suppression

Chemotherapy agents cause bone marrow suppression, which creates the need to institute precautions related to reduced white blood cell, red blood cell, and platelet counts. These precautions focus on preventing infection and bleeding.

2

Children with non-Hodgkin lymphoma are at risk for complications resulting from tumor lysis syndrome (TLS). The nurse should assess for

a.Liver failure
b.CNS deficit
c.Kidney failure
d.Respiratory distress

ANS: C

Kidney failure

In TLS, the tumor’s intracellular contents are dumped into the child’s extracellular fluid as the tumor cells are lysed in response to chemotherapy. Because of the large volume of these cells, their intracellular electrolytes overload the kidneys and, if not monitored, can cause kidney failure.

3

What should the nurse teach parents about oral hygiene for the child receiving chemotherapy?

a. Brush the teeth briskly to remove bacteria.
b. Use a mouthwash that contains alcohol.
c. Inspect the child’s mouth daily for ulcers.
d. Perform oral hygiene twice a day.

ANS: C

Inspect the child’s mouth daily for ulcers.

4

The public health nurse is planning a program to decrease the incidence of meningitis in adolescents and young adults. Which action is most important?

a. Encourage adolescents and young adults to avoid crowds in the winter.

b. Vaccinate 11- and 12-year-old children against Haemophilus influenza.

c. Immunize adolescents and college freshman against Neisseria meningitides.

d. Emphasize the importance of hand washing to prevent the spread of infection.

ANS: C

Immunize adolescents and college freshman against Neisseria meningitides.

5

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?

a. The bedrails at the head and foot of the bed are both elevated.

b. The patient receives a regular diet from the dietary department.
c. The lights in the patient’s room are turned off and the blinds are shut.

d. Unlicensed assistive personnel enter the patient’s room without a mask.

ANS: D

Unlicensed assistive personnel enter the patient’s room without a mask.

Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.

6

A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order for collaborative intervention should the nurse implement first?

a. Administer ceftizoxime (Cefizox) 1 g IV.
b. Give acetaminophen (Tylenol) 650 mg PO.
c. Use a cooling blanket to lower temperature.
d. Swab the nasopharyngeal mucosa for cultures.

ANS: D

Swab the nasopharyngeal mucosa for cultures.

Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.

7

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question?

a. Elevate the head of the bed 20 degrees.

b. Restrict oral fluids to 1000 mL daily.

c. Administer ceftriaxone (Rocephin) 1 g IV every 12 hours.

d. Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.

ANS: B

Restrict oral fluids to 1000 mL daily.

The patient with meningitis has increased fluid needs, so oral fluids should be encouraged. The other actions are appropriate. Slight elevation of the head of the bed will decrease headache without causing leakage of cerebrospinal fluid from the lumbar puncture site. Antibiotics should be administered until bacterial meningitis is ruled out by the cerebrospinal fluid analysis.

8

When the nurse is administering a vesicant chemotherapeutic agent intravenously, an important consideration is to

a. infuse the medication over a short period of time.

b. stop the infusion if swelling is observed at the site.

c. administer the chemotherapy through small-bore catheter.

d. hold the medication unless a central venous line is available.

b. stop the infusion if swelling is observed at the site.

9

The nurse should base a response to a parent’s question about the prognosis of acute lymphoblastic leukemia (ALL) on the knowledge that

a. Leukemia is a fatal disease, although chemotherapy provides increasingly longer periods of remission.

b. Research to find a cure for childhood cancers is very active.

c. The majority of children go into remission and remain symptom free when treatment is completed.

d. t usually takes several months of chemotherapy to achieve a remission.

c. The majority of children go into remission and remain symptom free when treatment is completed.

10

Which client does the nurse encourage to seek genetic counseling regarding her risk for BRCA1 or BCRA2 gene mutation–related breast cancer?

a. Woman whose father had lung cancer and mother had leukemia

b. Woman whose sister has breast cancer and mother has ovarian cancer

c. Woman whose fraternal twin sister has breast cancer

d. Older woman who has bilateral benign breast disease

b. Woman whose sister has breast cancer and mother has ovarian cancer

11

When teaching the patient who is receiving standard multidrug therapy for tuberculosis (TB) about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops

a. yellow-tinged skin.
b. changes in hearing.
c. orange-colored sputum.
d. thickening of the fingernails.

a. yellow-tinged skin.

12

A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102° F (38.9° C), and severe back pain. Which physician order will the nurse implement first?

a. Administer morphine sulfate 4 mg IV.

b. Give acetaminophen (Tylenol) 650 mg.

c. Infuse normal saline 500 mL over 30 minutes.

d. Schedule complete blood count and coagulation studies.

c. Infuse normal saline 500 mL over 30 minutes.

13

A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102° F (38.9° C), and severe back pain. Which physician order will the nurse implement first?

a. Administer morphine sulfate 4 mg IV.

b. Give acetaminophen (Tylenol) 650 mg.

c. Infuse normal saline 500 mL over 30 minutes.

d. Schedule complete blood count and coagulation studies.

c. Infuse normal saline 500 mL over 30 minutes.

14

A client has advanced breast cancer and bone metastasis. Which problem does the nurse consider the priority?

a. Pain
b. Mobility problems
c. Risk for infection
d. Malnutrition

a. Pain

15

A client is experiencing lymphedema in the arm on the operative side after a modified radical mastectomy. Which statement indicates correct understanding of managing this problem?

a. “I will reduce my intake of salt and water.”
b. “I will elevate my arm on a pillow at night.”
c. “I will try to drink at least 3 liters of water each day.”
d. “I will wear long sleeves to prevent sun exposure.”

b. “I will elevate my arm on a pillow at night.”

16

The nurse is assigned to work with a new nursing assistant. Which action by the nursing assistant requires intervention by the registered nurse?

a. Using an alcohol-based hand rub after caring for a client with diarrhea

b. Washing hands for 20 seconds using warm water and friction

c. Cleaning especially carefully under fingernails and around a wedding band

d. Using chlorhexidine for handwashing when caring for clients on neutropenic precautions

a. Using an alcohol-based hand rub after caring for a client with diarrhea

17

The nurse is caring for a client with a large leg wound that has been slow to heal. Which action by the nurse is most appropriate?

a. Use Contact Precautions when caring for the client.
b. Double-glove when providing wound care.
c. Help the client choose high-protein items at meals.
d. Assess the client’s knowledge of causative factors.

c. Help the client choose high-protein items at meals.

18

A client is being treated at home for vancomycin-resistantEnterococcus (VRE). The client and the family are worried about spreading the infection. Which action by the nurse is best?

a. Instruct the client to use a separate bathroom.

b. Encourage the family to stay 3 feet away from the client.

c. Tell the client to cough into tissues and dispose of them immediately.

d. Teach the family ways to increase their immune system functioning.

a. Instruct the client to use a separate bathroom.

19

A client is receiving a chemotherapeutic agent intravenously through a peripheral line. What is the nurse’s first action when the client reports burning at the site?

a. Check for a blood return.
b. Slow the rate of infusion.
c. Discontinue the infusion.
d. Apply a cold compress.

c. Discontinue the infusion.

20

A client is on chemotherapy and has a platelet count of 25,000. Which intervention is most important to teach this client?

a. “Eat a low-bacteria diet.”
b. “Take your temperature daily.”
c. “Use a soft-bristled toothbrush.”
d. “Avoid alcohol-based mouthwashes.”

c. “Use a soft-bristled toothbrush.”

21

A client is hospitalized for chemotherapy. The registered nurse intervenes when observing which action by the nursing assistant?

a. Allowing the client to rest instead of making him or her perform oral hygiene

b. Helping the client wash the groin and axillary areas every 12 hours

c. Cutting food and opening food packages when the client’s meal tray arrives

d. Reminding the client to use the incentive spirometer every hour while awake

a. Allowing the client to rest instead of making him or her perform oral hygiene

22

The nurse teaches a client with superior vena cava syndrome that improvement is characterized by which clinical manifestation?

a. The client’s hands are less swollen.
b. Breath sounds are clear bilaterally.
c. The client’s back pain is relieved.
d. Pedal edema is present.

a.
The client’s hands are less swollen.

23

A client has late-stage colon cancer with metastasis to the spine and bones. Which nursing intervention does the nurse add to the care plan to address a priority problem?

a. Provide six small meals and snacks daily.
b. Offer the client prune juice twice a day.
c. Ensure that the client gets adequate rest.
d. Give the client pain medications around the clock.

d. Give the client pain medications around the clock.

24

The nurse monitors for which acid-base problem in a client who is taking furosemide (Lasix) for hypertension?

a. Acid excess secondary to respiratory acidosis
b. Acid deficit secondary to respiratory alkalosis
c. Acid excess secondary to metabolic acidosis
d. Acid deficit secondary to metabolic alkalosis

ANS: D

d. Acid deficit secondary to metabolic alkalosis

Many diuretics, especially loop diuretics, increase the excretion of hydrogen ions, leading to excess acid loss through the renal system. This situation is an acid deficit of metabolic origin.

25

The hand grasps of a client with acidosis have diminished since the previous assessment 1 hour ago. What action does the nurse take next?

a. Assess client’s rate, rhythm, and depth of respiration.
b. Measure the client’s pulse and blood pressure.
c. Document findings and continue to monitor.
d. Notify the physician as soon as possible.

a. Assess client’s rate, rhythm, and depth of respiration.

Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle weakness can lead to severe respiratory insufficiency. Acidosis does lead to dysrhythmias (due to hyperkalemia) but these would best be assessed with cardiac monitoring. Findings should be documented, but simply continuing to monitor is not sufficient. Before notifying the physician, the nurse needs to have more data to report.

26

The nurse interprets which arterial blood gas values as partially compensated metabolic acidosis?

a. pH 7.28, HCO3– 19 mEq/L, PCO2 45 mm Hg, PO2 96 mm Hg

b. pH 7.45, HCO3– 22 mEq/L, PCO2 40 mm Hg, PO2 98 mm Hg

c. pH 7.32, HCO3– 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg

d. pH 7.48, HCO3– 28 mEq/L, PCO2 45 mm Hg, PO2 92 mm Hg

c. pH 7.32, HCO3– 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg

27

The nurse assesses the client with which condition most carefully for the risk of developing acute respiratory acidosis?

a. Allergic rhinitis and sinusitis on sulfa antibiotics

b. Type 1 diabetes and urinary tract infection

c. Emphysema and undergoing nasogastric (NG) tube suctioning

d. On patient-controlled analgesia after abdominal surgery

ANS: D

d. On patient-controlled analgesia after abdominal surgery

Respiratory acidosis often occurs as the result of underventilation. The client who is taking narcotics, especially IV narcotics, is at risk for respiratory depression. The client may also be breathing more shallowly than usual to prevent pain. This gives the client two risk factors for developing hypoventilation and subsequent respiratory acidosis. None of the other clients are at risk for ineffective ventilation.

28

The nurse correlates which condition with the following arterial blood gas values: pH 7.48, HCO3– 22 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg?

a. Diarrhea and vomiting for 36 hours
b. Anxiety-induced hyperventilation
c. Chronic obstructive pulmonary disease
d. Diabetic ketoacidosis and emphysema

ANS: B

b. Anxiety-induced hyperventilation

The elevated pH indicates alkalosis. The bicarbonate level is normal, and so is the oxygen partial pressure. Loss of carbon dioxide is the cause of the alkalosis, which would occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic alterations, COPD would lead to respiratory acidosis, and the person with emphysema most likely would have combined metabolic acidosis on top of a mild, chronic respiratory acidosis.

29

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

a. “Benign tumors do not cause damage to other tissues.”

b. “Benign tumors are likely to recur in the same location.”

c. “Malignant tumors may spread to other tissues or organs.”

d. “Malignant cells reproduce more rapidly than normal cells.”

ANS: C

c. “Malignant tumors may spread to other tissues or organs.”

The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors do not metastasize. The other statements are inaccurate. Both types of tumors may cause damage to adjacent tissues. Malignant cells do not reproduce more rapidly than normal cells. Benign tumors do not usually recur.

30

The nurse is caring for a patient who smokes two packs/day. Which action by the nurse could help reduce the patient’s risk of lung cancer?

a. Teach the patient about the seven warning signs of cancer.

b. Plan to monitor the patient’s carcinoembryonic antigen (CEA) level.

c. Teach the patient about annual chest x-rays for lung cancer screening.

d. Discuss risks associated with cigarette smoking during each patient encounter.

ANS: D

d. Discuss risks associated with cigarette smoking during each patient encounter.

Teaching about the risks associated with cigarette smoking is recommended at every patient encounter because cigarette smoking is associated with multiple health problems. The other options may detect lung cancer that is already present but do not reduce the risk.


31

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

a. Fruit salad
c. Creamed broccoli
b. Baked chicken
d. Toasted wheat bread

b. Baked chicken

Protein is needed for wound healing. To minimize the diarrhea that is commonly associated with bowel radiation, the patient should avoid foods high in roughage, such as fruits and whole grains. Lactose intolerance may develop secondary to radiation, so dairy products should also be avoided.

32

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

a. Obtain more information about the family history.

b. Schedule a sigmoidoscopy to provide baseline data.

c. Teach the patient about the need for a colonoscopy at age 50.

d. Teach the patient how to do home testing for fecal occult blood.

ANS: A

a. Obtain more information about the family history.

The patient may be at increased risk for colon cancer, but the nurse’s first action should be further assessment. The other actions may be appropriate, depending on the information that is obtained from the patient with further questioning.

33

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

a. “The cancer involves only the cervix.”

b. “The cancer cells look like normal cells.”

c. “Further testing is needed to determine the spread of the cancer.”

d. “It is difficult to determine the original site of the cervical cancer.”

ANS: A

a. “The cancer involves only the cervix.”

Cancer in situ indicates that the cancer is localized to the cervix and is not invasive at this time. Cell differentiation is not indicated by clinical staging. Because the cancer is in situ, the origin is the cervix. Further testing is not indicated given that the cancer has not spread.

34

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?

a. “The biopsy will remove the cancer in my prostate gland.”

b. “The biopsy will determine how much longer I have to live.”

c. “The biopsy will help decide the treatment for my enlarged prostate.”

d. “The biopsy will indicate whether the cancer has spread to other organs.”



ANS: C

c. “The biopsy will help decide the treatment for my enlarged prostate.”

A biopsy is used to determine whether the prostate enlargement is benign or malignant and determines the type of treatment that will be needed. A biopsy does not give information about metastasis, life expectancy, or the impact of cancer on the patient’s life.

35

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?

a. “After cancer has not recurred for 5 years, it is considered cured.”

b. “The cancer will be cured if the entire tumor is surgically removed.”

c. “I will need follow-up examinations for many years after treatment before I can be considered cured.”

d. “Cancer is never cured, but the tumor can be controlled with surgery, chemotherapy, and radiation.”



ANS: C

c. “I will need follow-up examinations for many years after treatment before I can be considered cured.”

The risk of recurrence varies by the type of cancer. Some cancers are considered cured after a shorter time span or after surgery, but stage III breast cancer will require additional therapies and ongoing follow-up.

36

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?

a.Test all stools for the presence of blood.

b.Maintain a high-residue, high-fiber diet.

c.Clean the perianal area carefully after every bowel movement.

d.Inspect the mouth and throat daily for the appearance of thrush.




ANS: C

c. Clean the perianal area carefully after every bowel movement.

Radiation to the abdomen will affect organs in the radiation path, such as the bowel, and cause frequent diarrhea. Careful cleaning of this area will help decrease the risk for skin breakdown and infection. Stools are likely to have occult blood from the inflammation associated with radiation, so routine testing of stools for blood is not indicated. Radiation to the abdomen will not cause stomatitis. A low-residue diet is recommended to avoid irritation of the bowel when patients receive abdominal radiation.

37

A patient with Hodgkin’s 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?

a.Minimize activity until the treatment is completed.

b.Establish time to take a short walk almost every day.

c.Consult with a psychiatrist for treatment of depression.

d.Arrange for delivery of a hospital bed to the patient’s home.



ANS: B

b. Establish time to take a short walk almost every day.

Walking programs are used to keep the patient active without excessive fatigue. Having a hospital bed does not necessarily address the fatigue. The better option is to stay as active as possible while combating fatigue. Fatigue is expected during treatment and is not an indication of depression. Minimizing activity may lead to weakness and other complications of immobility.

38

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?

a.The patient has a history of dental caries.

b.The patient swims several days each week.

c.The patient snacks frequently during the day.

d.The patient showers each day with mild soap.



ANS: B

b. The patient swims several days each week.

The patient is instructed to avoid swimming in salt water or chlorinated pools during the treatment period. The patient does not need to change habits of eating frequently or showering with a mild soap. A history of dental caries will not impact the patient who is scheduled for abdominal radiation.

39

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

a.“I can use ice packs to relieve itching.”

b.“I will scrub the area with warm water.”

c.“I can buy aloe vera gel to use on my skin.”

d.“I will expose my skin to a sun lamp each day.”

ANS: C

c. “I can buy aloe vera gel to use on my skin.”

Aloe vera gel and cream may be used on the radiated skin area. Ice and sun lamps may injure the skin. Treatment areas should be cleaned gently to avoid further injury.

40

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

a.Have the patient eat large meals when nausea is not present.

b.Offer dry crackers and carbonated fluids during chemotherapy.

c.Administer prescribed antiemetics 1 hour before the treatments.

d Give the patient a glass of a citrus fruit beverage during treatments.

ANS: C

c. Administer prescribed antiemetics 1 hour before the treatments.

Treatment with antiemetics before chemotherapy may help prevent nausea. The patient should eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea. The acidity of citrus fruits may be further irritating to the stomach.

41

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

a.Infuse the medication over a short period of time.

b.Stop the infusion if swelling is observed at the site.

c.Administer the chemotherapy through a small-bore catheter.

d.Hold the medication unless a central venous line is available.

ANS: B

b. Stop the infusion if swelling is observed at the site.

Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication generally should be given slowly to avoid irritation of the vein. The size of the catheter is not as important as administration of vesicants into a running IV line to allow dilution of the chemotherapy drug. These medications can be given through peripheral lines, although central vascular access devices are preferred.

42

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

a.Encourage the patient to purchase a wig or hat to wear when hair loss begins.

b.Suggest that the patient limit social contacts until regrowth of the hair occurs.

c.Teach the patient to wash hair gently with mild shampoo to minimize hair loss.

d.Inform the patient that hair usually grows back once chemotherapy is complete.

ANS: A

a. Encourage the patient to purchase a wig or hat to wear when hair loss begins.

The patient is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats. Limiting social contacts is not appropriate at a time when the patient is likely to need a good social support system. The damage occurs at the hair follicles and will occur regardless of gentle washing or use of a mild shampoo. The information that the hair will grow back is not immediately helpful in maintaining the patient’s self-esteem.

43

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?

a.Offer the patient frequent small snacks between meals.

b.Assist the patient to choose favorite foods from the menu.

c.Provide teaching about the importance of nutritional intake.

d.Apply prescribed anesthetic gel to oral lesions before meals.

ANS: D

d. Apply prescribed anesthetic gel to oral lesions before meals.

Because the etiology of the patient’s poor nutrition is the painful oral ulcers, the best intervention is to apply anesthetic gel to the lesions before the patient eats. The other actions might be helpful for other patients with impaired nutrition but would not be as helpful for this patient.

44

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

a.“I have frequent muscle aches and pains.”

b.“I rarely have the energy to get out of bed.”

c.“I experience chills after I inject the interferon.”

d.“I take acetaminophen (Tylenol) every 4 hours.”

ANS: B

b. I rarely have the energy to get out of bed.”

Fatigue can be a dose-limiting toxicity for use of immunotherapy. Flulike symptoms, such as muscle aches and chills, are common side effects with interferon use. Patients are advised to use acetaminophen every 4 hours.

45

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

a.Donor bone marrow is transplanted through a sternal or hip incision.

b.Hospitalization is required for several weeks after the stem cell transplant.

c.The transplant procedure takes place in a sterile operating room to minimize the risk for infection.

d.Transplant of the donated cells can be very painful because of the nerves in the tissue lining the bone.

ANS: B

b. Hospitalization is required for several weeks after the stem cell transplant.

The patient requires strict protective isolation to prevent infection for 2 to 4 weeks after HSCT while waiting for the transplanted marrow to start producing cells. The transplanted cells are infused through an IV line so the transplant is not painful, nor is an operating room or incision required.

46

A patient with cancer has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which nursing action would address the cause of the patient problem?

a.Add protein powder to foods such as casseroles.

b.Tell the patient to eat foods that are high in nutrition.

c.Avoid giving the patient foods that are strongly disliked.

d.Add spices to enhance the flavor of foods that are served.

ANS: C

c. Avoid giving the patient foods that are strongly disliked.

47

During the teaching session for a patient who has a new diagnosis of acute leukemia, the patient is restless and looks away without making eye contact. The patient asks the nurse to repeat the information about the complications associated with chemotherapy. Based on this assessment, which nursing diagnosis is appropriate for the patient?

a.Risk for ineffective adherence to treatment related to denial of need for chemotherapy

b.Acute confusion related to infiltration of leukemia cells into the central nervous system

c.Deficient knowledge: chemotherapy related to a lack of interest in learning about treatment

d.Risk for ineffective health maintenance related to possible anxiety about leukemia diagnosis

ANS: D

d. Risk for ineffective health maintenance related to possible anxiety about leukemia diagnosis

48

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

a. The patient ambulates around the room.

b. The patient’s visitors bring in fresh peaches.

c. The patient cleans with a warm washcloth after having a stool.

d. The patient uses soap and shampoo to shower every other day.

ANS: B

b. The patient’s visitors bring in fresh peaches.

Fresh, thinned-skin fruits are not permitted in a neutropenic diet because of the risk of bacteria being present. The patient should ambulate in the room rather than the hospital hallway to avoid exposure to other patients or visitors. Because overuse of soap can dry the skin and increase infection risk, showering every other day is acceptable

49

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

a. “How long ago were you diagnosed with this cancer?”

b. “Do you have any concerns about body image changes?”

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

d. “Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon?”

ANS: C

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

Information about how the patient has coped with past stressful situations helps the nurse determine usual coping mechanisms and their effectiveness. The length of time since the diagnosis will not provide much information about the patient’s need for support. The patient’s knowledge of typical stages in adjustment to a critical diagnosis does not provide insight into patient needs for assistance. Because surgical interventions for stage I cancer

50

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

a. Generalized muscle aches
b. Crackles heard at the lung bases
c. Complaints of nausea and anorexia
d. Oral temperature of 100.6° F (38.1° C)

ANS: B

b. Crackles heard at the lung bases

Capillary leak syndrome and acute pulmonary edema are possible toxic effects of interleukin-2. The patient may need oxygen and the nurse should rapidly notify the health care provider. The other findings are common side effects of interleukin-2.

51

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 cancer therapy with the health care provider?

a. Frequent loose stools
b. Nausea and vomiting
c. Elevated white blood count (WBC)
d. Increased carcinoembryonic antigen (CEA)

ANS: D

d. Increased carcinoembryonic antigen (CEA)

An increase in CEA indicates that the chemotherapy is not effective for the patient’s cancer and may need to be modified. Gastrointestinal adverse effects are common with chemotherapy. The nurse may need to address these, but they would not necessarily indicate a need for a change in therapy. An elevated WBC may indicate infection but

52

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?

a. Hematocrit 30%
b. Platelets 95,000/µL
c. Hemoglobin 10 g/L
d. White blood cells (WBC) 2700/µL

ANS: D

d. White blood cells (WBC) 2700/µL

The low WBC count places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that WBC growth factors such as filgrastim (Neupogen) are needed. Although the other laboratory data indicate decreased levels, they do not indicate any immediate life-threatening adverse effects of the chemotherapy. Hematocrit 38.8-50% M/34.9-44.5% F, Platelets 150,000 to 450,000/µL, Hemoglobin 14-18 g/dL M/12-16 g/dL F, White blood cells (WBC) 4,500 to 11,000/µL

53

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

a. The UAP assists the patient to use dental floss after eating.

b. The UAP adds baking soda to the patient’s saline oral rinses.

c. The UAP puts fluoride toothpaste on the patient’s toothbrush.

d. The UAP has the patient rinse after meals with a saline solution.

ANS: A

a. The UAP assists the patient to use dental floss after eating.

Use of dental floss is avoided in patients with pancytopenia because of the risk for infection and bleeding. The other actions are appropriate for oral care of a pancytopenic patient.

54

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?

a. The UAP flushes the toilet once after emptying the patient’s bedpan.

b. The UAP stands by the patient’s bed for 30 minutes talking with the patient.

c. The UAP places the patient’s bedding in the laundry container in the hallway.

d. The UAP gives the patient an alcohol-containing mouthwash to use for oral care.

ANS: B

b. The UAP stands by the patient’s bed for 30 minutes talking with the patient.

Because patients with temporary implants emit radioactivity while the implants are in place, exposure to the patient is limited. Laundry and urine and feces do not have any radioactivity and do not require special precautions. Cervical radiation will not affect the oral mucosa, and alcohol-based mouthwash is not contraindicated

55

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

a. A 35-yr-old patient who has wet desquamation associated with abdominal radiation

b. A 42-yr-old patient who is sobbing after receiving a new diagnosis of ovarian cancer

c. A 24-yr-old patient who received neck radiation and has blood oozing from the neck

d. A 56-yr-old patient who developed a new pericardial friction rub after chest radiation

ANS: C

c. A 24-yr-old patient who received neck radiation and has blood oozing from the neck

Because neck bleeding may indicate possible carotid artery rupture in a patient who is receiving radiation to the neck, this patient should be seen first. The diagnoses and clinical manifestations for the other patients are not immediately life threatening.

56

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

a.Teach the patient to rest the brain by avoiding new activities.
b.Teach that “chemo-brain” is a short-term effect of chemotherapy.
c.Report patient symptoms immediately to the health care provider.
d.Suggest use of a daily planner and encourage adequate rest and sleep.

ANS: D

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

Use of tools to enhance memory and concentration such as a daily planner and adequate rest are helpful for patients who develop “chemo-brain” while receiving chemotherapy. Patients should be encouraged to exercise the brain through new activities. Chemo-brain may be short or long term. There is no urgent need to report common chemotherapy side effects to the provider

57

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

a. Shortness of breath
b. Shivering and chills
c. Muscle aches and pains
d. Temperature of 100.2° F (37.9° C)

ANS: A

a. Shortness of breath

Rituximab (Rituxan) is a monoclonal antibody. Shortness of breath should be investigated rapidly because anaphylaxis is a possible reaction to monoclonal antibody administration. The nurse will need to rapidly take actions such as

58

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

a. Patient complains of severe fatigue.
b. Patient voids every hour during the day.
c. Patient takes only 50% of meals and refuses snacks.
d. Patient has crackles up to the midline posterior chest.

ANS: D

d. Patient has crackles up to the midline posterior chest.

Rapid fluid infusions may cause heart failure, especially in older patients. The other findings are common in patients who have cancer or are receiving chemotherapy.

59

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

a. Patient who has a platelet count of 82,000/µL after chemotherapy

b. Patient who has xerostomia after receiving head and neck radiation

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

d. Patient who is worried about getting the prescribed long-acting opioid on time

ANS: C

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

Temperature elevation is an emergency in neutropenic patients because of the risk for rapid progression to severe infections and sepsis. The other patients also require assessments or interventions but do not need to be assessed as urgently. Patients with thrombocytopenia do not have spontaneous bleeding until the platelets are 20,000/µL. Xerostomia does not require immediate intervention. Although breakthrough pain needs to be addressed rapidly

60

The nurse at the clinic is interviewing a 64-yr-old woman who is 5 feet, 3 inches tall and weighs 125 lb (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 two or three 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)?

a. Pap testing
b. Tobacco use
c. Sunscreen use
d. Mammography
e. Colorectal screening

ANS: A, C, D, E

a. Pap testing
c. Sunscreen use
d. Mammography
e. Colorectal screening

The patient’s age, gender, and history indicate a need for screening and teaching about colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use tobacco or excessive alcohol, she is physically active, and her body weight is healthy

61

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)?

a. Cook food thoroughly before eating.
b. Choose low fiber, low residue foods.
c. Avoid public transportation such as buses.
d. Use rectal suppositories if needed for constipation.
e. Talk to the oncologist before having any dental work.

ANS: A, C, E

a. Cook food thoroughly before eating.
c. Avoid public transportation such as buses.
e. Talk to the oncologist before having any dental work

Eating only cooked food and avoiding public transportation will decrease infection risk. A high-fiber diet is recommended for neutropenic patients to decrease constipation. Because bacteria may enter the circulation during dental work or oral surgery, the patient may need to postpone dental work or take antibiotics.

62

Which comment made by a client with breast cancer indicates a need for clarification regarding cancer causes and prevention?

a.“I will eat a low-fat, high-fiber diet from now on.”

b.“Probably nothing I did or didn’t do caused this cancer.”

c.“I hope my daughter doesn’t develop breast cancer.”

d.“Regular mammograms on my other breast will prevent cancer.”

ANS: D

d. “Regular mammograms on my other breast will prevent cancer.”

Regular mammography can help detect breast cancer at an early stage, but it does not prevent breast cancer. For the most part, the specific cause of many cancers is unknown. Some associations have been noted with dietary habits. High fat, low fiber, high intake of red meat, and eating food with preservatives and other additives all have been suspected to contribute to carcinogenesis

63

The nurse counsels a woman who has a BRCA1 gene that she has what chance for developing breast cancer during her lifetime?

a. None; this gene has a protective effect
b. Same as the general population
c. Lower than the general population
d. Higher than the general population

ANS: D

d. Higher than the general population

BRAC1 is a genetic mutation that increases risk for both breast and ovarian cancer.

64

A client has colorectal cancer. Which activities are especially important for the nurse to conduct for this client? (Select all that apply.)

a. Monitor liver function studies.
b. Maintain accurate intake and output.
c. Obtain daily weight using the same scale.
d. Palpate lymph nodes at each clinic visit.
e. Ask the client about changes in belly size.

ANS: A, D, E

a. Monitor liver function studies.
d. Palpate lymph nodes at each clinic visit.
e. Ask the client about changes in belly size.

Common sites of metastasis for colorectal cancer include the liver, lymph nodes, and adjacent structures such as the abdominal cavity. Intake and output and daily weights would not provide data related to possible metastases.

65

A client who has just had a mastectomy is crying. When the nurse asks about her crying, the client responds, “I know I shouldn’t cry because this surgery may well save my life.” What is the nurse’s best response?

a. “It is all right to cry. Mourning this loss will help make you stronger.”

b. “I know this is hard, but your chances of survival are better now.”

c. “I can arrange for someone who had a mastectomy to come visit if you like.”

d. “How have you coped with difficult situations in the past?”

ANS: C

c. “I can arrange for someone who had a mastectomy to come visit if you like.”

Often, cancer surgery involves the loss of a body part or a decrease in function. Mourning or grieving for a body image alteration is a healthy part of adapting or adjusting to a new image. Visiting with someone who has experienced the same situation as the client is very helpful in showing the client that many aspects of life can be the same afterward

66

A client scheduled to undergo radiation therapy for breast cancer asks why 6 weeks of daily treatment is necessary. What is the nurse’s best response?

a. “Your cancer is widespread and requires more than the usual amount of radiation treatment.”

b. “Giving larger doses of radiation for a shorter period of time does not produce better effects and has worse side effects.”

c. “Research has shown that more cancer cells are killed if radiation is given in smaller doses over a longer time period.”

d. “It is less likely that your hair will fall out or that you will become anemic if radiation is given in this manner.”

ANS: C

c. “Research has shown that more cancer cells are killed if radiation is given in smaller doses over a longer time period.”

Because of varying responses of all cancer cells within a given tumor, small doses of radiation are given on a daily basis for a set period of time. This method allows multiple opportunities to destroy cancer cells while minimizing damage to normal tissues.

67

A client is receiving interleukin-2 (IL-2) for cancer. Which drug is the nurse prepared to administer if needed?

a. Lorazepam (Ativan)
b. Meperidine (Demerol)
c. Furosemide (Lasix)
d. Epoetin alfa (Epogen)

ANS: B

b. Meperidine (Demerol)

Clients receiving IL-2 therapy usually experience chills, fever, and rigors during the infusion, especially the first time that they receive the drug. These reactions are a normal response to the administration of biological response modifiers such as IL-2. Clients are treated symptomatically for the discomfort. Demerol is used to treat the chills and rigor. The other medications would not treat a side effect of IL-2 therapy.

68

A client has late-stage colon cancer with metastasis to the spine and bones. Which nursing intervention does the nurse add to the care plan to address a priority problem?

a.Provide six small meals and snacks daily.
b. Offer the client prune juice twice a day.
c.Ensure that the client gets adequate rest.
d. Give the client pain medications around the clock.

ANS: D

d. Give the client pain medications around the clock.

Although all interventions might be appropriate, a client with late-stage cancer and bone metastases is at risk for severe pain. Giving the client pain medication around the clock is the best way to manage this type of pain.

69

A patient preparing to undergo a colon resection for cancer of the colon asks about the elevated carcinoembryonic antigen (CEA) test result. The nurse explains that the test is used to

a. identify any metastasis of the cancer.
b. monitor the tumor status after surgery.
c. confirm the diagnosis of a specific type of cancer.
d. determine the need for postoperative chemotherapy.

ANS: B

b. monitor the tumor status after surgery.

CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help to determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made on the basis of biopsy. Chemotherapy use is based on factors other than CEA.

70

A patient preparing to undergo a colon resection for cancer of the colon asks about the elevated carcinoembryonic antigen (CEA) test result. The nurse explains that the test is used to

a. identify any metastasis of the cancer.
b. monitor the tumor status after surgery.
c. confirm the diagnosis of a specific type of cancer.
d. determine the need for postoperative chemotherapy.

ANS: B

b. monitor the tumor status after surgery.

CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help to determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made on the basis of biopsy. Chemotherapy use is based on factors other than CEA.

71

A 71-yr-old patient had an abdominal-perineal resection for colon cancer. Which nursing action is most important to include in the plan of care for the day after surgery?
a. Teach about a low-residue diet.
b. Monitor output from the stoma.
c. Assess the perineal drainage and incision.
d. Encourage acceptance of the colostomy stoma.

ANS: C

c. Assess the perineal drainage and incision.

Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound. Teaching about diet is best done closer to discharge from the hospital. There will be very little drainage into the colostomy until peristalsis returns. The patient will be encouraged to assist with the colostomy, but this is not the highest priority in the immediate postoperative period

72

The nurse is screening clients at a health fair. Which client is at highest risk for the development of colon cancer?

a. Older white client with irritable bowel syndrome

b. Middle-aged African-American client who smokes cigars

c. Middle-aged Asian client who travels and eats out frequently

d. Older American Indian client taking hormone replacement therapy

ANS: B

b. Middle-aged African-American client who smokes cigars

Colon cancer is more prevalent among African Americans and smokers. Irritable bowel syndrome, travel, and hormone replacement therapy do not increase the risk for colon cancer.

73

The client is scheduled for a colonoscopy. Which statement indicates that the client needs additional teaching about the procedure?

a. “I may have gas and abdominal cramps after the test.”

b. “I will take strong laxatives the afternoon before the test.”

c. “I will take my Coumadin with a sip of water tomorrow morning.”

d. “I will take nothing by mouth after midnight on the day of the test.”

ANS: C

c. “I will take my Coumadin with a sip of water tomorrow morning.”

Blood thinners should not be taken before colonoscopy because bleeding may occur if polyps are removed. The client should stop taking warfarin (Coumadin) approximately 2 weeks before the colonoscopy. The other answers describe accurate complications of the colonoscopy and preparation for the procedure.

74

A client has a family history of colon cancer. Which laboratory tests are ordered to rule out colon cancer?

a. Cholesterol
b. Serum lipase
c. Carcinoembryonic antigen
d. Xylose absorption

ANS: C

c. Carcinoembryonic antigen

The carcinoembryonic antigen can indicate colorectal, stomach, or pancreatic cancer if elevated. Elevated cholesterol and serum lipase may indicate pancreatitis. Decreased xylose absorption may indicate malabsorption in the small intestine.

75

During a well-woman physical examination, a 43-yr-old patient asks about her risk for breast cancer. Which question is most pertinent for the nurse to ask?

a. “Do you currently smoke tobacco?”

b. “Have you ever had a breast injury?”

c. “At what age did you start having menstrual periods?”

d. “Is there a family history of fibrocystic breast changes?”

ANS: C

c. “At what age did you start having menstrual periods?”

Early menarche and late menopause are risk factors for breast cancer because of the prolonged exposure to estrogen that occurs. Cigarette smoking, breast trauma, and fibrocystic breast changes are not associated with increased breast cancer risk.

76

A 51-yr-old patient with a small immobile breast lump is considering having a fine-needle aspiration (FNA) biopsy. The nurse explains that an advantage to this procedure is that

a. FNA is done in the outpatient clinic, and results are available in 1 to 2 days.

b. only a small incision is needed, resulting in minimal breast pain and scarring.

c. if the biopsy results are negative, no further diagnostic testing will be needed.

d. FNA is guided by a mammogram, ensuring that cells are taken from the lesion.

ANS: A

a. FNA is done in the outpatient clinic, and results are available in 1 to 2 days.

FNA is done in outpatient settings, and results are available in 24 to 48 hours. No incision is needed. FNA may be guided by ultrasound but not by mammogram. Because the immobility of the breast lump suggests cancer, further testing will be done if the FNA results are negative.

77

A 53-yr-old woman who is experiencing menopause is discussing the use of hormone therapy (HT) with the nurse. Which information about the risk of breast cancer will the nurse provide?

a. HT is a safe therapy for menopausal symptoms if there is no family history of BRCA genes.

b. HT does not appear to increase the risk for breast cancer unless there are other risk factors.

c. The patient and her health care provider must weigh the benefits of HT against the risks of breast cancer.

d. Natural herbs are as effective as estrogen in relieving symptoms without increasing the risk of breast cancer.

ANS: C

c. The patient and her health care provider must weigh the benefits of HT against the risks of breast cancer.


Because HT has been linked to increased risk for breast cancer, the patient and health care provider must determine whether or not to use HT. Breast cancer incidence is increased in women using HT, independent of other risk factors. HT increases the risk for both non–BRCA-associated cancer and BRCA-related cancers. Alternative therapies can be used but are not consistent in relieving menopausal symptoms.

78

A 58-yr-old woman tells the nurse, “I understand that I have stage II breast cancer and I need to decide on a surgery, but I feel overwhelmed. What do you think I should do?” Which response by the nurse is best?

a. “I would have a lumpectomy, but you need to decide what is best for you.”

b. “Tell me what you understand about the surgical options that are available.”

c. “It would not be appropriate for me to make a decision about your health.”

d. “There is no need to make a decision rapidly; you have time to think about this.”

ANS: B

b. “Tell me what you understand about the surgical options that are available.”

Inquiring about the patient’s understanding shows the nurse’s willingness to assist the patient with the decision-making process without imposing the nurse’s values or opinions. Treatment decisions for breast cancer do need to be made relatively quickly. Imposing the nurse’s opinions or showing an unwillingness to discuss the topic could cut off communication

79

The nurse will teach a patient with metastatic breast cancer who has a new prescription for trastuzumab (Herceptin) that

a. hot flashes may occur with the medication.
b. serum electrolyte levels will be drawn monthly.
c. the patient will need frequent eye examinations.
d. the patient should call if she notices ankle swelling.

ANS: D

d. the patient should call if she notices ankle swelling.

Trastuzumab can lead to ventricular dysfunction, so the patient is taught to self-monitor for symptoms of heart failure. There is no need to monitor serum electrolyte levels. Hot flashes or changes in visual acuity may occur with tamoxifen, but not with trastuzumab.

80

A patient newly diagnosed with stage I breast cancer is discussing treatment options with the nurse. Which statement by the patient indicates that additional teaching may be needed?

a. “There are several options that I can consider for treating the cancer.”

b. “I will probably need radiation to the breast after having the surgery.”

c. “Mastectomy is the best choice to decrease the chance of cancer recurrence.”

d. “I can probably have reconstructive surgery at the same time as a mastectomy.”

ANS: C

c. “Mastectomy is the best choice to decrease the chance of cancer recurrence.”

The survival rates with lumpectomy and radiation or modified radical mastectomy are comparable. The other patient statements indicate a good understanding of stage I breast cancer treatment.

81

A patient diagnosed with breast cancer asks the nurse what “triple negative” means. An accurate response from the nurse about triple-negative breast cancer should include that

a. the tumor is not likely to be responsive to hormone therapy.

b. HER-2 receptor testing was repeated for a total of three samples.

c. treatment with chemotherapy is not likely to be recommended.

d. estrogen receptor testing identified the three hormones causing the cancer.

ANS: A

a.
the tumor is not likely to be responsive to hormone therapy.

A patient whose breast cancer tests negative for all three receptors (estrogen, progesterone, and HER-2) has triple-negative breast cancer. These cancers do not usually respond to hormone therapy or therapy for the human epidermal growth factor receptor 2 (HER-2). Chemotherapy appears to have the most success in treating triple-negative breast cancer.

82

The nurse will anticipate teaching a patient who is diagnosed with lobular carcinoma in situ (LCIS) about

a. tamoxifen
c. lymphatic mapping.
b. lumpectomy.
d. MammaPrint testing.

ANS: A

a. tamoxifen

Tamoxifen is used as a chemopreventive therapy in some patients with LCIS. The other diagnostic tests and therapies are not needed because LCIS does not usually require treatment.

83

When the nurse is working in the women’s health care clinic, which action is appropriate to take?

a. Teach a healthy 30-yr-old patient about the need for an annual mammogram.

b. Discuss scheduling an annual clinical breast examination with a 22-year-old patient.

c. Explain to a 60-yr-old patient that mammography frequency can be reduced to every 3 years.

d. Teach a 28-yr-old patient with a BRCA-1 mutation about magnetic resonance imaging (MRI).

ANS: D

d. Teach a 28-yr-old patient with a BRCA-1 mutation about magnetic resonance imaging (MRI).

MRI (in addition to mammography) is recommended for women who are at high risk for breast cancer. A woman should have a clinical breast examination about every 3 years for women in their 20s and 30s and every year for women age 40 years and older. Annual mammograms are recommended for women older than 40 years of age

84

Which action will the nurse include in the plan of care for a patient with right arm lymphedema?

a. Avoid isometric exercise on the right arm.
b. Assist with application of a compression sleeve.
c. Keep the right arm at or below the level of the heart.
d. Check blood pressure (BP) on both right and left arms.

ANS: B

b. Assist with application of a compression sleeve.

Compression of the arm assists in improving lymphatic flow toward the heart. Isometric exercises may be prescribed for lymphedema. BPs should only be done on the patient’s left arm. The arm should not be placed in a dependent position.

85

The outpatient clinic receives telephone calls from four patients. Which patient should the nurse call back first?

a. A 57-yr-old patient with ductal ectasia who has sticky multicolored nipple discharge and severe nipple itching

b. A 21-yr-old patient with a family history of breast cancer who wants to discuss genetic testing for the BRCA gene

c. A 40-yr-old patient who still has left side chest and arm pain 2 months after a left modified radical mastectomy

d. A 50-yr-old patient with stage 2 breast cancer who is receiving doxorubicin and has ankle swelling and fatigue

ANS: D

d. A 50-yr-old patient with stage 2 breast cancer who is receiving doxorubicin and has ankle swelling and fatigue

Although all the patients have needs that the nurse should address, the patient who is receiving a cardiotoxic medication and has symptoms of heart failure should be assessed by the nurse first. BRCA testing may be appropriate for the 21-yr-old patient, but it does not need to be done immediately. Chest and arm pain are normal up to 3 months after mastectomy. Nipple discharge and itching is a common finding with ductal ectasia.

86

A client recently had a mammogram. Which statement by the client indicates a need for clarification regarding the importance or purpose of this procedure?

a. “Now that I have had a mammogram, my risk for getting breast cancer is reduced.”

b. “I will still do a breast self-examination monthly even after the mammogram.”

c. “Yearly mammograms can reduce my risk of dying from breast cancer.”

d. “The amount of radiation exposure from a mammogram is very low.”

ANS: A

a. “Now that I have had a mammogram, my risk for getting breast cancer is reduced.”

Regular or yearly mammography does not decrease the incidence of breast cancer. It only assists in early detection and diagnosis and decreases the mortality rate from breast cancer. The client should be instructed that the mammogram uses a very small amount of radiation in the test, and that consistent scheduling of a mammogram, along with a breast self-examination performed at least monthly, can reduce the client’s risk of dying from breast cancer.

87

When performing a clinical breast examination on a client, the nurse palpates a thickened area where the skin folds under the breast. Which is the nurse’s best action?

a. Proceed with the examination.
b. Determine whether the thickness is bilateral.
c. Ask how long the thickness has been present.
d. Change the client’s position and re-assess.

ANS: A

a. Proceed with the examination.

A thickened area where the skin folds under the breast is the inframammary ridge, a normal anatomic finding. Clients should be taught to identify this ridge and not confuse it with the presence of a lump or abnormal tissue thickening. Because this is a normal finding, no concern is necessary about whether it is present bilaterally or occurs in a different position, or how long the finding has been notable.

88

A client who has discovered a lump in her breast becomes tearful when scheduling a mammogram. Which is the nurse’s best response?

a. “All lumps are considered cancerous until proven otherwise.”

b. “Unless you have a relative with breast cancer, this lump is probably benign.”

c. “Diagnosing cancer at this early stage is most likely to result in a cure.”

d. “Many women have breast lumps, and most of the lumps are benign.”

ANS: D

d. “Many women have breast lumps, and most of the lumps are benign.”

The finding of a breast lump or mass is a frightening experience. Clients should be reassured, until they can be seen or testing is done, that 90% of all breast lumps or masses are benign. It is inaccurate for the nurse to state that all lumps are considered cancerous until proven benign, or that the lump is probably benign unless the client has a relative with breast cancer.

89

A client has just been diagnosed with fibrocystic breast disease. She asks what this means in terms of her health. Which is the nurse’s best response?

a. “This increases your risk for breast cancer, so schedule yearly mammograms.”

b. “This will increase as you age, especially if you have never been pregnant.”

c. “This will diminish with menopause if you don’t take replacement hormones.”

d. “This is genetic and you should teach your daughters about it.”

ANS: C

c. “This will diminish with menopause if you don’t take replacement hormones.”

Although the cause of fibrocystic breast changes is unknown, the condition seems to be related to normal fluctuations in estrogen levels during the menstrual cycle. Symptoms usually resolve after menopause in the absence of estrogen supplementation. The presence of fibrocystic breast changes does not necessarily increase the client’s risk for breast cancer, will not necessarily increase with age, and does not routinely have a genetic component.

90

Which client does the nurse encourage to seek genetic counseling regarding her risk for BRCA1 or BCRA2 gene mutation–related breast cancer?

a. Woman whose father had lung cancer and mother had leukemia

b. Woman whose sister has breast cancer and mother has ovarian cancer

c. Woman whose fraternal twin sister has breast cancer

d. Older woman who has bilateral benign breast disease

ANS: B

b. Woman whose sister has breast cancer and mother has ovarian cancer

The best-defined increased genetic risk for breast cancer is related to mutations in the BRCA1 or BRCA2 gene. Families in which either of these genes is mutated have higher rates of breast and ovarian cancer in first-degree relatives. Being older is the primary risk factor for developing breast cancer but is not related to the genetic component; neither is benign breast disease. Lung cancer and leukemia are not genetically related to breast cancer. Having a twin with breast cancer does increase the genetic risk, but not as much as having two first-degree relatives with related cancers.

91

Which statement made by a client about breast cancer indicates correct understanding of the disease?

a. “Breast cancer is the leading cause of cancer deaths among women in the United States.”

b. “Breast cancer is the leading type of cancer among women in North America.”

c. “Late onset of menses and early menopause increase the risk for breast cancer.”

d. “Breast cancer decreases with age, and very old women have virtually no risk.”

ANS: B

b. “Breast cancer is the leading type of cancer among women in North America.”

Breast cancer is the second most common form of cancer diagnosed in women (after skin cancer) and is the second leading cause of cancer deaths in women in the United States (after lung cancer). The incidence of breast cancer increases with age. Early onset of menses and late menopause increase the risk for breast cancer.

92

Which comment made by a client with breast cancer indicates correct understanding regarding cancer causes and prevention?

a. “I will prevent recurrence of my cancer by eating a low-fat diet from now on.”

b. “If I had breast-fed my children, this would not have happened to me.”

c. “I hope this doesn’t increase my risk for bone cancer or lung cancer.”

d. “I will have regular mammograms on my other breast to detect cancer early.”

ANS: D

d. “I will have regular mammograms on my other breast to detect cancer early.”

Regular mammography can help detect breast cancer at an early stage. Women who have had breast cancer have a greater risk of developing cancer in the other breast. The other statements are inaccurate.

93

A client has advanced breast cancer and bone metastasis. Which problem does the nurse consider the priority?

a. Pain
b. Mobility problems
c. Risk for infection
d. Malnutrition

ANS: A

a. Pain

Bone metastasis can cause intense continuous pain that disrupts the client’s activities and sleep and reduces the client’s quality of life. This problem should be managed ahead of all other problems. Although the client may also be experiencing impaired mobility and risks for infection and malnutrition, none of these problems will be as disruptive as acute pain.

94

A client had a mastectomy nearly a year ago and is distressed over continued tingling and burning in the ipsilateral arm. What orders does the nurse prepare to implement?

a. Teach the client about gabapentin (Neurontin).
b. Demonstrate the use of heat therapy to the axilla.
c. Discuss ways to prevent constipation with pain meds.
d. Reassure the client that this will disappear shortly.

ANS: A

a. Teach the client about gabapentin (Neurontin).

Injury to nerves causes paresthesias such as burning, tingling, “pins and needles,” and numbness after a mastectomy. These sensations are usually gone by the end of a year. Because this client’s symptoms are distressing and have lasted so long, the nurse should anticipate an order for Neurontin. Narcotic pain medications will not be helpful or needed. Heat therapy may or may not be helpful, and reassuring the client at this point will sound unbelievable.

95

A client had a mastectomy and axillary node dissection. The nurse empties sanguineous drainage from the client’s incisional Jackson-Pratt drain on the first postoperative day. Which other action regarding the drain is of high priority for the nurse?

a. Flushing the tubing with urokinase to ensure patency
b. Compressing and closing the drain to ensure suction
c. Advancing the tubing inch from the insertion site
d. Clamping the drain for 2 hours and releasing it for 2 hours

ANS: B

b. Compressing and closing the drain to ensure suction

The Jackson-Pratt drain removes fluid from the wound through closed suction. The drain must be compressed and closed to create suction as it slowly re-expands. The drain should never be flushed with urokinase, tubing should not be advanced, and the drain should not be clamped and released for 2 hours.

96

A client is postoperative from a left-sided mastectomy. She says that the incision and the inner side of her arm from the armpit to the elbow are numb. Which is the nurse’s best action?

a. Teach the client to avoid lifting heavy objects.
b. Measure the circumference of the client’s left arm.
c. Reassure the client that this is an expected finding.
d. Notify the surgeon as soon as possible.

ANS: C

c. Reassure the client that this is an expected finding.

The nerves supplying the skin in the area were injured during surgery, decreasing sensation to the area. These problems frequently resolve over time. Teaching the client to avoid lifting heavy objects or measuring the circumference of the arm will not improve sensation to the client’s arm. The surgeon does not need to be notified about normal findings.

97

A client receiving tamoxifen (Tamofen) asks how this therapy helps fight breast cancer. Which is the nurse’s best response?

a. “This agent decreases estrogen levels. so the cancer stops growing.”

b. “The drug causes you to secrete testosterone, which limits cancer growth.”

c. “Tamoxifen kills estrogen-secreting cells and growth of blood vessels to cancer cells.”

d. “It blocks estrogen receptors, and this limits cancer cell growth.”

ANS: D

d. “It blocks estrogen receptors, and this limits cancer cell growth.”


Tamoxifen is an estrogen antagonist-agonist. Its use in breast cancer is limited to cancers that express the estrogen receptor. Tamoxifen binds to estrogen receptors, inhibiting the binding of estrogen to receptors, thereby “starving” the cancer cells of an essential growth factor. The drug does not decrease circulating levels of estrogen, does not cause testosterone to be secreted instead of estrogen, and does not kill off estrogen-secreting cells.

98

A client asks how soon after a mastectomy she can engage in sexual activity. Which is the nurse’s best response?

a. “When do you want to resume sexual activity?”
b. “Most surgeons say to wait several weeks after the operation.”
c. “As soon as the incision has healed completely.”
d. “You shouldn’t worry about sexuality right now.”

ANS: B

b. “Most surgeons say to wait several weeks after the operation.”

Most surgeons prefer that the client wait 4 to 6 weeks postoperatively before resuming sexual activity, although this very personal advice should be individualized. Asking the client when she wants to resume sexual activity places the burden on her to make a tentative decision. Until the incision is healed, clients should be taught how to protect the incision and avoid contact with the surgical site during intercourse. Telling the client not to worry about sexuality is dismissing and disrespectful.

99

Which exercise plan or activity does the nurse teach the client for the first postoperative day after a modified radical mastectomy?

a. “Perform no movement or exercise today. Keep the arm supported and the elbow flexed, and as close to your body as possible.”

b. “Without moving your shoulder, straighten your elbow three times hourly and squeeze a rubber ball with your fingers.”

c. “Face the wall and extend your arm straight out to the wall. Walk your fingers as far above your head as your arm will reach, and then walk them back down.”

d. “Hold your operative arm straight out from the shoulder to the side. Use your nonoperative arm to pull the operative arm completely straight above your head.”

ANS: B

b. “Without moving your shoulder, straighten your elbow three times hourly and squeeze a rubber ball with your fingers.”

Mild exercise begins on the first postoperative day. Exercises should not put stress on the incision and do not involve the shoulder at this point. Full extension of the elbow, with support, is important, as is using grip maneuvers for the hand on the affected side. Total immobility is not recommended. The other two exercises can be performed a few days after the operation.

100

A client is experiencing lymphedema in the arm on the operative side after a modified radical mastectomy. Which statement indicates correct understanding of managing this problem?

a. “I will reduce my intake of salt and water.”
b. “I will elevate my arm on a pillow at night.”
c. “I will try to drink at least 3 liters of water each day.”
d. “I will wear long sleeves to prevent sun exposure.”

ANS: B

b. “I will elevate my arm on a pillow at night.”

The formation of edema is aggravated by having the arm in a position dependent to the heart. Elevating the arm as much as possible assists gravity to promote better venous and lymph return. This will be a more effective intervention than salt reduction or drinking large amounts of water. Preventing sun exposure will have no effect on the lymphedema.

101

A woman is asking about monthly breast self-examination (BSE). What information does the nurse provide to the client?

a. “It is a valuable tool for finding breast lumps early.”
b. “After menopause, it is no longer useful.”
c. “BSE should be combined with other assessments.”
d. “Women in their 30s should begin monthly BSE.”

ANS: C

c. “BSE should be combined with other assessments.”

BSE can be presented as an option for breast self-awareness. However, BSE is no better than awareness of normal breast findings. It is best when combined with clinical breast examinations and mammography. Women of all ages can practice BSE.

102

A client with a family history of breast cancer tells the nurse that she has made several recent lifestyle changes. Which question by the nurse about these practices is most important?

a. “Are you a vegetarian?”
b. “Do you drink green tea?”
c. “What supplements do you use?”
d. “Do you smoke cigarettes?”

ANS: C

c. “What supplements do you use?”

Soy supplements in high amounts should be avoided by women who have breast cancer or who are at high risk for breast cancer. Dietary soy, eaten in normal amounts, does not appear to present the same risk. The other activities do not have the same risk as taking large quantities of soy supplements.

103

A client is undergoing treatment for breast cancer and asks the nurse about “natural” treatments for her chemotherapy-induced nausea. Which is the most appropriate response by the nurse?

a. “Anything you can take will interfere with your chemotherapy.”

b. “I don’t know of any recommended complementary treatments for nausea.”

c. “Black cohosh and flaxseed are good for combating nausea.”

d. “Ginger has been used for nausea; would you consider taking it?”

ANS: D

d. “Ginger has been used for nausea; would you consider taking it?”

Up to 80% of women with breast cancer have used complementary therapies. Ginger, along with acupuncture, aromatherapy, hypnosis, progressive muscle relaxation, and shiatsu, has been used for nausea. Black cohosh and flaxseed are used for hot flashes. The client should check with her provider and other credible sources regarding any desired therapies to ensure that they won’t interfere with the chemotherapy. Even if the nurse doesn’t know of specific therapies, it is never appropriate to just say, “I don’t know.” The nurse should investigate for the client

104

A client had a mastectomy with reconstruction, and several axillary nodes were dissected. Which statement by the client indicates good understanding of discharge instructions?

a. “I must be careful not to injure the arm or hand on the side of my surgery.”

b. “I’m glad that lymphedema is no longer a problem, as it was in my mother’s day.”

c. “I will have a hard time waiting for a whole year to see how my breast will look.”

d. “I need to pull my drains out by inch each day until they are totally out.”

ANS:A

a. “I must be careful not to injure the arm or hand on the side of my surgery.”

Lymphedema is a complication following mastectomy, especially if lymph nodes have been removed. The client must use measures to prevent this from occurring for the rest of her life. Preventing injury is one way of preventing lymphedema. Breast reconstruction should look optimal in 3 to 6 months. The health care provider will remove drains at a postoperative appointment.

105

A client is being treated with anastrozole (Arimidex) for breast cancer. The nurse is developing a plan of care for the client. Which intervention is the highest priority?

a. Teach the client to weigh herself each day at the same time.

b. Instruct the client to keep a symptom journal for menopausal symptoms.

c. Monitor the client closely for evidence of osteoporosis.

d. Review the client’s dietary habits to prevent weight gain.

ANS: C

c. Monitor the client closely for evidence of osteoporosis.

Arimidex is an aromatase inhibitor. A major side effect of the aromatase inhibitors is loss of bone density. Fluid retention, menopausal symptoms, and weight gain are not primary side effects of Arimidex or other aromatase inhibitors.

106

A client with a history of breast cancer is admitted through the emergency department with shortness of breath, weakness, fatigue, and new lower extremity edema. The client’s oxygen saturation is 88%. After stabilizing the client, which action by the nurse is most important?

a. Obtain a list of the client’s medications.
b. Orient her to her room and surroundings.
c. Place the client on intake and output.
d. Assess the client’s family cardiac history.

ANS: A

a. Obtain a list of the client’s medications.

Some chemotherapeutic drugs, such as doxorubicin (Adriamycin) and trastuzumab (Herceptin), are known to be cardiotoxic. Although all other actions are appropriate, the nurse (and the provider) must know the medications the client is on, with specific emphasis on assessing for causative agents.

107

The nurse is assessing a client with a history of ductal ectasia. Which signs and symptoms supporting this diagnosis does the nurse correlate with this condition? (Select all that apply.)

a. A soft mass on palpation
b. Greenish-brown nipple discharge
c. Enlarged axillary nodes
d. A mass with regular borders
e. Redness and edema over the site of the mass
f. Mass tenderness on palpation

ANS: B, C, E, F

b. Greenish-brown nipple discharge
c. Enlarged axillary nodes
e. Redness and edema over the site of the mass
f. Mass tenderness on palpation

The benign condition, ductal ectasia, is caused by dilation and thickening of collecting ducts in the subareolar area. It results in activation of the inflammatory response when the ducts fill with cellular debris. Clinical manifestations of this condition include development of a hard mass with irregular borders that is tender on palpation. A greenish-brown nipple discharge, enlarged axillary nodes, and redness and edema over the site of the mass are also noted. Palpation of a soft mass or a mass with regular borders is not applicable to ductal ectasia.

108

Which factors are considered to be indicative of a moderately increased risk of a client’s developing breast cancer? (Select all that apply.)

a. High postmenopausal bone density
b. Ionizing radiation
c. Family history of one first-degree relative
d. Genetic factors
e. First child born after age 30
f. Biopsy-confirmed atypical hyperplasia

ANS: A, B, C, F

a. High postmenopausal bone density
b. Ionizing radiation
c. Family history of one first-degree relative
f. Biopsy-confirmed atypical hyperplasia

Family history of one first-degree relative
Factors considered to be indicative of a moderately increased risk of a client’s developing breast cancer include high postmenopausal bone density, ionizing radiation, family history of one first-degree relative, and biopsy-confirmed atypical hyperplasia. Female gender and genetic factors are indicative of high increased risk. The first child born after age 30 is indicative of low increased risk of developing breast cancer.

109

A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure?

a. Elevate the head of the bed to 45 degrees.
b. Have the patient lie on the left side for 1 hour.
c. Apply a sterile 2-inch gauze dressing to the site.
d. Use a half-inch sterile gauze to pack the wound.

ANS: B

b. Have the patient lie on the left side for 1 hour.

To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60 minutes. After a bone marrow biopsy, the wound is small and will not be packed with gauze. A pressure dressing is used to cover the aspiration site. There is no indication to elevate the patient’s head.

110

The nurse examines the lymph nodes of a patient during a physical assessment. Which assessment finding would be of most concern to the nurse?

a. A 2-cm nontender supraclavicular node
b. A 1-cm mobile and nontender axillary node
c. An inability to palpate any superficial lymph nodes
d. Firm inguinal nodes in a patient with an infected foot

ANS: A

a. A 2-cm nontender supraclavicular node

Enlarged and nontender nodes are suggestive of malignancies such as lymphoma. Firm nodes are an expected finding in an area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5 to 1 cm and nontender.









111

A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test?

a. Bone marrow biopsy
b. Abdominal ultrasound
c. Complete blood count (CBC)
d. Activated partial thromboplastin time (aPTT)

ANS: A

a. Bone marrow biopsy

A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. The other procedures do not require a signed consent.

112

Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy?

a. Platelet count
c. Total lymphocyte count
b. Reticulocyte count
d. Absolute neutrophil count

ANS: D

d. Absolute neutrophil count

Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts are also important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim.

113

A patient who has acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate?

a. “If you do not want to have chemotherapy, other treatment options include stem cell transplantation.”

b. “The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy.”

c. “The decision about treatment is one that you and the doctor need to make rather than asking what I would do.”

d. “You don’t need to make a decision about treatment right now because leukemias in adults tend to progress slowly.”

ANS: B

b. “The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy.”

This response uses therapeutic communication by addressing the patient’s question and giving accurate information. The other responses either give inaccurate information or fail to address the patient’s question, which will discourage the patient from asking the nurse for information.

114

A patient who has acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to

a. discuss the need for insurance to cover post-HSCT care.

b. ask whether there are questions or concerns about HSCT.

c. emphasize the positive outcomes of a bone marrow transplant.

d. explain that a cure is not possible with any treatment except HSCT.

ANS: B

b. ask whether there are questions or concerns about HSCT.

Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.

115

Which action will the nurse include in the plan of care for a patient admitted with multiple myeloma?

a. Monitor fluid intake and output.
b. Administer calcium supplements.
c. Assess lymph nodes for enlargement.
d. Limit weight bearing and ambulation.

ANS: A

a. Monitor fluid intake and output.

A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient’s calcium level and are not used.

116

An appropriate nursing intervention for a patient with non-Hodgkin’s lymphoma whose platelet count drops to 18,000/µL during chemotherapy is to

a. check all stools for occult blood.
b. encourage fluids to 3000 mL/day.
c. provide oral hygiene every 2 hours.
d. check the temperature every 4 hours.

ANS: A

a. check all stools for occult blood.

Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.

117

A patient who has acute myelogenous leukemia develops an absolute neutrophil count of 850/µL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate?

a. Discuss the need for hospital admission to treat the neutropenia.

b. Teach the patient to administer filgrastim (Neupogen) injections.

c. Plan to discontinue the chemotherapy until the neutropenia resolves.

d. Order a high-efficiency particulate air (HEPA) filter for the patient’s home.

ANS: B

b. Teach the patient to administer filgrastim (Neupogen) injections.

The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count <500/µL), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient’s home environment.

118

Following successful treatment of Hodgkin’s lymphoma for a 55-yr-old woman, which topic will the nurse include in patient teaching?

a. Potential impact of chemotherapy treatment on fertility

b. Application of soothing lotions to treat residual pruritus

c. Use of maintenance chemotherapy to maintain remission

d. Need for follow-up appointments to screen for malignancy

ANS: D

d. Need for follow-up appointments to screen for malignancy

The chemotherapy used in treating Hodgkin’s lymphoma results in a high incidence of secondary malignancies; follow-up screening is needed. The fertility of a 55-yr-old woman will not be impacted by chemotherapy. Maintenance chemotherapy is not used for Hodgkin’s lymphoma. Pruritus is a clinical manifestation of lymphoma but should not be a concern after treatment.

119

A patient who has non-Hodgkin’s lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse?

a. Anorexia
c. Oral ulcers
b. Vomiting
d. Lip swelling

d. Lip swelling

Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The nurse should stop the infusion and further assess for anaphylaxis. The other findings may occur with chemotherapy but are not immediately life threatening.

120

Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider?

a. Serum calcium level is 15 mg/dL.
b. Patient reports no stool for 5 days.
c. Urine sample has Bence-Jones protein.
d. Patient is complaining of severe back pain.

ANS: A

a. Serum calcium level is 15 mg/dL.

Hypercalcemia may lead to complications such as dysrhythmias or seizures, and should be addressed quickly. The other patient findings will also be discussed with the health care provider but are not life threatening.

121

The nurse is teaching a client who has undergone a bone marrow biopsy. Which instruction does the nurse give the client?

a. “Wear protective gear when playing contact sports.”
b. “Monitor the biopsy site for bruising.”
c. “Remain in bed for at least 12 hours.”
d. “Use a heating pad for pain at the biopsy site.”

ANS: B

b. “Monitor the biopsy site for bruising.”

The most important instruction is to have the client monitor the area for external or internal bleeding. Activities such as contact sports should be avoided, and an ice pack can be used to limit bruising.

122

The nurse is caring for a client who is receiving chemotherapy for cancer. Which intervention does the nurse implement for this client?

a. Assess the client’s fibrinogen level.
b. Administer the prescribed iron.
c. Maintain strict Standard Precautions.
d. Monitor the client’s pulse oximetry.

ANS: C

c. Maintain strict Standard Precautions.

The client who is receiving chemotherapy drugs that suppress the bone marrow will be at risk for a decreased white blood cell (WBC) count and infection. The nurse will be most therapeutic by adhering to Standard Precautions to prevent infection, such as handwashing. The nurse will not expect the fibrinogen level to be affected by this therapy. Iron is not typically administered with chemotherapy because this is bone marrow suppression, so the administration of epoetin (Epogen) or filgrastim (Neupogen) is most effective. Monitoring the pulse oximetry is part of routine care and probably would not need to be done continuously.

123

The nurse is caring for a client who had a bone marrow aspiration. The client begins to bleed from the aspiration site. Which action does the nurse perform?

a. Apply external pressure to the site.
b. Elevate the extremities.
c. Cover the site with a dressing.
d. Immobilize the leg.

ANS: A

a. Apply external pressure to the site.

All these options could be done after a bone marrow aspiration and biopsy. However, the most important action when bleeding occurs is to apply external pressure to the site until hemostasis is ensured. The other measures could then be carried out.

124

The nurse is preparing a client for a bone biopsy and aspiration. The client asks, “Will this be painful?” How does the nurse respond?

a. “The procedure is always done under general anesthesia.”
b. “The biopsy lasts for only 2 minutes.”
c. “There is a chance that you may have pain.”
d. “You can relieve pain with guided imagery.”

ANS: C

c. “There is a chance that you may have pain.”

Clients may have pain during this procedure. The type and amount of anesthesia or sedation depend on the physician’s preference, the client’s preference, and previous experience with bone marrow aspiration. The procedure takes from 5 to 15 minutes. Guided imagery can relieve pain but works well only with some clients.

125

The registered nurse is assigning a practical nurse to care for a client who has leukemia. Which instruction does the registered nurse provide to the practical nurse when delegating this client’s care?

a. Evaluate the amount of protein the client eats.

b. Assess the client’s roommate for symptoms of infection.

c. Perform effective hand hygiene frequently.

d. Wear a mask when entering the room.

ANS: C

c. Perform effective hand hygiene frequently.

A major objective in caring for the client with leukemia is protection from infection. Frequent handwashing is of the utmost importance. If at all possible, the client should be in a private room. Masks are worn by anyone who has an upper respiratory tract infection. The client may be on a “minimal bacteria diet.” Protein is not a factor in this diet.

126

The nurse is planning discharge teaching for a client who has acute myelogenous leukemia (AML). Which instruction does the nurse include in this client’s discharge plan?

a. Avoid contact sports.
b. Refrain from intercourse.
c. Apply heat to any bruised areas.
d. Use aspirin for headaches.

ANS: A

a. Avoid contact sports.

Clients with AML have a low platelet count and are at risk for bleeding. Contact sports can cause bleeding and should be avoided by those with a low platelet count. Anal intercourse should be avoided, but it is not necessary to refrain from all types of intercourse. Ice should be placed on bruised areas instead of heat, and aspirin should not be used by those with a low platelet count.

127

The nurse is providing health promotion education to a client who has a family history of leukemia. Which factor does the nurse teach this client to avoid?

a. Alcohol consumption
b. Exposure to ionizing radiation
c. High-cholesterol diet
d. Smoking cigarettes

ANS: B

b. Exposure to ionizing radiation

Many genetic and environmental factors are involved in the development of leukemia. Exposure to radiation increases the risk for development of leukemia, particularly acute myelogenous leukemia (AML). Although alcohol consumption, high-cholesterol diet, and smoking are not healthy behaviors, they do not increase the risk for leukemia.

128

The nurse is planning care for a client who has leukemia. Which intervention does the nurse include in the plan of care to prevent fatigue?

a. Arrange for a family member to stay with the client.

b. Plan care for times when the client has the most energy.

c. Schedule for daily physicals and occupational therapy.

d. Plan all activities to occur in the morning to allow for afternoon naps.

ANS: B

b. Plan care for times when the client has the most energy.

With leukemia, energy management is needed to help conserve the client’s energy. Care should be scheduled when the client has the most energy. This client may not have the most energy in the morning. If the benefit of an activity such as physical or occupational therapy is less than its worsening of fatigue, it may be postponed. The nurse should limit the number of visitors and interruptions by visitors, as appropriate.

129

The nurse is teaching a client who is being discharged to home after bone marrow transplantation. The client asks, “Why is it so important to protect myself from injury?” How does the nurse respond?

a. “Injuries put you at high risk for infection.”

b. “Platelet recovery is slow, which makes you at risk for bleeding.”

c. “Severe trauma could result in rejection of the transplant.”

d. “The medications you are taking will make you bruise easily.”

ANS: B

b. Platelet recovery is slow, which makes you at risk for bleeding.”

Platelets recover more slowly than other blood cells after bone marrow transplantation. Thus the client is still thrombocytopenic at home and remains at risk for excessive bleeding after any trauma or injury. Injured tissue makes a client at risk for infection, and trauma could result in injury to the transplant (but not rejection). However, these are not the best responses to give the client. A steroid regimen may make a client more at risk for bruising, but

130

The nurse is caring for a 20-year-old man who has Hodgkin’s lymphoma in the abdominal and pelvic regions. The client is scheduled for radiation therapy and states, “I want to have children someday, and this procedure will destroy my chances.” How does the nurse respond?

a. “Adoption is always an option.”

b. “Infertility is not seen with this type of radiation therapy.”

c. “Sperm production will be permanently disrupted.”

d. “You have the option to store sperm in a sperm bank.”

ANS: D

d. “You have the option to store sperm in a sperm bank.”

Permanent sterility can occur in male clients receiving radiation in the abdominal and pelvic regions. The client should be informed of this side effect and given the option to store sperm in a sperm bank before treatment. The other options do not appropriately address the client’s concerns.

131

The nurse is preparing a client with leukemia for a peripheral stem cell transfusion. Which information does the nurse provide the client?

a. “Nausea and vomiting are common after the transfusion.”

b. “The transfusion will take about 6 hours.”

c. “You may have numbness in your fingers and toes.”

d. “Your urine may be red for a short time.”

ANS: D

d. “Your urine may be red for a short time.”

Red urine can occur as a result of red blood cell breakage within infused stem cells. The cells are transfused during the time frame of an ordinary blood transfusion, numbness and tingling may have been seen during pheresis (not transfusion), and nausea and vomiting may occur during administration of chemotherapy before the stem cell transfusion.

132

The nurse is teaching a client who is scheduled to undergo allogeneic bone marrow transplantation. Which statements indicate that the client correctly understands the teaching? (Select all that apply.)

a. “The surgeon will insert the marrow into my femur bone.”

b. “Until the marrow transplant takes, I can have visitors.”

c. “The transplant does not start working immediately.”

d. “I will need chemotherapy before my transplant.”

e. “Radiation treatments will begin 2 days after transplantation.”

ANS: C, D

c. “The does not start working immediately.”
d. “I will need chemotherapy before my transplant.”

Engraftment, or the successful take of transplanted cells, takes anywhere from 8 to 28 days, depending on the type of cell transplantation. For donated marrow or stem cells to work, the client will require large doses of chemotherapy before transplantation. The client will not require radiation after the transplant. Transplanted marrow is delivered intravenously. It is not placed into any bone. The client is at risk for infection until the bone marrow begins to produce white blood cells. Therefore visitors should be limited to prevent infection to the client.

133

The nurse understands that the type of precautions needed for children receiving chemotherapy is based on which actions of chemotherapeutic agents?

a. Gastrointestinal upset
b. Bone marrow suppression
c. Decreased creatinine level
d. Alopecia

ANS: B

b. Bone marrow suppression

A
Although gastrointestinal upset may be an adverse effect of chemotherapy, it is not caused by all chemotherapeutic agents. No special precautions are instituted for gastrointestinal upset.
B
Chemotherapy agents cause bone marrow suppression, which creates the need to institute precautions related to reduced white blood cell, red blood cell, and platelet counts. These precautions focus on preventing infection and bleeding.
C
A decreased creatinine level is consistent with renal pathologic conditions, not chemotherapy.
D
Not all chemotherapeutic agents cause alopecia. No precautions are taken to prevent alopecia.

134

The nurse should base a response to a parent’s question about the prognosis of acute lymphoblastic leukemia (ALL) on the knowledge that

a. Leukemia is a fatal disease, although chemotherapy provides increasingly longer periods of remission.

b. Research to find a cure for childhood cancers is very active.

c. The majority of children go into remission and remain symptom free when treatment is completed.

d. It usually takes several months of chemotherapy to achieve a remission.

ANS: C

c. The majority of children go into remission and remain symptom free when treatment is completed.

Children diagnosed with the most common form of leukemia, ALL, can almost always achieve remission, with a 5-year disease-free survival rate approaching 85%.

135

Hematopoietic stem cell transplantation (HSCT) is the standard treatment for a child in his or her first remission with what cancer?

a. ALL
b. Non-Hodgkin lymphoma
c. Wilms’ tumor
d. Acute myeloblastic leukemia (AML)

ANS: D

d. Acute myeloblastic leukemia (AML)

HSCT is often used interchangeably with bone marrow transplantation and is currently standard treatment for children in their first remission with AML.

136

A child with a history of fever of unknown origin, excessive bruising, lymphadenopathy, anemia, and fatigue is exhibiting symptoms most suggestive of

a. Ewing sarcoma
b. Wilms’ tumor
c. Neuroblastoma
d. Leukemia

ANS: D

d. Leukemia

These symptoms reflect bone marrow failure and organ infiltration, which occur in leukemia.

137

What is a priority nursing diagnosis for the 4-year-old child newly diagnosed with leukemia?

a. Ineffective Breathing Pattern related to mediastinal disease

b. Risk for Infection related to immunosuppressed state

c. Disturbed Body Image related to alopecia

d. Impaired Skin Integrity related to radiation therapy

ANS: B

b. Risk for Infection related to immunosuppressed state

Leukemia is characterized by the proliferation of immature white blood cells, which lack the ability to fight infection.

138

A nurse determines that parents understood the teaching from the pediatric oncologist if the parents indicate that which test confirms the diagnosis of leukemia in children?

a. Complete blood cell count (CBC)
b. Lumbar puncture
c. Bone marrow biopsy
d. Computed tomography (CT) scan

ANS: C

c. Bone marrow biopsy

The confirming test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspiration and biopsy.

139

Which statement, if made by a nurse to the parents of a child with leukemia, indicates an understanding of teaching related to home care associated with the disease?

a. “Your son’s blood pressure must be taken daily while he is on chemotherapy.”

b. “Limit your son’s fluid intake just in case he has central nervous system involvement.”

c. “Your son must receive all of his immunizations in a timely manner.”

d. “Your son’s temperature should be taken frequently.”

ANS: D

d. “Your son’s temperature should be taken frequently.”

An elevated temperature may be the only sign of an infection in an immunosuppressed child. Parents should be instructed to monitor their child’s temperature as often as necessary.

140

What is the most appropriate nursing action when the nurse notes a reddened area on the forearm of a neutropenic child with leukemia?

a. Massage the area.
b. Turn the child more frequently.
c. Document the finding and continue to observe the area.
d. Notify the physician.

ANS: D

d. Notify the physician.

Skin is the first line of defense against infection. Any signs of infection in a child who is immunosuppressed must be reported to the physician. When a child is neutropenic, pus may not be produced and the only sign of infection may be redness.

141

. What is the nurse’s best response to a mother whose child has a diagnosis of acute lymphoblastic leukemia and is expressing guilt about not having responded sooner to her boy’s symptoms?

a. “You should always call the physician when your child has a change in what is normal for him.”

b. “It is better to be safe than sorry.”

c. “It is not uncommon for parents not to notice subtle changes in their children’s health.”

d. “I hope this delay does not affect the treatment plan.”

ANS: C

c. “It is not uncommon for parents not to notice subtle changes in their children’s health.”

This statement minimizes the role the mother played in not seeking early medical attention. It also displays empathy, which helps to build trust, thereby enabling the mother to talk about her feelings. Identifying concerns and clarifying misconceptions will help families cope with the stress of chronic illness.

142

Children with non-Hodgkin lymphoma are at risk for complications resulting from tumor lysis syndrome (TLS). The nurse should assess for

a. Liver failure
b. CNS deficit
c. Kidney failure
d. Respiratory distress

ANS: C

c. Kidney failure

In TLS, the tumor’s intracellular contents are dumped into the child’s extracellular fluid as the tumor cells are lysed in response to chemotherapy. Because of the large volume of these cells, their intracellular electrolytes overload the kidneys and, if not monitored, can cause kidney failure.

143

What is an expected physical assessment finding for an adolescent with a diagnosis of Hodgkin disease?

a. Protuberant, firm abdomen
b. Enlarged, painless, firm cervical lymph nodes
c. Soft tissue swelling
d. Soft to hard, nontender mass in pelvic area

ANS: B

b. Enlarged, painless, firm cervical lymph nodes'

Painless, firm, movable adenopathy (enlarged lymph nodes) palpated in the cervical region is an expected assessment finding in Hodgkin disease. Other systemic symptoms include unexplained fevers, weight loss, and night sweats.

144

A child with non-Hodgkin lymphoma will be starting chemotherapy. What intervention is initiated before chemotherapy to prevent tumor lysis syndrome?

a. Insertion of a central venous catheter

b. Intravenous (IV) hydration containing sodium bicarbonate

c. Placement of an externalized ventriculoperitoneal (VP) shunt

d. Administration of pneumococcal and Haemophilus influenzae type B vaccines

ANS B

b. Intravenous (IV) hydration containing sodium bicarbonate

Intensive hydration with an IV fluid containing bicarbonate alkalinizes the urine to help prevent the formation of uric acid crystals, which damage the kidney.

145

A child with acute myeloblastic leukemia is scheduled to have a bone marrow transplant (BMT). The donor is the child’s own umbilical cord blood that had been previously harvested and banked. This type of BMT is termed

a. Autologous
b. Allogeneic
c. Syngeneic
d. Stem cell

ANS: A

a. Autologous

In an autologous transplant, the child’s own marrow or previously harvested and banked cord blood is used.

146

While collecting a health history on a patient admitted for colon cancer, which of the following questions would be a priority to ask this patient?

a. “Have you noticed any blood in your stool?”
b. “Have you been experiencing nausea?”
c. “Do you have back pain?”
d. “Have you noticed any swelling in your abdomen?”

ANS: A

a. “Have you noticed any blood in your stool?”

Early colon cancer is often asymptomatic, with occult or frank blood in the stool being an assessment finding in a patient diagnosed with colon cancer. If pain is present, it is usually lower abdominal cramping. Constipation and diarrhea are more frequent findings than nausea or ascites.

147

The nurse is caring for a patient who received a bone marrow transplant 10 days ago. The nurse would monitor for which of the following clinical manifestations that could indicate a potentially life-threatening situation?
a. Mucositis
b. Confusion
c. Depression
d. Mild temperature elevation

ANS: D

d. Mild temperature elevation

During the first 100 days after a bone marrow transplant, patients are at high risk for life-threatening infections. The earliest sign of infection in an immunosuppressed patient can be a mild fever. Mucositis, confusion, and depression are possible clinical manifestations but are representative of less life-threatening complications.

148

A female patient complains of a “scab that just won’t heal” under her left breast. During your conversation, she also mentions chronic fatigue, loss of appetite, and slight cough, attributed to allergies. What is the nurse’s best action?

a. Continue to conduct a symptom analysis to better understand the patient’s symptoms and concerns.

b. End the appointment and tell the patient to use skin protection during sun exposure.

c. Suggest further testing with a cancer specialist and provide the appropriate literature.

d. Tell her to put a bandage on the scab and set a follow-up appointment in one week.

ANS: A

a. Continue to conduct a symptom analysis to better understand the patient’s symptoms and concerns.

A comprehensive health history is vital to treating and caring for the patient. Often times, symptoms are vague. The nurse should conduct a symptom analysis to gather as much information as possible. Questions should address the duration of the symptoms and include the location, characteristics, aggravating and relief factors, and any treatments taken thus far.

149

A nurse is working on a cancer unit. The unit uses the National Coalition for Cancer Survivorship definition for a cancer survivor. Which definition will the nurse use?

a. Been cancer free for 5 years after diagnosis
b. Been cancer free for 3 years after diagnosis
c. Had cancer and is declared cancer free
d. Had cancer and extends until death

ANS: D

d. Had cancer and extends until death

Cancer survivorship begins at the time of cancer diagnosis, includes treatment, and extends to the rest of the person’s life. Being cancer free for any length of time does not relate to the definition of a cancer survivor put forth by the National Coalition for Cancer Survivorship.

150

The nurse is caring for a young woman with breast cancer. The stress between the woman and spouse is obvious, as is anxiety among the children. What is the nurse’s best action in this situation?

a. Help find or develop an educational program for the patient and spouse.

b. Encourage the patient to agree with the spouse.

c. Support the spouse, and explain that the spouse knows what is best.

d. Take the children away and recommend foster care.

ANS; A

a. Help find or develop an educational program for the patient and spouse.

It is a nurse’s responsibility to educate (develop an educational program) cancer survivors and their families about the effects of cancer and cancer treatment. Spouses often do not know what to do to support the survivor, and they struggle with how to help; therefore, agreeing even if disagreeing does not help and the spouse does not always know what is best. Foster care is not necessary at this time.

151

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis

ANS: D

d. Respiratory alkalosis

The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3.

152

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take?

a. Give the prescribed PRN lorazepam (Ativan).
b. Encourage the patient to take deep slow breaths.
c. Start the prescribed PRN oxygen at 2 to 4 L/min.
d. Administer the prescribed normal saline bolus and insulin.

ANS: D

d. Administer the prescribed normal saline bolus and insulin.

The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis.

153

An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?
a. Pallor
b. edema
c. Confusion
d. Restlessness

ANS: B

b. Edema

The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels

154

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis

ANS: A

a. Metabolic acidosis

The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.

155

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. The patient complains of anxiety and incisional pain. The patient’s respiratory rate is 32 breaths/min, and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?

a. Check to make sure the nasogastric tube is patent.

b. Give the patient the PRN IV morphine sulfate 4 mg.

c.Notify the health care provider about the ABG results.

d. Teach the patient how to take slow, deep breaths when anxious.

ANS: B

b. Give the patient the PRN IV morphine sulfate 4 mg.

The patient’s respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse’s first action should be to medicate the patient for pain. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain. Checking the nasogastric tube can wait until the patient has been medicated for pain.

156

Following a thyroidectomy, a patient complains of “a tingling feeling around my mouth.” Which assessment should the nurse complete?

a. Presence of the Chvostek’s sign
b. Abnormal serum potassium level
c. Decreased thyroid hormone level
d. Bleeding on the patient’s dressing

ANS: A

a. Presence of the Chvostek’s sign

The patient’s symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury or removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding.

157

The nurse observes skin tenting on the back of the older adult client’s hand. Which action by the nurse is most appropriate?

a. Notify the physician.
b. Examine dependent body areas.
c. Assess turgor on the client’s forehead.
d. Document the finding and continue to monitor.

ANS: C

c. Assess turgor on the client’s forehead.

Skin turgor cannot be accurately assessed on an older adult client’s hands because of age-related loss of tissue elasticity in this area. Areas that more accurately show skin turgor status on an older client include the skin of the forehead, chest, and abdomen. These should also be assessed, rather than merely examining dependent body areas. Further assessment is needed rather than only documenting, monitoring, and notifying the physician.

158

The client is taking a medication that inhibits aldosterone secretion and release. The nurse assesses for what potential complication?

a. Fluid retention
b. Hyperkalemia
c. Hyponatremia
d. Hypervolemia

ANS: B

b. Hyperkalemia

Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client’s risk for excessive water loss and increased potassium reabsorption. The client would not be at risk for overhydration or sodium imbalance.

159

Which client is at greatest risk for dehydration?
a.
Younger adult client on bedrest
b.
Older adult client receiving hypotonic IV fluid
c.
Younger adult client receiving hypertonic IV fluid
d.
Older adult client with cognitive impairment

d.
Older adult client with cognitive impairment

Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration.

160

Which item of assessment data obtained by the home care nurse suggests that an older adult client may be dehydrated?
a.
The client has dry, scaly skin on bilateral upper and lower extremities.
b.
The client states that he gets up three or more times during the night to urinate.
c.
The client states that he feels lightheaded when he gets out of bed or stands up.
d.
The nurse observes tenting on the back of the hand when testing skin turgor.

c.
The client states that he feels lightheaded when he gets out of bed or stands up.

Orthostatic or postural hypotension can be caused by or worsened by dehydration. The other statements are not as indicative of the severe degree of dehydration as dizziness on standing.

161

Which action does the nurse teach a client to reduce the risk for dehydration?
a.
Restricting sodium intake to no greater than 4 g/day
b.
Maintaining an oral intake of at least 1500 mL/day
c.
Maintaining a daily oral intake approximately equal to daily fluid loss
d.
Avoiding the use of glycerin suppositories to manage constipation

c.
Maintaining a daily oral intake approximately equal to daily fluid loss

Although a fixed oral intake of 1500 mL daily is good, the key to prevention of dehydration is to match all fluid losses with the same volume for fluid intake. This is especially true in warm or dry environments, or when conditions result in greater than usual fluid loss through perspiration or ventilation.

162

In a client with less than the normal amount of bicarbonate in the blood and other extracellular fluids, what response does the nurse anticipate?
a.
Increased risk for acidosis
b.
Decreased risk for acidosis
c.
Increased risk for alkalosis
d.
Decreased risk for alkalosis

a.
Increased risk for acidosis

Bicarbonate (H2CO3–) is a weak base with an overall negative charge. When hydrogen ions are present in slight or mild excess (mild acidosis), bicarbonate can buffer or absorb the excess hydrogen ions, reducing the hydrogen ion concentration and bringing the pH back up to normal. If the total body bicarbonate concentration is low, especially in the blood, the action of buffering or absorbing excess hydrogen ions is reduced, and the person is at increased risk for acidosis.

163

Which response is an example of compensation for an acid-base imbalance?
a.
Increase in the rate and depth of respirations when exercising
b.
Increased urinary output when blood pressure increases during exercise
c.
Increased thirst when spending time in an excessively dry environment
d.
Increased release of acids from kidneys during exacerbation of chronic obstructive pulmonary disease (COPD)

a.
Increase in the rate and depth of respirations when exercising

The respiratory system increases its activity by blowing off excess carbon dioxide. This occurs as a result of the occurrence of lactic acidosis in skeletal muscle, when blood flow and oxygenation are insufficient to meet the increased demand for oxygen (oxygen debt) created during increased skeletal muscle metabolism. The other three options are not compensatory mechanisms for acid-base imbalances.

164

When a client has an arterial blood pH of 7.48, which buffer action will bring the pH back to normal?
a.
Absorption of bicarbonate ions from the blood
b.
Release of bicarbonate ions into the blood
c.
Absorption of hydrogen ions from the blood
d.
Release of hydrogen ions into the blood

d.
Release of hydrogen ions into the blood

Buffers can act as an acid (releasing a hydrogen ion) or as a base (absorbing a hydrogen ion) to assist in keeping the pH and hydrogen ion concentration of body fluids within the normal range. An arterial pH of 7.48 indicates a deficiency of hydrogen ions. This situation would cause buffers to act like acids and release hydrogen ions into the blood.

165

A client has moderate acidosis. Which assessment does the nurse perform first?
a.
Take the client’s pulse and blood pressure, and analyze the electrocardiogram (ECG) strip.
b.
Assess respiratory rate and depth and work of breathing.
c.
Perform assessments of musculoskeletal strength.
d.
Determine whether the client is awake, alert, and oriented.

a.
Take the client’s pulse and blood pressure, and analyze the electrocardiogram (ECG) strip.

Priority assessments for the client with acidosis relate to the cardiovascular system. Acidosis can lead to lethal cardiac dysrhythmias.

166

In the client with hypoventilation, which change in arterial blood gases does the nurse evaluate to determine whether treatment measures are being effective?
a.
Decreased arterial blood pH
b.
Decreased arterial blood carbon dioxide
c.
Increased arterial blood bicarbonate
d.
Increased arterial blood oxygen

c.
Increased arterial blood bicarbonate

Because kidneys regulate pH by controlling bicarbonate concentration and the lungs regulate pH by controlling carbon dioxide loss, loss of one function can be at least partially compensated for by the other function. When pulmonary function is decreased, so that adequate amounts of carbon dioxide are not excreted, the pH falls, stimulating the kidneys to reabsorb more bicarbonate to balance the increased acid production.

167

In a client 4 minutes post cardiac arrest, the nurse correlates the largest source of excess hydrogen ions with which cause?
a.
Excess renal retention of carbon dioxide due to hypoxia
b.
Release of intracellular acids due to widespread tissue destruction
c.
Anaerobic metabolism, leading to the buildup of lactic acid
d.
Using fat as a fuel source, resulting in increased fat degradation

c.
Anaerobic metabolism, leading to the buildup of lactic acid

Glucose metabolism continues under anaerobic conditions to supply the body with chemical energy (adenosine triphosphate [ATP]). However, this metabolism is incomplete, stopping at lactic acid production instead of continuing into the Krebs’ cycle. This results in a large buildup of lactic acid, which releases excessive amounts of hydrogen ions into the blood.

168

A client has mild acidosis but after a day has not compensated for it. Which action by the nurse is best?
a.
Review the client’s daily hemoglobin and hematocrit.
b.
Ask the laboratory to rerun today’s arterial blood gases.
c.
Document the finding and notify the physician.
d.
Apply 2 L of oxygen via nasal cannula.

a.
Review the client’s daily hemoglobin and hematocrit.

Hemoglobin is part of the buffering system. Low hemoglobin affects acid-base balance by decreasing the body’s ability to compensate for mild acidosis. Rerunning the specimen would take time and might require another sample. The nurse may need to notify the physician but would need more information to report, such as hemoglobin and hematocrit values. Adding 2 liters of oxygen would not help the client as much as he or she would be helped if the cause of the refractory acidosis was determined.

169

A client has an arterial blood gas pH of 7.48. How does the nurse interpret this client’s acid-base status?
a.
An unknown acid-base balance status
b.
A normal blood hydrogen ion concentration
c.
A deficit in blood hydrogen ion concentration
d.
An excess in blood hydrogen ion concentration

c.
A deficit in blood hydrogen ion concentration

The pH is the negative log of the hydrogen ion concentration. The normal pH of arterial blood ranges between 7.35 and 7.45. A pH of 7.48 indicates a decrease in the hydrogen ion concentration (alkalosis).

170

The nurse reads in the medical record that a client has Kussmaul respirations. Which assessment finding is consistent with this condition?
a.
Deep, rapid respirations
b.
Respirations with an irregular pattern
c.
Shallow, grunting respirations
d.
Use of accessory muscles when breathing

a.
Deep, rapid respirations

Kussmaul respirations are described as deep and rapid and are the body’s attempt to compensate for acidosis by “blowing off” excess H+ in the form of carbon dioxide.

171

The nurse monitors for which acid-base imbalance in a client who has hypoxemia?
a.
Reduced carbon dioxide production leading to alkalosis
b.
Reduced carbon dioxide retention leading to alkalosis
c.
Excess carbon dioxide production leading to acidosis
d.
Excess carbon dioxide retention leading to acidosis

c.
Excess carbon dioxide production leading to acidosis

Hypoxemia (lower than normal blood oxygen level) causes some organs, tissues, and cells to have anaerobic metabolism. This situation leads to a buildup of carbon dioxide. Elevated levels of carbon dioxide lead to an increase in blood hydrogen ion levels and acidosis.

172

A client has been placed on a ventilator. The physician has ordered that the ventilator be set to deliver a respiratory rate set of 28 breaths/min. The nurse questions the order, citing concerns about which acid-base problem?
a.
Acid deficit: alkalosis
b.
Base excess: alkalosis
c.
Acid excess: acidosis
d.
Base deficit: acidosis

a.
Acid deficit: alkalosis

A ventilator set at too high a ventilation rate and/or too high a tidal volume will cause the client to lose too much carbon dioxide, leading to an acid deficit and respiratory alkalosis.

173

The nurse monitors for which acid-base problem in a client who is taking furosemide (Lasix) for hypertension?
a.
Acid excess secondary to respiratory acidosis
b.
Acid deficit secondary to respiratory alkalosis
c.
Acid excess secondary to metabolic acidosis
d.
Acid deficit secondary to metabolic alkalosis

d.
Acid deficit secondary to metabolic alkalosis

Many diuretics, especially loop diuretics, increase the excretion of hydrogen ions, leading to excess acid loss through the renal system. This situation is an acid deficit of metabolic origin.

174

The nurse expects to find renal compensation for an acid-base imbalance in which situation?
a.
Mild to moderate dehydration in a middle-aged client who jogged for 2 hours
b.
Acute asthma attack with wheezing of 6 hours’ duration in an older man
c.
Food poisoning with vomiting for 12 hours in a middle-aged woman
d.
Hypoxemia for 4 days from pneumonia in an adult woman

d.
Hypoxemia for 4 days from pneumonia in an adult woman

Renal compensation (change in excretion or reabsorption of hydrogen ions and bicarbonate ions) for an acid-base imbalance is very potent and requires from many hours up to several days to begin. It does not provide immediate compensation, nor does it respond to acute imbalances. For a person who has been hypoxemic for several days, renal compensation with increased excretion of hydrogen ions and increased reabsorption of bicarbonate would have been initiated.

175

A client has moderate metabolic alkalosis. What is the priority intervention for the nurse?
a.
Monitor daily laboratory values.
b.
Assess the client’s muscle strength.
c.
Determine the cause of the problem.
d.
Teach the client preventive measures.

b.
Assess the client’s muscle strength.

Although all options are viable nursing interventions, the priority is providing for client safety. Clients with metabolic alkalosis have muscle weakness and thus are at risk for falling.

176

A client has acute pancreatitis and a risk for acid-base imbalance. The nurse plans to assess for which manifestation consistent with this condition?
a.
Agitation
b.
Kussmaul respirations
c.
Seizures
d.
Positive Chvostek’s sign

b.
Kussmaul respirations

The pancreas is a major site of bicarbonate production. Pancreatitis can cause a relative metabolic acidosis through underproduction of bicarbonate ions. Manifestations of acidosis include lethargy and Kussmaul respirations. Agitation, seizures, and a positive Chvostek’s sign are manifestations of the electrolyte imbalances that accompany alkalosis.

177

The nurse assesses for acidosis in the client with which assessment data?
a.
Serum sodium level of 130 mEq per liter and peripheral edema
b.
Serum sodium level of 144 mEq per liter and tachycardia
c.
Serum potassium level of 6.5 mEq per liter and flaccid paralysis
d.
Serum potassium level of 4.5 mEq per liter and hyperactive deep tendon reflexes

c.
Serum potassium level of 6.5 mEq per liter and flaccid paralysis

When acidosis is present, the hydrogen ion concentration of the extracellular fluid (ECF) is increased above normal. The physiologic action to reduce the ECF hydrogen ion concentration is to move the hydrogen ions into the cells in exchange for potassium ions, thereby maintaining the electroneutrality of the intracellular fluid. As a result, acidosis is accompanied by hyperkalemia, which diminishes nerve and skeletal muscle excitability, causing flaccid paralysis.

178

The hand grasps of a client with acidosis have diminished since the previous assessment 1 hour ago. What action does the nurse take next?
a.
Assess client’s rate, rhythm, and depth of respiration.
b.
Measure the client’s pulse and blood pressure.
c.
Document findings and continue to monitor.
d.
Notify the physician as soon as possible.

a.
Assess client’s rate, rhythm, and depth of respiration.

Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle weakness can lead to severe respiratory insufficiency. Acidosis does lead to dysrhythmias (due to hyperkalemia) but these would best be assessed with cardiac monitoring. Findings should be documented, but simply continuing to monitor is not sufficient. Before notifying the physician, the nurse needs to have more data to report.

179

In evaluating the electrocardiogram (ECG) in a client with acidosis, the nurse correlates which ECG change with effectiveness of therapy?
a.
Small U-waves present after each complex
b.
Heart rate decreased to 62 beats/min
c.
T-waves present, normal height
d.
P-wave preceding the QRS complex

c.
T-waves present, normal height

Acidosis and accompanying hyperkalemia affect cardiac conduction, inducing tall T-waves, widened QRS complexes, and prolonged PR intervals. When T-waves return to a height of less than 3 mm, acidosis and hyperkalemia are resolving.

180

A client has the following arterial blood results: pH 7.12, HCO3– 22 mEq/L, PCO2 65 mm Hg, PO2 56 mm Hg. The nurse correlates these values with which clinical situation?
a.
Diabetic ketoacidosis in a person with emphysema
b.
Tracheal obstruction related to aspiration of a hot dog
c.
Anxiety-induced hyperventilation in an adolescent
d.
Diarrhea for 36 hours in an older, frail woman

b.
Tracheal obstruction related to aspiration of a hot dog

Arterial blood gas values indicate that the client is in acidosis and has normal levels of bicarbonate, suggesting that the problem is not metabolic. Arterial concentrations of oxygen and carbon dioxide are abnormal, with low oxygen and high carbon dioxide levels. Thus, this client has respiratory acidosis from inadequate gas exchange. The fact that the bicarbonate level is normal indicates that this is an acute respiratory problem rather than a chronic problem, because no renal compensation has occurred.

181

Which client does the nurse assess for potential metabolic acidosis?
a.
Client admitted after collapsing during a marathon run
b.
Young adult following a carbohydrate-free diet
c.
Older adult with asthma who is on long-term steroid therapy
d.
Older client on antacids for gastroesophageal reflux disease

b.
Young adult following a carbohydrate-free diet

One cause of acidosis is a strict low-calorie diet or one that is low in carbohydrate content. Such a diet increases the rate of fat catabolism and results in the formation of excessive ketoacids. Dehydration is not directly associated with acid-base disorders. In the client with asthma, acid-base status will be determined by a combination of depth of respirations and oxygen saturation. Excessive intake of sodium bicarbonate may increase the risk of metabolic alkalosis.

182

The nurse interprets which arterial blood gas values as partially compensated metabolic acidosis?
a.
pH 7.28, HCO3– 19 mEq/L, PCO2 45 mm Hg, PO2 96 mm Hg
b.
pH 7.45, HCO3– 22 mEq/L, PCO2 40 mm Hg, PO2 98 mm Hg
c.
pH 7.32, HCO3– 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg
d.
pH 7.48, HCO3– 28 mEq/L, PCO2 45 mm Hg, PO2 92 mm Hg

c.
pH 7.32, HCO3– 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg

The pH is lower than normal, indicating mild acidosis. The acidosis is metabolic in origin, as indicated by the normal arterial oxygen partial pressure and the low bicarbonate level. The decreased carbon dioxide level indicates an increased respiratory rate, causing the carbon dioxide to be blown off and bringing the pH closer to normal (but not completely normal). Thus, the metabolic acidosis is only partially compensated for by the respiratory effort.

183

A client has just experienced a 90-second tonic-clonic seizure and has these arterial blood gas values: pH 6.88, HCO3– 22 mEq/L, PCO2 60 mm Hg, PO2 50 mm Hg. Which intervention by the nurse is most appropriate?
a.
Apply oxygen by mask or nasal cannula.
b.
Apply a paper bag over the client's nose and mouth.
c.
Administer 50 mL of sodium bicarbonate intravenously.
d.
Administer 50 mL of 20% glucose and 20 units of regular insulin.

a.
Apply oxygen by mask or nasal cannula.

The client has experienced a combination of metabolic and acute respiratory acidosis through heavy skeletal muscle contractions and no gas exchange. When the seizures have stopped and the client can breathe again, the fastest way to return to acid-base balance is to administer oxygen. Sodium bicarbonate should not be administered because the client’s arterial bicarbonate level is normal. Applying a paper bag over the client’s nose and mouth would worsen the acidosis.

184

A client who was malnourished is being discharged. The nurse evaluates that teaching to decrease risk for the development of metabolic acidosis has been effective when the client states, “I will:
a.
Increase my milk intake to at least three glasses daily.”
b.
Be sure to eat three well-balanced meals and a snack daily.”
c.
Avoid taking pain medication and antihistamines together.”
d.
Not add salt to food when cooking or during meals.”

b.
Be sure to eat three well-balanced meals and a snack daily.”

Starvation or a diet with too few carbohydrates can lead to metabolic acidosis by forcing cells to switch to using fats for fuel and by creating ketoacids as a by-product of excessive fat metabolism. Eating sufficient calories from all food groups helps reduce this risk.

185

The nurse assesses the client with which condition most carefully for the risk of developing acute respiratory acidosis?
a.
Allergic rhinitis and sinusitis on sulfa antibiotics
b.
Type 1 diabetes and urinary tract infection
c.
Emphysema and undergoing nasogastric (NG) tube suctioning
d.
On patient-controlled analgesia after abdominal surgery

d.
On patient-controlled analgesia after abdominal surgery

Respiratory acidosis often occurs as the result of underventilation. The client who is taking narcotics, especially IV narcotics, is at risk for respiratory depression. The client may also be breathing more shallowly than usual to prevent pain. This gives the client two risk factors for developing hypoventilation and subsequent respiratory acidosis. None of the other clients are at risk for ineffective ventilation

186

The nurse correlates which condition with the following arterial blood gas values: pH 7.48, HCO3– 22 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg?
a.
Diarrhea and vomiting for 36 hours
b.
Anxiety-induced hyperventilation
c.
Chronic obstructive pulmonary disease
d.
Diabetic ketoacidosis and emphysema

b.
Anxiety-induced hyperventilation

The elevated pH indicates alkalosis. The bicarbonate level is normal, and so is the oxygen partial pressure. Loss of carbon dioxide is the cause of the alkalosis, which would occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic alterations, COPD would lead to respiratory acidosis, and the person with emphysema most likely would have combined metabolic acidosis on top of a mild, chronic respiratory acidosis.

187

A postoperative client received six units of packed red blood cells (PRBCs) for intraoperative blood loss. The nurse monitors the client for which acid-base imbalance?
a.
Metabolic alkalosis
b.
Metabolic acidosis
c.
Respiratory alkalosis
d.
Respiratory acidosis

a.
Metabolic alkalosis

Citrate is a substance used as a preservative in blood products. It is not only a base, it is also a precursor for bicarbonate (bicarbonate can be formed from citrate). Rapid administration of blood products can cause metabolic alkalosis by infusing large amounts of citrate intravenously. Although this problem is more likely to occur with administration of whole blood or blood plasma, multiple transfusions with packed red cells can also result in excessive amounts of citrate being received by the client

188

A client has severe metabolic alkalosis. Which nursing diagnosis does the nurse choose as the client’s priority problem?
a.
Fluid volume excess related to reduced kidney function
b.
Fluid volume deficit related to increased insensitive fluid loss through lungs
c.
Risk for impaired skin integrity related to accompanying peripheral edema
d.
Risk for injury related to increased neuronal sensitivity from hypocalcemia

d.
Risk for injury related to increased neuronal sensitivity from hypocalcemia

Metabolic alkalosis is manifested by a high pH, which causes serum calcium to bind and reduces the concentration of free calcium. This relative hypocalcemia increases the risk for increased neuromuscular activity, including tetany and seizures.

189

A client has respiratory acidosis. The nurse evaluates that treatment is being effective with which arterial blood gas values?
a.
pH 7.28, HCO3– 12 mEq/L, PCO2 45 mm Hg, PO2 96 mm Hg
b.
pH 7.32, HCO3– 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg
c.
pH 7.35, HCO3– 36 mEq/L, PCO2 65 mm Hg, PO2 78 mm Hg
d.
pH 7.48, HCO3– 12 mEq/L, PCO2 35 mm Hg, PO2 85 mm Hg

c.
pH 7.35, HCO3– 36 mEq/L, PCO2 65 mm Hg, PO2 78 mm Hg

A pH of 7.35 is normal, indicating acid-base balance (fully compensated). A respiratory problem with carbon dioxide retention and inadequate gas exchange is apparent from the high PCO2 and the low PO2. The bicarbonate level is greatly elevated, indicating renal synthesis and reabsorption of HCO3–, a powerful acid-base compensatory mechanism. Thus, the amount of bicarbonate (base) in the blood adequately compensates for the increased carbon dioxide level, so that the pH is normal, although no other arterial blood gas value is normal.

190

The nurse monitors the client with which condition most carefully for metabolic alkalosis?
a.
A critical illness receiving total parenteral nutrition
b.
Type 1 diabetes on once-daily insulin therapy
c.
Metastatic breast cancer on continuous IV morphine
d.
Asthma using an adrenergic agonist inhaler

a.
A critical illness receiving total parenteral nutrition

The IV fluid mixture for total parenteral nutrition (TPN) has an overall basic pH. One common substance in TPN is lactate, which is rapidly converted in the body to bicarbonate. In addition, the TPN mixture is often administered as a continuous slow infusion. A client with diabetes would be at higher risk of metabolic acidosis. The client on IV morphine is more at risk for respiratory acidosis, as is the client with asthma.

191

A client is in the emergency department after an overdose of an unknown substance. Which assessment findings does the nurse correlate with possible salicylate poisoning?
a.
Increased deep tendon reflexes
b.
Increased rate and depth of respiration
c.
Decreased capillary refill
d.
Decreased intestinal motility and paralytic ileus

b.
Increased rate and depth of respiration

Salicylates are acidic, and salicylate poisoning increases the rate and depth of ventilation in two ways. First, salicylates directly stimulate the respiratory centers. Second, by causing a metabolic acidosis and reducing the pH of the blood, the respiratory centers are stimulated to compensate.

192

A client has a prolonged fever. For which acid-base imbalance does the nurse assess the client further?
a.
Metabolic acidosis from excess bicarbonate production
b.
Metabolic alkalosis from dehydration and hyperkalemia
c.
Metabolic acidosis from increased production of hydrogen ions
d.
Respiratory alkalosis from impaired gas exchange

c.
Metabolic acidosis from increased production of hydrogen ions

Increased body temperature is associated with hypermetabolism and increases the rate at which hydrogen ions are produced. Increased bicarbonate production would lead to metabolic alkalosis. Hyperkalemia leads to metabolic acidosis. Having a fever would not directly lead to gas exchange problems.

193

The nurse is providing discharge teaching. Which statement by the client indicates the need for further teaching regarding increased risk for metabolic alkalosis?
a.
“I don’t drink milk because it gives me gas and diarrhea.”
b.
“I have been taking digoxin every day for the last 15 years.”
c.
“I take sodium bicarbonate after every meal to prevent heartburn.”
d.
“In hot weather, I sweat so much that I drink six glasses of water each day.”

c.
“I take sodium bicarbonate after every meal to prevent heartburn.”

Excessive oral ingestion of sodium bicarbonate and other bicarbonate-based antacids can cause a metabolic alkalosis. Avoiding milk, taking digoxin, and sweating would not lead to increased risk of metabolic alkalosis.

194

A client with chronic respiratory acidosis is receiving oxygen by nasal cannula at 6 L/min. The client’s respiratory rate is 8 breaths/min. Which action by the nurse is the priority?
a.
Notify the Rapid Response Team and prepare for intubation.
b.
Change the nasal cannula to a mask and reassess in 10 minutes.
c.
Place the client in Fowler’s position if he or she is able to tolerate it.
d.
Decrease the flow rate of oxygen to 2 to 4 L/min, and reassess.

a.
Notify the Rapid Response Team and prepare for intubation.

The primary trigger for respiration in a client with chronic respiratory acidosis is a decreased arterial oxygen level (hypoxic drive). Oxygen therapy can inhibit respiratory efforts in this case, eventually causing respiratory arrest and death. The nurse could decrease the oxygen flow rate; eventually, this might improve the client’s respiratory rate, but the priority action would be to call the Rapid Response Team whenever a client with chronic carbon dioxide retention has a respiratory rate less than 10. Changing the cannula to a mask does nothing to improve the client’s hypoxic drive, nor would it address the client’s most pressing need. Positioning will not help the client breathe at a normal rate nor maintain client safety.

195

A client is being discharged from the emergency department with several broken ribs. For which acid-base imbalance does the nurse provide discharge teaching?
a.
Respiratory alkalosis from anxiety and hyperventilation
b.
Respiratory acidosis from inadequate ventilation
c.
Metabolic acidosis from calcium loss from broken bones
d.
Metabolic alkalosis from taking base-containing analgesics

b.
Respiratory acidosis from inadequate ventilation

Pain from broken ribs often causes the client to breathe more shallowly to avoid moving his or her ribs and increasing pain. If respiration is shallow enough, ventilation is inadequate, leading to poor gas exchange and respiratory acidosis. Hyperventilation would more likely cause respiratory alkalosis. The calcium loss from broken ribs probably would not affect acid-base balance. Taking analgesics as prescribed for pain probably also would not affect acid-base balance.

196

The nurse prepares to administer bicarbonate intravenously to the client with which clinical manifestations?
a.
pH 7.28, HCO3– 22 mEq/L, PCO2 52 mm Hg, PO2 82 mm Hg secondary to an acute asthma attack
b.
pH 7.28, HCO3– 16 mEq/L, PCO2 45 mm Hg, PO2 98 mm Hg secondary to excessive diarrhea
c.
Client with chronic emphysema and bronchitis who has the following arterial blood gases: pH 7.30, HCO3– 30 mEq/L, PCO2 60 mm Hg, PO2 72 mm Hg secondary to chronic bronchitis and emphysema
d.
pH 7.31, HCO3– 20 mEq/L, PCO2 34 mm Hg, PO2 96 mm Hg secondary to a urinary tract infection and type 2 diabetes

b.
pH 7.28, HCO3– 16 mEq/L, PCO2 45 mm Hg, PO2 98 mm Hg secondary to excessive diarrhea

The only client who has lower than normal bicarbonate levels is the client with diarrhea. This deficit is most likely the result of an actual bicarbonate loss, and bicarbonate should be replaced to help return this client’s acid-base balance to normal. Giving bicarbonate to any of the other clients listed would be adding too much base and would risk the development of alkalosis.

197

A client has metabolic alkalosis. Which laboratory results is the nurse most likely to assess as consistent with this condition?
a.
Na+ 134 mg/dL
b.
Mg2+ 1.5 mg/dL
c.
K+ 3.1 mEq/L
d.
Ca2+ 11.5 mg/dL

c.
K+ 3.1 mEq/L

Both potassium and hydrogen ions carry or express an overall positive charge (cations). Body fluids maintain electroneutrality by keeping the number of positive ions matched with an equal number of negative ions (anions). A compensation of alkalosis is the movement of hydrogen ions into cells inside the blood and other extracellular fluids. To prevent the blood from expressing too many positive charges, another positive ion must leave the blood and enter the cells. Potassium is the positive ion that usually is exchanged for a hydrogen ion. Thus, a relative hypokalemia usually accompanies alkalosis as extracellular potassium ions move into cells in exchange for intracellular hydrogen ions entering the extracellular fluid

198

A client is admitted with mixed respiratory and metabolic acidosis secondary to bronchitis and diabetic ketoacidosis. The nurse evaluates that teaching about the client’s confusion was effective when a family member makes which statement?
a.
“It is too early to tell if the ketoacidosis will cause permanent changes.”
b.
“Her memory will improve, but loss of some brain cells has occurred.”
c.
“The confusion should clear when oxygen and electrolyte levels are normal.”
d.
“The confusion should clear when blood glucose levels and other laboratory tests are normal.”

c.
“The confusion should clear when oxygen and electrolyte levels are normal.”

The pH abnormality alone is not responsible for the confusion. Most of the confusion is caused by hypoxia in combination with electrolyte imbalances that accompany severe combined acidosis. None of the other options address the client’s hypoxia.

199

A client is being discharged and continues to be at risk for developing metabolic alkalosis. Which statement by the client indicates to the nurse that teaching has been effective?
a.
“I will avoid excess use of antacids.”
b.
“I’ll drink at least three glasses of milk daily.”
c.
“I’ll avoid medications containing aspirin.”
d.
“I will not add salt to my food during meals.”

a.
“I will avoid excess use of antacids.”

Many antacids contain bicarbonate or calcium carbonate, both of which (when taken in excess) can increase the bicarbonate content of the blood and other extracellular fluids, increasing the risk for alkalosis even further. None of the other options address a risk factor for developing metabolic alkalosis.

200

In clients with any type of acid-base imbalance, the nurse places the priority on monitoring which electrolyte?
a.
Sodium
b.
Calcium
c.
Potassium
d.
Magnesium

c.
Potassium

Any type of acid-base imbalance usually alters the blood potassium level. Both potassium and hydrogen ions carry or express an overall positive charge (cations). Body fluids maintain electroneutrality by keeping the number of positive ions matched with an equal number of negative ions (anions). In acidosis, hydrogen ions enter cells in exchange for potassium ions. Thus, a relative hyperkalemia accompanies acidosis. In alkalosis, hydrogen ions leave the cells and enter the blood in exchange for potassium ions. Thus, a relative hypokalemia usually accompanies alkalosis as extracellular potassium ions move into cells in exchange for intracellular hydrogen ions entering the extracellular fluid. The normal potassium level of the blood has a narrow range (3.5 to 5.0 mEq/L). When blood potassium levels are too high, lethal cardiac dysrhythmias may occur. When blood potassium levels are too low, skeletal muscle weakness and respiratory failure may occur.

201

A client has acidosis. Which laboratory finding is of greatest concern to the nurse?
a.
Sodium 154 mEq/L
b.
Potassium 5.9 mEq/L
c.
Calcium 8.9 mg/dL
d.
Magnesium 2.1 mg/dL

b.
Potassium 5.9 mEq/L

In the client with acidosis, intracellular buffering leads to entry of hydrogen ions (H+) into cells, and in return potassium leaves the cell. This leads to elevated serum potassium levels. Many severe problems with acidosis are due to the accompanying hyperkalemia.

202

A client has the following arterial blood gases: pH 7.30, HCO3– 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg. Which intervention by the nurse is most appropriate?
a.
Prepare to give intravenous sodium bicarbonate.
b.
Document the findings and continue to assess.
c.
Assist the physician in determining the cause.
d.
Administer oxygen at 2 L per nasal cannula.

c.
Assist the physician in determining the cause.

The client has a partially compensated metabolic acidosis. Interventions are aimed at reducing or eliminating the cause. The nurse needs to assist in determining the cause so that proper interventions can be initiated. Sodium bicarbonate is rarely used for acidosis unless the pH is life threatening, or for specific causes of acidosis wherein bicarbonate deficit is known to be the problem. Simply documenting the findings will not help the client. Because the client’s PO2 is 98 mm Hg, oxygen therapy is not indicated on the basis of these arterial blood gases.

203

A client has the following arterial blood gases (ABGs): pH 7.30, HCO3– 22 mEq/L, PCO2 55 mm Hg, PO2 86 mm Hg. Which intervention by the nurse takes priority?
a.
Assessing the airway
b.
Administering bronchodilators
c.
Administering mucolytics
d.
Providing oxygen

a.
Assessing the airway

All interventions are important for clients with respiratory acidosis; this is indicated by the ABGs. However, the priority is assessing and maintaining an airway. Without a patent airway, other interventions will not be helpful.

204

A client has been NPO after a colectomy with nasogastric (NG) suction in place. On assessment, the nurse finds the client reporting cramps in the calves. Which action by the nurse is most appropriate?
a.
Document findings and notify the physician.
b.
Stop suction and request that the laboratory draw arterial blood gases.
c.
Prepare to administer lorazepam (Ativan).
d.
Raise the siderails and notify the physician.

d.
Raise the siderails and notify the physician.


The client has a metabolic alkalosis probably caused by prolonged suctioning. The client also is experiencing tetany, caused by the accompanying hypocalcemia, and is at risk for seizures. The priority is to maintain the client’s safety; this includes raising the siderails and then notifying the physician. Documentation is important but not as important as providing safety. The nurse would not stop the suction without an order. The client may need lorazepam if he or she has seizures, but this is not the first action the nurse would perform.

205

In the client with alkalosis, the nurse assesses for which clinical manifestations? (Select all that apply.)
a.
Positive Chvostek’s sign
b.
Positive Trousseau’s sign
c.
Hyporeflexia
d.
Bradycardia
e.
Elevated blood pressure
f.
Elevated urinary output

ANS: A, B, D

a.
Positive Chvostek’s sign
b.
Positive Trousseau’s sign
d.
Bradycardia

The client with alkalosis demonstrates signs of hypocalcemia and decreased heart rate. Many symptoms are the result of low calcium levels (hypocalcemia) and low potassium levels (hypokalemia), which usually occur with alkalosis. These problems change the function of the nervous, neuromuscular, cardiac, and respiratory systems.

206

The parents of a child with acid-base imbalance ask the nurse about mechanisms that regulate acid base balance. Which statement by the nurse accurately explains the mechanisms regulating acid-base
balance in children?
a. The respiratory, renal, and chemical-buffering systems
b. The kidneys balance acid; the lungs balance base
c. The cardiovascular and integumentary systems
d. The skin, kidney, and endocrine systems

a. The respiratory, renal, and chemical-buffering systems

The acid-base system is regulated by chemical buffering, respiratory control of carbon dioxide, and renal regulation of bicarbonate and secretion of hydrogen ions.

207

Which statement best describes why infants are at greater risk for dehydration than older children?

a. Infants have an increased ability to concentrate urine.
b. Infants have a greater volume of intracellular fluid.
c. Infants have a smaller body surface area.
d. Infants have an increased extracellular fluid volume.

d. Infants have an increased extracellular fluid volume.

The larger ratio of extracellular fluid to intracellular fluid predisposes the infant to dehydration.

208

Which action is the primary concern in the treatment plan for a child with persistent vomiting?

a. Detecting the cause of vomiting
b. Preventing metabolic acidosis
c. Positioning the child to prevent further vomiting
d. Recording intake and output

a. Detecting the cause of vomiting

The primary focus of managing vomiting is detection of the cause and then treatment of the cause.

209

A nurse is teaching parents about diarrhea. Which statement by the parents indicates understanding of the teaching?

a. Diarrhea results from a fluid deficit in the small intestine.
b. Organisms destroy intestinal mucosal cells, resulting in an increased intestinal surface area.
c. Malabsorption results in metabolic alkalosis.
d. Increased motility results in impaired absorption of fluid and nutrients.

d. Increased motility results in impaired absorption of fluid and nutrients.

Increased motility results in impaired absorption of fluid and nutrients.

210

Bodily fluids are composed of two elements; water and _____.

ANS: solutes

Water is the primary constituent of bodily fluids. An infant’s weight is approximately 75% water compared to the adult’s weight, which is 55% to 60% water. Solutes are composed of both electrolytes and nonelectrolytes. The body’s solutes include sodium, potassium, chloride, calcium, and magnesium.

211

Alterations in acid-base balance can affect cellular metabolism and enzymatic processes. When alterations in pH become too much for buffer systems to handle, compensatory mechanisms are activated. If the pH drops below normal than acidosis will occur. Is this statement true or false?

ANS: TRUE

Acidosis is the result of a drop in blood pH. The respiratory rate and depth will increase, removing carbon dioxide and raising blood

212

The patient had diarrhea for 5 days and developed an acid-base imbalance. Which statement would indicate that the nurse's teaching about the acid-base imbalance has been effective?
a.
"To prevent another problem, I should eat less sodium during diarrhea."
b.
"My blood became too acid because I lost some base in the diarrhea fluid."
c.
"Diarrhea removes fluid from the body, so I should drink more ice water."
d.
"I should try to slow my breathing so my acids and bases will be balanced."

b.
"My blood became too acid because I lost some base in the diarrhea fluid."

Diarrhea causes metabolic acidosis through loss of bicarbonate, which is a base. Eating less sodium during diarrhea increases the risk of ECV deficit. Although diarrhea does remove fluid from the body, it also removes sodium and bicarbonate which need to be replaced. Rapid deep respirations are the compensatory mechanism for metabolic acidosis and should be encouraged rather than stopped.

213

The patient has type B chronic obstructive pulmonary disease (COPD) exacerbated by an acute upper respiratory infection. Which blood gas values should the nurse expect to see?
a.
pH high, PaCO2 high, HCO3 high
b.
pH low, PaCO2 low, HCO3 low
c.
pH low, PaCO2 high, HCO3 high
d.
pH low, PaCO2 high, HCO3 normal

c.
pH low, PaCO2 high, HCO3 high

Type B COPD is a chronic disease that causes impaired excretion of carbonic acid, thus causing respiratory acidosis, with PaCO2 high and pH low. This chronic disease exists long enough for some renal compensation to occur, manifested by high HCO3. Answers that include low or normal bicarbonate are not correct, because the renal compensation for respiratory acidosis involves excretion of more hydrogen ions than usual, with retention of bicarbonate in the blood.

214

The patient has severe hyperthyroidism and will have surgery tomorrow. What assessment is most important for the nurse to assess in order to detect development of the acid-base imbalance for which the patient has highest risk?
a.
Urine output and color
b.
Level of consciousness
c.
Heart rate and blood pressure
d.
Lung sounds in lung bases

b.
Level of consciousness

Thyroid hormone increases metabolic rate, causing a patient with severe hyperthyroidism to have high risk of metabolic acidosis from increased production of metabolic acids. Metabolic acidosis decreases level of consciousness. Changes in urine output, urine color, and lung sounds are not signs of metabolic acidosis. Although metabolic acidosis often causes tachycardia, many other factors influence heart rate and blood pressure, including thyroid hormone.

215

The nurse is making a home visit to a child who has a chronic disease. Which finding has the greatest implication for acid-base aspects of this patient's care?
a.
Urine output is very small today.
b.
Whites of the eyes appear more yellow.
c.
Skin around the mouth is very chapped.
d.
Skin is sweaty under three blankets.

a.
Urine output is very small today.

Oliguria decreases the excretion of metabolic acids and is a risk factor for metabolic acidosis. Jaundice requires follow-up but is not an acid-base problem. Perioral chapped skin needs intervention but is not an acid-base issue. With three blankets, diaphoresis is not unusual.

216

The nurse has telephone messages from four patients who requested information and assistance. Which one should the nurse refer to a social worker or community agency first?
a.
"Is there a place that I can dispose of my unused morphine pills?"
b.
"I want to lose at least 20 pounds without getting sick this time."
c.
"I think I have asthma because I cough when dogs are near."
d.
"I ran out of money and am cutting my insulin dose in half."

d.
"I ran out of money and am cutting my insulin dose in half."

Decreasing an insulin dose by half creates high risk of diabetic ketoacidosis, and this patient has the highest priority. The other patients have less priority due to lower risk situations with longer time course before development of an acid-base imbalance. The coughing when dogs are near is not a sign of a severe asthma episode that causes respiratory acidosis, although this patient does need attention after the insulin situation is handled.

217

The patient is hyperventilating from anxiety and abdominal pain. Which assessment findings should the nurse attribute to respiratory alkalosis? (Select all that apply.)
a.
Skin pale and cold
b.
Tingling of fingertips
c.
Heart rate of 102
d.
Numbness around mouth
e.
Cramping in feet

ANS: B, D, E
b.
Tingling of fingertips
d.
Numbness around mouth
e.
Cramping in feet

Hyperventilation is a risk factor for respiratory alkalosis. Respiratory alkalosis can cause perioral and digital paresthesias and pedal spasms. Pallor, cold skin, and tachycardia are characteristic of activation of the sympathetic nervous system, not respiratory alkalosis.

218

Which statements said by patients indicate that the nurse's teaching regarding prevention of acid-base imbalances is successful? (Select all that apply.)
a.
"Baking soda is an effective and inexpensive antacid."
b.
"I should take my insulin on time every day."
c.
"My aspirin is on a high shelf away from children."
d.
"I have reliable transportation to dialysis sessions."
e.
"Fasting is a great way to lose weight rapidly."

ANS: B, C, D
b.
"I should take my insulin on time every day."
c.
"My aspirin is on a high shelf away from children."
d.
"I have reliable transportation to dialysis sessions."

Taking insulin as prescribed helps prevent diabetic ketoacidosis. Safeguarding aspirin from children prevents metabolic acidosis from increased acid intake. Regular dialysis reduces the risk of metabolic acidosis from decreased renal excretion of metabolic acid. Baking soda is sodium bicarbonate and should not be used as an antacid due to the risk of metabolic alkalosis. Fasting without carbohydrate intake is a risk factor for starvation ketoacidosis.

219

A 2-year-old child is brought into the emergency department after ingesting a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child?
a.
Respiratory alkalosis
b.
Respiratory acidosis
c.
Metabolic acidosis
d.
Metabolic alkalosis

b.
Respiratory acidosis

Respiratory depression leads to hypoventilation. Hypoventilation results in retention of CO2 and respiratory acidosis. Respiratory alkalosis would result from hyperventilation, causing a decrease in CO2 levels. Metabolic acid-base imbalance would be a result of kidney dysfunction, vomiting, diarrhea, or other conditions that affect metabolic acids.

220

A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe?
a.
Respiratory alkalosis
b.
Metabolic alkalosis
c.
Metabolic acidosis
d.
Respiratory acidosis

b.
Metabolic alkalosis

The patient is losing acid from the nasogastric tube so the patient will have metabolic alkalosis. Lung problems will produce respiratory alkalosis or acidosis. Metabolic acidosis will occur when too much acid is in the body like kidney failure.

221

Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis?
a.
pH 7.60, PaCO2 40 mm Hg, HCO3– 30 mEq/L
b.
pH 7.53, PaCO2 30 mm Hg, HCO3– 24 mEq/L
c.
pH 7.35, PaCO2 35 mm Hg, HCO3– 26 mEq/L
d.
pH 7.25, PaCO2 48 mm Hg, HCO3– 23 mEq/L

b.
pH 7.53, PaCO2 30 mm Hg, HCO3– 24 mEq/L

Respiratory alkalosis should show an alkalotic pH and decreased CO2 (respiratory) values, with a normal HCO3–. In this case, pH 7.53 is alkaline (normal = 7.35 to 7.45), PaCO2 is 30 (normal 35 to 45 mm Hg), and HCO3– is 24 (normal = 22 to 26 mEq/L). A result of pH 7.60, PaCO2 40 mm Hg, HCO3– 30 mEq/L is metabolic alkalosis. pH 7.35, PaCO2 35 mm Hg, HCO3– 26 mEq/L is within normal limits. pH 7.25, PaCO2 48 mm Hg, HCO3– 23 mEq/L is respiratory acidosis.

222

A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient?
a.
Renal
b.
Endocrine
c.
Respiratory
d.
Gastrointestinal

a.
Renal

The kidneys (renal) are responsible for respiratory acidosis compensation. A problem with the respiratory system causes respiratory acidosis, so another organ system (renal) needs to compensate. Problems with the gastrointestinal and endocrine systems can cause acid-base imbalances, but these systems cannot compensate for an existing imbalance.

223

The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which laboratory findings are consistent with metabolic acidosis?
a.
pH 7.3, PaCO2 36 mm Hg, HCO3– 19 mEq/L
b.
pH 7.5, PaCO2 35 mm Hg, HCO3– 35 mEq/L
c.
pH 7.32, PaCO2 47 mm Hg, HCO3– 23 mEq/L
d.
pH 7.35, PaCO2 40 mm Hg, HCO3– 25 mEq/L

a.
pH 7.3, PaCO2 36 mm Hg, HCO3– 19 mEq/L

The laboratory values that reflect metabolic acidosis are pH 7.3, PaCO2 36 mm Hg, HCO3– 19 mEq/L. A laboratory finding of pH 7.5, PaCO2 35 mm Hg, HCO3– 35 mEq/L is metabolic alkalosis. pH 7.32, PaCO2 47 mm Hg, HCO3– 23 mEq/L is respiratory acidosis. pH 7.35, PaCO2 40 mm Hg, HCO3– 25 mEq/L values are within normal range

224

A nurse is assisting the health care provider in inserting a central line. Which action indicates the nurse is following the recommended bundle protocol to reduce central line-associated bloodstream infections (CLABSI)?
a.
Preps skin with povidone-iodine solution.
b.
Suggests the femoral vein for insertion site.
c.
Applies double gloving without hand hygiene.
d.
Uses chlorhexidine skin antisepsis prior to insertion.

d.
Uses chlorhexidine skin antisepsis prior to insertion.

A recommended bundle at insertion of a central line is hand hygiene prior to catheter insertion; use of maximum sterile barrier precautions upon insertion; chlorhexidine skin antisepsis prior to insertion and during dressing changes; avoidance of the femoral vein for central venous access for adults; and daily evaluation of line necessity, with prompt removal of non-essential lines. Povidone-iodine is not recommended.

225

Which of these patients who have arrived at the human immunodeficiency virus (HIV) clinic should the nurse assess first?
a.
Patient whose rapid HIV-antibody test is positive
b.
Patient whose latest CD4+ count has dropped to 250/µL
c.
Patient who has had 10 liquid stools in the last 24 hours
d.
Patient who has nausea from prescribed antiretroviral drugs

c.
Patient who has had 10 liquid stools in the last 24 hours

The nurse should assess the patient for dehydration and hypovolemia. The other patients also will require assessment and possible interventions, but do not require immediate action to prevent complications such as hypovolemia and shock.

226

The registered nurse (RN) caring for an HIV-positive patient admitted with tuberculosis can delegate which action to unlicensed assistive personnel (UAP)?
a.
Teach the patient how to dispose of tissues with respiratory secretions.
b.
Stock the patient’s room with the necessary personal protective equipment.
c.
Interview the patient to obtain the names of family members and close contacts.
d.
Tell the patient’s family members the reason for the use of airborne precautions.

b.
Stock the patient’s room with the necessary personal protective equipment.

A patient diagnosed with tuberculosis would be placed on airborne precautions. Because all health care workers are taught about the various types of infection precautions used in the hospital, the UAP can safely stock the room with personal protective equipment. Obtaining contact information and patient teaching are higher-level skills that require RN education and scope of practice.

227

According to the Center for Disease Control and Prevention (CDC) guidelines, which personal protective equipment will the nurse put on before assessing a patient who is on contact precautions for Clostridium difficile diarrhea (select all that apply)?
a.
Mask
b.
Gown
c.
Gloves
d.
Shoe covers
e.
Eye protection

ANS: B, C
b.
Gown
c.
Gloves

Because the nurse will have substantial contact with the patient and bedding when doing an assessment, gloves and gowns are needed. Eye protection and masks are needed for patients in contact precautions only when spraying or splashing is anticipated. Shoe covers are not recommended in the CDC guidelines.

228

The nurse plans a presentation for community members about how to decrease the risk for antibiotic-resistant infections. Which information will the nurse include in the teaching plan (select all that apply)?
a.
Antibiotics may sometimes be prescribed to prevent infection.
b.
Continue taking antibiotics until all of the prescription is gone.
c.
Unused antibiotics that are more than a year old should be discarded.
d.
Antibiotics are effective in treating influenza associated with high fevers.
e.
Hand washing is effective in preventing many viral and bacterial infections.

ANS: A, B, E
a.
Antibiotics may sometimes be prescribed to prevent infection.
b.
Continue taking antibiotics until all of the prescription is gone.
e.
Hand washing is effective in preventing many viral and bacterial infections.

All prescribed doses of antibiotics should be taken. In some situations, such as before surgery, antibiotics are prescribed to prevent infection. There should not be any leftover antibiotics because all prescribed doses should be taken. However, if there are leftover antibiotics, they should be discarded immediately because the number left will not be enough to treat a future infection. Hand washing is generally considered the single most effective action in decreasing infection transmission. Antibiotics are ineffective in treating viral infections such as influenza.

229

After an infection control in-service, which statement by the nurse demonstrates an accurate understanding of the mode of transmission of influenza?
a.
“I will not develop the infection unless I have physical contact with the client.”
b.
“I should wear an N95 respirator to provide care for the client with influenza.”
c.
“I should try to stay at least 3 feet away from the client, if at all possible.”
d.
“The infection is spread through droplets suspended in the air and inhaled.”

c.
“I should try to stay at least 3 feet away from the client, if at all possible.”

Influenza is transmitted via droplets. Droplets are produced when a person talks or sneezes and travel short distances (up to 3 feet) but are not suspended in the air for long. Staff should stay at least 3 feet (1 m) away from a client with droplet infection. Actual physical contact with the client is not necessary for infection to occur. It is not necessary for staff to wear an N95 respirator mask for Droplet Precautions; these masks are used in the care of clients with tuberculosis

230

A client and his family are waiting for the results of clinical tests to determine whether the client has an infection. They are becoming anxious. What is the most important assessment that the nurse should make of the client and family members?
a.
Understanding of insurance reimbursement for testing
b.
Use of appropriate coping mechanisms for anxiety
c.
Understanding of the infectious disease process
d.
Understanding of the diagnostic procedures

d.
Understanding of the diagnostic procedures

Assess the client’s and family’s level of understanding about various diagnostic procedures and the time required to obtain test results. This is more important than whether the family has any understanding of their insurance and will help reduce anxiety if understanding is accurate. The client with an infectious disease often has psychosocial concerns. Delay in diagnosis caused by the need to wait for clinical test results produces anxiety. Plan education on infection risk reduction when the client and the family are ready to learn.

231

The nurse is preparing to administer a prescribed IV antibiotic to a client admitted with a serious infection. Which action by the nurse is most important?
a.
Check the IV for patency.
b.
Assess the client for allergies.
c.
Double check the “five rights.”
d.
Teach the client about the drug.

b.
Assess the client for allergies.

All actions are appropriate and important before administering any medications. However, client safety is the priority. The nurse should first assess the client for medication allergies by asking the client or checking the chart (or both). Ensuring a patent IV and checking the five rights will not protect the client from an allergic reaction.

232

The nurse is assigned to work with a new nursing assistant. Which action by the nursing assistant requires intervention by the registered nurse?
a.
Using an alcohol-based hand rub after caring for a client with diarrhea
b.
Washing hands for 20 seconds using warm water and friction
c.
Cleaning especially carefully under fingernails and around a wedding band
d.
Using chlorhexidine for handwashing when caring for clients on neutropenic precautions

a.
Using an alcohol-based hand rub after caring for a client with diarrhea

Alcohol-based hand rubs are not effective against spore-forming organisms such as Clostridium difficile, which is a common cause of diarrhea among hospitalized clients. The nursing assistant should wash hands with soap after caring for such clients in case they have an undiagnosed infection with this bacterium. The other actions are appropriate

233

A client comes to the emergency department with a fever, diarrhea, and general malaise. Which information obtained during assessment does the nurse communicate immediately to the health care provider?
a.
Blood pressure of 110/90 mm Hg
b.
Allergy to aspirin
c.
The client having just returned from a 14-day trip to Asia
d.
A blood transfusion 12 years ago

c.
The client having just returned from a 14-day trip to Asia

Travel can expose the client to infectious organisms that he or she might not ordinarily encounter in the local community, increasing the chance that infection could lead to illness. The client’s diastolic blood pressure is slightly high but would not need to be reported immediately. The aspirin allergy should be noted on the client’s chart but most likely will not be a factor in the client’s immediate problem. A blood transfusion 12 years ago would not likely be the cause of the client’s current problems.

234

An older adult client is admitted with an infection. On assessment, the nurse finds the client slightly confused. Vital signs are as follows: temperature 99.2° F (37.3° C), blood pressure 100/60 mm Hg, pulse 100, and respiratory rate 20. Which action by the nurse is most appropriate?
a.
Perform a Mini-Mental Status Examination.
b.
Assess the client for other signs of infection.
c.
Document the findings and continue to monitor.
d.
Assess the client’s pain level and treat if needed.

b.
Assess the client for other signs of infection.

Because of an age-related decline in immune function, an older adult’s normal temperature may be 1° to 2° lower than normal. A temperature of 99.2° F may be a fever in this population. Often a change in mental status is an early sign of illness for the older adult. The nurse should assess for other indications of infection.

235

A client has scabies. In addition to Standard Precautions, which information is most important to communicate to visitors and health care providers?
a.
Do not allow children to visit.
b.
Wear gloves when entering the room.
c.
Wear a mask when within 3 feet of the client.
d.
Keep head covered when providing care.

b.
Wear gloves when entering the room.

Contact Precautions are necessary when providing care to a client infected with the skin parasite scabies. Gloves are required when entering a contact isolation room.

236

A client has been admitted for the second time to treat tuberculosis (TB). Which referral does the nurse initiate as a priority?
a.
Social worker to see if the client can afford the medications
b.
Visiting nurses to arrange directly observed therapy on dismissal
c.
Psychiatric nurse liaison to assess reasons for noncompliance
d.
Infection control nurse to arrange testing for drug resistance

b.
Visiting nurses to arrange directly observed therapy on dismissal

The client has a risk of noncompliance as evidenced by the second admission to treat TB. When the client is dismissed, he or she most likely will need to be placed on directly observed therapy to ensure compliance. The other referrals may be appropriate depending on the client’s needs.

237

The nurse is caring for a client with a suspected infection. Which action by the nurse is most appropriate?
a.
Give antibiotics as soon as possible to prevent sepsis.
b.
Obtain all required cultures, then administer the antibiotic.
c.
Wait for culture results to give the most appropriate antibiotic.
d.
Defer cultures unless the client shows signs of drug resistance.

b.
Obtain all required cultures, then administer the antibiotic.

The best diagnostic test for infection is a culture and sensitivity. The nurse should first collect any ordered cultures. Then the nurse should administer the ordered antibiotic. Because final culture results take 72 hours, empiric antibiotic therapy should be started before the results are back.

238

The nurse reviews laboratory results for a client and notes that the erythrocyte sedimentation rate (ESR) is 32 mm/hr. What action by the nurse is best?
a.
Document the findings and call the health care provider.
b.
Assess the client for any manifestations of infection or inflammation.
c.
Review the client’s chart to see what medications have been given.
d.
Call the physician and request blood cultures and a chest x-ray.

b.
Assess the client for any manifestations of infection or inflammation.

The ESR is elevated (normal is <20 mm/hr) and indicates inflammation, which could be the result of an infectious process. The nurse should assess the client for manifestations of infection or inflammation before notifying the health care provider. Documentation is always important. Medications would not affect the ESR. Cultures and x-rays may be ordered, but not until the client has been thoroughly assessed.

239

A client is admitted with infection and a high fever. Which assessments by the nurse take priority? (Select all that apply.)
a.
Blood pressure
b.
Mental status
c.
Pulse quality
d.
Respiratory effort
e.
Skin turgor
f.
Bowel sounds

ANS: A, B, C, E
a.
Blood pressure
b.
Mental status
c.
Pulse quality
e.
Skin turgor

Dehydration can accompany fever, especially if the client is sweating profusely. Blood pressure, pulse quality, and skin turgor are assessments of fluid status. Mental status changes can accompany fluid losses, especially in older clients

240

The nurse is assessing a client’s skin for local signs of infection. Which signs does the nurse assess for? (Select all that apply.)
a.
Fever
b.
Redness
c.
Warmth
d.
Pain
e.
Swelling
f.
Increased erythrocyte sedimentation rate (ESR)

ANS: B, C, D, E
b.
Redness
c.
Warmth
d.
Pain
e.
Swelling

Localized signs of infection include redness, warmth, pain, swelling, heat, and pus. Fever and increased ESR are systemic signs of infection.

241

Which action should the nurse plan to prevent aspiration in a high-risk patient?
a.
Turn and reposition an immobile patient at least every 2 hours.
b.
Place a patient with altered consciousness in a side-lying position.
c.
Insert a nasogastric tube for feeding a patient with high calorie needs.
d.
Monitor respiratory symptoms in a patient who is immunosuppressed.

b.
Place a patient with altered consciousness in a side-lying position.

With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and O2 saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration.

242

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?
a.
Teach about the reason for the blood tests.
b.
Schedule an appointment for a chest x-ray.
c.
Teach the patient about providing specimens for 3 consecutive days.
d.
Instruct the patient to collect several separate sputum specimens today.

c.
Teach the patient about providing specimens for 3 consecutive days.

Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for Mycobacterium tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB.

243

A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider’s order to discontinue airborne precautions unless which assessment finding is documented?
a.
Chest x-ray shows no upper lobe infiltrates.
b.
TB medications have been taken for 6 months.
c.
Mantoux testing shows an induration of 10 mm.
d.
Sputum smears for acid-fast bacilli are negative.

d.
Sputum smears for acid-fast bacilli are negative.

Repeated negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment.

244

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?
a.
“I will take the bus instead of driving.”
b.
“I will stay indoors whenever possible.”
c.
“My spouse will sleep in another room.”
d.
“I will keep the windows closed at home.”

c.
“My spouse will sleep in another room.”

Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation.

245

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient’s illness?
a.
Ask the patient about any visual changes in red-green color discrimination.
b.
Question the patient about experiencing shortness of breath, hives, or itching.
c.
Explain that orange discolored urine and tears are normal while taking this medication.
d.
Advise the patient to stop the drug and report the symptoms to the health care provider.

c.
Explain that orange discolored urine and tears are normal while taking this medication.

Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop taking the medication. The findings are not indicative of an allergic reaction. Alterations in red-green color discrimination commonly occurs when taking ethambutol, which is a different tuberculosis medication.

246

An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding?
a.
Yellow-tinged sclera
b.
Orange-colored sputum
c.
Thickening of the fingernails
d.
Difficulty hearing high-pitched voices

a.
Yellow-tinged sclera

Noninfectious hepatitis is a toxic effect of isoniazid, rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.

247

A patient diagnosed with active tuberculosis (TB) is homeless and has a history of alcohol abuse. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?
a.
Repeat warnings about the high risk for infecting others several times.
b.
Give the patient written instructions about how to take the medications.
c.
Arrange for a daily meal and drug administration at a community center.
d.
Arrange for the patient’s friend to administer the medication on schedule.

c.
Arrange for a daily meal and drug administration at a community center.

Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient’s situation.

248

After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?
a.
Teach about drug-resistant TB.
b.
Schedule directly observed therapy.
c.
Ask the patient whether medications have been taken as directed.
d.
Discuss the need for an injectable antibiotic with the health care provider.

c.
Ask the patient whether medications have been taken as directed.

The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated.

249

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse?
a.
Use and side effects of isoniazid
b.
Standard four-drug therapy for TB
c.
Need for annual repeat TB skin testing
d.
Bacille Calmette-Guérin (BCG) vaccine

a.
Use and side effects of isoniazid

The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test result. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection.

250

The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse?
a.
The patient is offered a tissue from the box at the bedside.
b.
A surgical face mask is applied before visiting the patient.
c.
A snack is brought to the patient from the unit refrigerator.
d.
Hand washing is performed before entering the patient’s room.

b.
A surgical face mask is applied before visiting the patient.

A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient’s room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before entering the patient’s room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The student nurse should perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.

251

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?
a.
Chest x-ray via stretcher
b.
Blood cultures from two sites
c.
Ciprofloxacin (Cipro) 400 mg IV
d.
Acetaminophen (Tylenol) rectal suppository

b.
Blood cultures from two sites

Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest x-ray and acetaminophen administration can be done last.

252

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first?
a.
Codeine
c.
Acetaminophen (Tylenol)
b.
Guaifenesin
d.
Piperacillin/tazobactam (Zosyn)

d.
Piperacillin/tazobactam (Zosyvn)

Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.

253

A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider?
a.
The Mantoux test had an induration of 7 mm.
b.
The chest-x-ray showed infiltrates in the lower lobes.
c.
The patient has a cough that is productive of blood-tinged mucus.
d.
The patient is being treated with antiretrovirals for HIV infection.

d.
The patient is being treated with antiretrovirals for HIV infection.

Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat TB. The other data are expected in a patient with HIV and TB.

254

The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?
a.
UAP assist the patient to ambulate to the bathroom.
b.
UAP help splint the patient’s chest during coughing.
c.
UAP transfer the patient to a bedside chair for meals.
d.
UAP lower the head of the patient’s bed to 15 degrees.

d.
UAP lower the head of the patient’s bed to 15 degrees.

Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia.

255

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?
a.
“Do you take any over-the-counter (OTC) medications?”
b.
“Do you have any family members with a history of TB?”
c.
“How long has it been since you moved to the United States?”
d.
“Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?”

d.
“Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?”

Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (e.g., chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing.

256

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching?
a.
Listening to the patient’s lung sounds several times during the shift
b.
Placing the patient on droplet precautions in a private hospital room
c.
Monitoring patient serology results to identify the infecting organism
d.
Increasing the O2 flow rate to keep the O2 saturation over 90%

b.
Placing the patient on droplet precautions in a private hospital room

Fungal infections are not transmitted from person to person. Therefore no isolation procedures are necessary. The other actions by the new nurse are appropriate.

257

A client has multidrug-resistant tuberculosis (TB). What is the most important fact for the nurse to teach the client?
a.
“You will need to take medications longer than clients with other strains.”
b.
“You will need to remain in the hospital until cultures are negative.”
c.
“You will need to wear a mask when you go out in public.”
d.
“You will need to have drug cultures done weekly.”

c.
“You will need to wear a mask when you go out in public.”

The client should wear a mask when out of the home environment and in crowds to prevent spread of the infection. The other statements are not accurate.

258

The newly employed nurse received a bacillus Calmette-Guérin (BCG) vaccine before moving to the United States. The nurse needs to receive a tuberculin (TB) test as part of the pre-employment physical. What does the nurse do?
a.
The nurse should not receive the tuberculin test.
b.
The nurse will need a two-step TB test.
c.
The nurse will need a chest x-ray instead.
d.
A physician should examine the nurse before the TB test is given.

c.
The nurse will need a chest x-ray instead.

The bacillus Calmette-Guérin (BCG) vaccine contains attenuated tubercle bacilli and is used in many countries to produce increased resistance to TB. The nurse will have a positive skin test. The client should be evaluated for TB with a chest x-ray. A physician examination is not necessary.

259

The nurse is caring for several clients on a respiratory floor. The nurse should place the client with which condition in isolation?
a.
Fever and weight loss
b.
Negative QuantiFERON TB gold test
c.
Negative acid-fast bacillus (AFB) stain
d.
Positive nucleic acid amplification test (NAAT)

d.
Positive nucleic acid amplification test (NAAT)

The NAAT is a new rapid test for the diagnosis of tuberculosis (TB). Results are available in less than 2 hours. A positive test is conclusive for TB, and the client should be placed in isolation per facility policy. A client with a negative QuantiFERON gold test would not have tuberculosis. Likewise, a client with a negative AFB would not have tuberculosis. The client with fever and weight loss could have tuberculosis, but diagnostic tests would be needed because these are nonspecific manifestations.

260

The nurse is worried that a client who is not entirely reliable is being discharged home on therapy for multidrug-resistant tuberculosis. What strategy is the best to use for this client?
a.
Directly observed therapy
b.
IV drug administration
c.
Remaining in the hospital
d.
Isolation

a.
Directly observed therapy

If a client is “not reliable,” the risk is that the client will not take medications as required, causing spread of an organism that may become more drug resistant. The other answers are not correct.

261

A client has a tuberculin skin test as a pre-employment physical requirement. Which statement by the nurse is best made to the client who has the test result seen in the photograph below?

a.
“Your PPD is negative. No further follow-up is necessary.”
b.
“You will need to have a second PPD.”
c.
“You will need to have titers drawn.”
d.
“You will need further testing.”

d.
“You will need further testing.”

The tuberculin test (Mantoux test) result is the most commonly used reliable test of TB infection. The photo shows a positive reaction. A positive reaction does not mean that active disease is present but indicates exposure to TB or the presence of inactive (dormant) disease. Conclusive evidence of TB is not provided through an examination of the chest or a chest x-ray. Only a sputum specimen will provide definitive evidence of the disease process

262

A client who previously had a bacillus Calmette-Guérin (BCG) vaccine has a positive tuberculosis (TB) test. What symptoms assist in determining that the client has active disease? (Select all that apply.)
a.
Nausea
b.
Weight loss
c.
Insomnia
d.
Ankle edema
e.
Night sweats
f.
Increased urination

ANS: A, B, E
a.
Nausea
b.
Weight loss
e.
Night sweats

TB symptoms include nausea and weight loss, as well as night sweats. Inability to sleep and ankle edema are not typical symptoms. Increased urination also is not a typical symptom.

263

A client started on therapy for tuberculosis infection is reporting nausea. What does the nurse teach this client? (Select all that apply.)
a.
Eat a diet rich in protein, iron, and vitamins.
b.
Do not drink fluids with medications.
c.
Take medications at bedtime.
d.
Space medications 12 hours apart.
e.
Take medications with milk.
f.
Take an antiemetic daily.

ANS: A, C, F
a.
Eat a diet rich in protein, iron, and vitamins.
c.
Take medications at bedtime.
f.
Take an antiemetic daily.

Taking the daily dose of medications at bedtime may help to decrease nausea. A well-balanced diet with foods rich in iron, protein, and vitamins C and B also helps to decrease nausea. Antiemetics are often prescribed. Drinking fluids with medications should not influence the nausea; neither should taking medications with milk. Spacing medications 12 hours apart is not recommended therapy.

264

A 46-yr-old female patient returns to the clinic with recurrent dysuria after being treated with trimethoprim and sulfamethoxazole for 3 days. Which action will the nurse plan to take?

a. Remind the patient about the need to drink 1000 mL of fluids daily.

b. Obtain a midstream urine specimen for culture and sensitivity testing.

c. Suggest that the patient use acetaminophen (Tylenol) to relieve symptoms.

d. Teach the patient to take the prescribed trimethoprim and sulfamethoxazole for 3 more days.

ANS: B

b. Obtain a midstream urine specimen for culture and sensitivity testing.
Obtain a midstream urine specimen for culture and sensitivity testing.

Because uncomplicated urinary tract infections (UTIs) are usually successfully treated with 3 days of antibiotic therapy, this patient will need a urine culture and sensitivity to determine appropriate antibiotic therapy. Acetaminophen would not be as effective as other over-the-counter medications such as phenazopyridine in treating dysuria. The fluid intake should be increased to at least 1800 mL/day. Because the UTI has persisted after treatment with trimethoprim and sulfamethoxazole , the patient is likely to need a different antibiotic.

265

The nurse determines that instruction regarding prevention of future urinary tract infections (UTIs) has been effective for a 22-yr-old female patient with cystitis when the patient states which of the following?
a.
“I can use vaginal antiseptic sprays to reduce bacteria.”
b.
“I will drink a quart of water or other fluids every day.”
c.
“I will wash with soap and water before sexual intercourse.”
d.
“I will empty my bladder every 3 to 4 hours during the day.”

d.
“I will empty my bladder every 3 to 4 hours during the day.”

Voiding every 3 to 4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary to prevent UTI. A quart of fluids is insufficient to provide adequate urine output to decrease risk for UTI.

266

Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine?
a.
Take phenazopyridine for at least 7 days.
b.
Phenazopyridine may cause photosensitivity
c.
Phenazopyridine may change the urine color
d.
Take phenazopyridine before sexual intercourse.

c.
Phenazopyridine may change the urine color

Patients should be taught that phenazopyridine will color the urine deep orange. Urinary analgesics should only be needed for a few days until the prescribed antibiotics decrease the bacterial count. Phenazopyridine does not cause photosensitivity. Taking phenazopyridine before intercourse will not be helpful in reducing the risk for UTI.

267

Which finding by the nurse will be most helpful in determining whether a 67-yr-old patient with benign prostatic hyperplasia has an upper urinary tract infection (UTI)?
a.
Bladder distention
c.
Suprapubic discomfort
b.
Foul-smelling urine
d.
Costovertebral tenderness

d.
Costovertebral tenderness

Costovertebral tenderness is characteristic of pyelonephritis. Bladder distention, foul-smelling urine, and suprapubic discomfort are characteristic of a lower UTI and are likely to be present if the patient also has an upper UTI.

268

A 68-yr-old female patient admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action should be included in the plan of care?

a. Restrict fluids between meals and after the evening meal.

b. Insert an indwelling catheter until the symptoms have resolved.

c. Assist the patient to the bathroom every 2 hours during the day.

d. Apply absorbent adult incontinence diapers and pads over the bed linens.

ANS: C

c. Assist the patient to the bathroom every 2 hours during the day.

In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for urinary tract infection. Incontinent pads and diapers increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration.

269

Nursing staff on a hospital unit are reviewing rates of health care-associated infections (HAI) of the urinary tract. Which nursing action will be most helpful in decreasing the risk for urinary HAI in patients admitted to the hospital?

a. Testing urine with a dipstick daily for nitrites

b. Avoiding unnecessary urinary catheterizations

c. Encouraging adequate oral fluid and nutritional intake

d. Providing perineal hygiene to patients daily and as needed

ANS: B

b. Avoiding unnecessary urinary catheterizations

Because catheterization bypasses many of the protective mechanisms that prevent urinary tract infection (UTI), avoidance of catheterization is the most effective means of reducing HAI. The other actions will also be helpful but are not as useful as decreasing urinary catheter use.

270

Which assessment data reported by a patient is consistent with a lower urinary tract infection (UTI)?

a. Low urine output
c. Nausea and vomiting
b. Bilateral flank pain
d. Burning on urination

ANS: D

d. Burning on urination

Pain with urination is a common symptom of a lower UTI. Urine output does not decrease, but frequency may be experienced. Flank pain and nausea are associated with an upper UTI.

271

A client has a fungal urinary tract infection. Which assessment by the nurse is most helpful?

a. Palpating and percussing the kidneys and bladder
b. Assessing medical history and current medical problems
c. Performing a bladder scan to assess post-void residual
d. Inquiring about recent travel to foreign countries

ANS: B

b. Assessing medical history and current medical problems

Clients who are severely immune compromised or who have diabetes mellitus are more prone to fungal urinary tract infection. The nurse should assess for these factors. A physical examination and a post-void residual may be needed, but not until further information is obtained. Travel to foreign countries probably would not be as important, because even if exposed, the client needs some degree of immune compromise to develop a fungal urinary tract infection.

272

The nurse is assessing the laboratory findings of a client with a urinary tract infection. The laboratory report notes a “shift to the left” in a client’s white blood cell count. Which action by the nurse is most appropriate?

a. Request that the laboratory perform a differential analysis on the white blood cells.

b. Notify the health care provider and start an IV line for parenteral antibiotics.

c. Instruct the client to begin straining all urine for renal calculi.

d. Document the finding in the client’s chart and continue to monitor.

ANS: B

b. Notify the health care provider and start an IV line for parenteral antibiotics.

A left shift most commonly occurs with urosepsis and is seen rarely with uncomplicated urinary tract infections. The nurse will be administering antibiotics, most likely via IV, so he or she should notify the provider and prepare to give the antibiotics. The shift to the left is part of a differential white blood cell count. The client would not need to strain urine for stones, and because sepsis carries a high mortality rate, the nurse should not just note the findings as the only action.

273

Which client statement indicates a good understanding regarding antibiotic therapy for recurrent urinary tract infections?

a. “If my urine becomes lighter and clearer, I can stop taking my medicine.”

b. “Even if I feel completely well, I should take the medication until it is gone.”

c. “When my urine no longer burns, I will no longer need to take the antibiotics.”

d. “If I have a fever higher than 100° F (37.8° C), I should take twice as much medicine.”

ANS: B

b. “Even if I feel completely well, I should take the medication until it is gone.”

Antibiotic therapy is most effective, especially for recurrent urinary tract infections, when the client takes the prescribed medication for the entire course, not just when symptoms are present. The other statements demonstrate that additional teaching is needed for the client.

274

A client is hospitalized with urinary retention, has an indwelling catheter, and is getting IV fluids. Which intervention does the nurse add to the care plan to address the priority problem for this client?

a. Perform catheter care per policy every shift.

b. Encourage fluid intake to 1 liter/day.

c. Apply a moisture barrier cream daily.

d. Document accurate intake and output (I&O) each shift.

ANS: A

a. Perform catheter care per policy every shift.

The most common cause of sepsis in hospitalized clients is a urinary tract infection. Ascending infection from cystitis with an indwelling catheter is a major source of such infections. Encouraging fluids and documenting I&O are probably important interventions, but they do not take priority over preventing a catheter-related infection. Moisture barrier cream would not be needed.

275

A client has been admitted from a nursing home for a workup to determine the cause of several recent falls. What intervention by the nurse takes priority?

a. Obtain a clean catch or catheterized urine specimen.

b. Document the number of and causative factors for falls.

c. Review the results of recent laboratory work for kidney function.

d. Facilitate neurologic and social work consultations.

ANS: A

a. Obtain a clean catch or catheterized urine specimen.

Although all interventions are or might be important, obtaining a urine sample for urinalysis takes priority. Often UTI symptoms in older adults are atypical, and a UTI may present with new onset of confusion or of falling.

276

A young woman is being treated with amoxicillin (Amoxil) for a urinary tract infection. Which is the highest priority instruction for the nurse to give this client?

a. “Use a second form of birth control while on the drug.”

b. “You will experience increased menstrual bleeding while on this drug.”

c. “You may experience an irregular heartbeat while on the drug.”

d. “Watch for blood in your urine while taking this drug.”

ANS: A

a. “Use a second form of birth control while on the drug.”

The client should use a second form of birth control because penicillin seems to reduce the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding, an irregular heartbeat, or blood in her urine while taking the medication.

277

A client is receiving treatment with liquid nitrofurantoin (Furadantin). Which is the highest priority instruction that the nurse can provide to this client regarding accurate administration of the medication?

a. “The medication should be mixed with cold water before drinking it.”

b. “Urine will turn orange immediately after you swallow the drug.”

c. “You should ask the pharmacist for a syringe to measure the dose.”

d. “The drug is available in granules that must be dissolved.”

ANS: C

c. “You should ask the pharmacist for a syringe to measure the dose.”

Nitrofurantoin is available in a suspension that must be measured accurately for the correct dose. Common household spoons are not accurate for this task, and the client should request a syringe from the pharmacist. The medication does not have to be mixed before taking, and it will not discolor the urine. The drug is not available in granules that are dissolved.

278

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient’s nose. Which admission order should the nurse question?

a. Keep the head of bed elevated.
b. Insert nasogastric tube to low suction.
c. Turn patient side to side every 2 hours.
d. Apply cold packs intermittently to face.

ANS: B

b. Insert nasogastric tube to low suction.

Rhinorrhea may indicate a dural tear with cerebrospinal fluid leakage. Insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold packs are appropriate orders.

279

A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care?

a. Encourage family members to remain at the bedside.

b. Apply soft restraints to protect the patient from injury.

c. Keep the room well-lighted to improve patient orientation.

d. Minimize contact with the patient to decrease sensory input.

ANS: A

a. Encourage family members to remain at the bedside.

Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications. The use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim.

280

The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective?

a. Emphasize the importance of hand washing.

b. Immunize adolescents and college freshman.

c. Support serving healthy nutritional options in the college cafeteria.

d. Encourage adolescents and young adults to avoid crowds in the winter.

ANS: B

b. Immunize adolescents and college freshman.

The Neisseria meningitides vaccination is recommended for children ages 11 and 12 years, unvaccinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, and good nutrition may increase resistance to infection. but those are not as effective as immunization. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.

281

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?

a. The patient receives a regular diet tray.
b. The bedrails on both sides of the bed are elevated.
c. Staff have turned off the lights in the patient’s room.
d. Staff have entered the patient’s room without a mask.

ANS: D
.
Staff have entered the patient’s room without a mask.

Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the foot and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.

282

When assessing a 53-yr-old patient with bacterial meningitis, the nurse obtains the following data. Which finding requires the most immediate intervention?

a. The patient exhibits nuchal rigidity.
b. The patient has a positive Kernig’s sign.
c. The patient’s temperature is 101° F (38.3° C).
d. The patient’s blood pressure is 88/42 mm Hg.

ANS: D

d. The patient’s blood pressure is 88/42 mm Hg.

Shock is a serious complication of meningitis, and the patient’s low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig’s sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension.

283

Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit?

a. A 45-yr-old patient receiving IV antibiotics for meningococcal meningitis

b. A 35-yr-old patient with intracranial pressure (ICP) monitoring after a head injury

c. A 25-yr-old patient admitted with a skull fracture and craniotomy the previous day

d. A 55-yr-old patient who has increased intracranial pressure (ICP) and is receiving hyperventilation therapy

ANS: A

a. A 45-yr-old patient receiving IV antibiotics for meningococcal meningitis

An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The patient recovering from a craniotomy, the patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients.

284

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding indicates a possible complication that should be reported to the health care provider?

a. Complaint of severe headache
b. Large contusion behind left ear
c. Bilateral periorbital ecchymosis
d. Temperature of 101.4° F (38.6° C)

ANS: D

d. Temperature of 101.4° F (38.6° C)

Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the health care provider. The other findings are typical of a patient with a basilar skull fracture.

285

A patient being admitted with bacterial meningitis has a temperature of 102.5° F (39.2° C) and a severe headache. Which order should the nurse implement first?

a. Administer ceftizoxime (Cefizox) 1 g IV.
b. Give acetaminophen (Tylenol) 650 mg PO.
c. Use a cooling blanket to lower temperature.
d. Swab the nasopharyngeal mucosa for cultures.

ANS: D

d. Swab the nasopharyngeal mucosa for cultures.

Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.

286

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question?

a. Restrict oral fluids to 1000 mL/day.
b. Elevate the head of the bed 20 degrees.
c. Administer ceftriaxone (Rocephin) 1 g IV every 12 hours.
d. Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.

ANS: A

a. Restrict oral fluids to 1000 mL/day.

The patient with meningitis has increased fluid needs, so oral fluids should be encouraged. The other actions are appropriate. Slight elevation of the head of the bed will decrease headache without causing leakage of cerebrospinal fluid from the lumbar puncture site. Antibiotics should be administered until bacterial meningitis is ruled out by the cerebrospinal fluid analysis.

287

The nurse is taking the health history of a client suspected of having bacterial meningitis. Which question is most important for the nurse to ask?

a. “Do you live in a crowded residence?”
b. “When was your last tetanus vaccination?”
c.“Have you had any viral infections recently?”
d. “Have you traveled out of the country in the last month?”

ANS: A

a. “Do you live in a crowded residence?”

Meningococcal meningitis tends to occur in outbreaks. It is most likely to occur in areas of high-density population, such as college dormitories, prisons, and military barracks. The other questions do not identify risk factors for bacterial meningitis.

288

The nurse is planning to bathe a client diagnosed with meningococcal meningitis. In addition to gloves, what personal protective equipment does the nurse use?

a. Particulate respirator
b. Isolation gown
c. Shoe covers
d. Surgical mask

ANS: D

d. Surgical mask

Meningeal meningitis is spread via saliva and droplets. Caregivers should wear a surgical mask when within 6 feet of the client and should continue to use Standard Precautions. A particulate respirator, an isolation gown, and shoe covers are not necessary for Droplet Precautions.

289

The nurse is assessing the results of diagnostic tests on a client’s cerebrospinal fluid (CSF). Which values and observations does the nurse correlate as most indicative of viral meningitis? (Select all that apply.)

a. Clear
b. Cloudy
c. Normal protein level
d. Increased protein level
e. Normal glucose level
f. Decreased glucose level

ANS: A, D, E

a. Clear
d. Increased protein level
e. Normal glucose level

Viral meningitis does not cause cloudiness or increased turbidity of CSF. Protein levels are slightly increased, and glucose levels are normal. In bacterial meningitis, the presence of bacteria and white blood cells causes the fluid to be cloudy.

290

After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for
a. furosemide .
b. nitroglycerin .
c. norepinephrine .
d. sodium nitroprusside .

ANS: C

c. norepinephrine .

When fluid resuscitation is unsuccessful, vasopressor drugs are given to increase the systemic vascular resistance (SVR) and blood pressure and improve tissue perfusion. Furosemide would cause diuresis and further decrease the BP. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Nitroprusside is an arterial vasodilator and would further decrease SVR.

291

To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform?
a.
Auscultate bowel sounds.
c.
Check stools for occult blood.
b.
Ask the patient about nausea.
d.
Palpate for abdominal tenderness.

c.
Check stools for occult blood.

Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments will also be done, but these will not help in determining the effectiveness of the pantoprazole administration.

292

When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education?
a.
Placing the pulse oximeter on the ear for a patient with septic shock
b.
Keeping the head of the bed flat for a patient with hypovolemic shock
c.
Maintaining a cool room temperature for a patient with neurogenic shock
d.
Increasing the nitroprusside infusion rate for a patient with a very high SVR

c.
Maintaining a cool room temperature for a patient with neurogenic shock

Patients with neurogenic shock have poikilothermia. The room temperature should be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.

293

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider?
a.
Skin cool and clammy
c.
Blood pressure of 92/56 mm Hg
b.
Heart rate of 118 beats/min
d.
O2 saturation of 93% on room air

a.
Skin cool and clammy

Because patients in the early stage of septic shock have warm and dry skin, the patient’s cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patient’s status.

294

A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to
a.
obtain the blood pressure.
b.
check the level of orientation.
c.
administer supplemental oxygen.
d.
obtain a 12-lead electrocardiogram.

c.
administer supplemental oxygen.

The initial actions of the nurse are focused on the ABCs—airway, breathing, and circulation—and administration of O2 should be done first. The other actions should be accomplished as rapidly as possible after providing O2.

295

Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to report the finding to the health care provider?
a.
The patient’s urine output is 18 mL/hr.
b.
The patient is complaining of chest pain.
c.
The patient’s peripheral pulses are weak.
d.
The patient’s heart rate is 110 beats/minute.

b.
The patient is complaining of chest pain.

Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the patient’s diagnosis, and should be reported to the health care provider but does not indicate an immediate need for a change in therapy.

296

After change-of-shift report in the progressive care unit, who should the nurse care for first?
a.
Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases
b.
Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics
c.
Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute
d.
Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg

b.
Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics

Antibiotics should be given within the first hour for patients who have sepsis or suspected sepsis in order to prevent progression to systemic inflammatory response syndrome and septic shock. The data on the other patients indicate that they are more stable. Crackles heard only at the lung bases do not require immediate intervention in a patient who has had a myocardial infarction. Mild bradycardia does not usually require atropine in patients who have a spinal cord injury. The findings for the patient admitted with anaphylaxis indicate resolution of bronchospasm and hypotension.

297

After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the health care provider?

Physical Assessment
Laboratory Data
Vital Signs
 Petechiae noted on chest and legs
 Crackles heard bilaterally in lung bases
 No redness or swelling at central line IV site
 Blood urea nitrogen (BUN) 34 mg/Dl
 Hematocrit 30%
 Platelets 50,000/µL
 Temperature 100°F (37.8°C)
 Pulse 102/min
 Respirations 26/min
 BP 110/60 mm Hg
 O2 saturation 93% on 2L O2 via nasal cannula

a.
Temperature and IV site appearance
b.
Oxygen saturation and breath sounds
c.
Platelet count and presence of petechiae
d.
Blood pressure, pulse rate, respiratory rate.

c.
Platelet count and presence of petechiae

The low platelet count and presence of petechiae suggest that the patient may have disseminated intravascular coagulation and that multiple organ dysfunction syndrome is developing. The other information will also be discussed with the health care provider but does not indicate that the patient’s condition is deteriorating or that a change in therapy is needed immediately.

298

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)?
a.
Ambulate postoperative patients as soon as possible after surgery.
b.
Use aseptic technique when manipulating invasive lines or devices.
c.
Remove indwelling urinary catheters as soon as possible after surgery.
d.
Administer prescribed antibiotics within 1 hour for patients with possible sepsis.
e.
Advocate for parenteral nutrition for patients who cannot take in adequate calories.

ANS: A, B, C, D
a.
Ambulate postoperative patients as soon as possible after surgery.
b.
Use aseptic technique when manipulating invasive lines or devices.
c.
Remove indwelling urinary catheters as soon as possible after surgery.
d.
Administer prescribed antibiotics within 1 hour for patients with possible sepsis.

Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early ambulation should be included in the plan of care. Adequate nutrition is important in preventing SIRS. Enteral, rather than parenteral, nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine, thus decreasing infection risk. Antibiotics should be given within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS

299

The health care provider orders the following interventions for a 67-kg patient who has septic shock with a blood pressure of 70/42 mm Hg and O2 saturation of 90% on room air. In which order will the nurse implement the actions? (Put a comma and a space between each answer choice [A, B, C, D, E].)
a. Give vancomycin 1 g IV.
b. Obtain blood and urine cultures
c. Start norepinephrine 0.5 mcg/min.
d. Infuse normal saline 2000 mL over 30 minutes.
e. Titrate oxygen administration to keep O2 saturation above 95%.

ANS:
E, D, C, B, A

The initial action for this hypotensive and hypoxemic patient should be to improve the O2 saturation, followed by infusion of IV fluids and vasopressors to improve perfusion. Cultures should be obtained before giving antibiotics.

300

The nurse is caring for a client who has hypovolemic shock. After administering oxygen, what is the priority intervention for this client?
a.
Administer an aminoglycoside.
b.
Initiate a dopamine hydrochloride (Intropin) drip.
c.
Administer crystalloid fluids.
d.
Initiate an intravenous heparin drip.

c.
Administer crystalloid fluids.

IV therapy for fluid resuscitation is the primary intervention for hypovolemic shock. A dopamine hydrochloride drip is a secondary treatment if the client does not respond to fluids. Aminoglycosides and heparin are given to clients with septic shock

301

A client who has septic shock is admitted to the hospital. What priority intervention does the nurse implement first?
a.
Obtain two sets of blood cultures.
b.
Administer the prescribed IV vancomycin (Vancocin).
c.
Obtain central venous pressure (CVP) measurements.
d.
Administer the prescribed IV norepinephrine (Levophed).

a.
Obtain two sets of blood cultures.

Blood cultures should be obtained before IV antibiotics are started. If hypotension occurs, fluid resuscitation is used first. CVP monitoring and vasopressor therapy are started if hypotension persists.

302

The nurse is assessing a client who was admitted for treatment of shock. Which manifestation indicates that the client’s shock is caused by sepsis?
a.
Hypotension
b.
Pale clammy skin
c.
Anxiety and confusion
d.
Oozing of blood at the IV site

d.
Oozing of blood at the IV site

The late phase of sepsis-induced distributive shock is characterized by most of the same cardiovascular manifestations as any other type of shock. The distinguishing feature is lack of ability to clot blood, causing the client to bleed from areas of minor trauma and to bleed spontaneously. The other manifestations are associated with all types of shock.

303

A client was admitted 2 days ago with early stages of septic shock. Today the nurse notes that the client’s systolic blood pressure, pulse pressure, and cardiac output are decreasing rapidly. Which intervention does the nurse do first?
a.
Insert a Foley catheter to monitor urine output closely.
b.
Ask the client’s family to come to the hospital because death is near.
c.
Initiate the prescribed dobutamine (Dobutrex) intravenous drip.
d.
Obtain blood cultures before administering the next dose of antibiotics.

c.
Initiate the prescribed dobutamine (Dobutrex) intravenous drip.

The hypodynamic phase of septic shock is characterized by a rapid decrease in cardiac output, systolic blood pressure, and pulse pressure. The nurse must initiate drug therapy to maintain blood pressure and cardiac output. Accurate urinary output and blood cultures are important to the treatment but are not the priority when a client’s pulse pressure is decreasing rapidly. The family should be updated appropriately.

304

The nurse is assessing clients in the emergency department. Which client is at highest risk for developing septic shock?
a.
25-year-old man who has irritable bowel syndrome
b.
37-year-old woman who is 20% above ideal body weight
c.
68-year-old woman who is being treated with chemotherapy
d.
82-year-old man taking beta blockers for hypertension

c.
68-year-old woman who is being treated with chemotherapy

Certain conditions or treatments that cause immune suppression, such as having cancer and being treated with chemotherapeutic agents, aspirin, and certain antibiotics, can predispose a person to septic shock. The other client situations do not increase the client’s risk for septic shock.

305

The nurse is caring for a client in the hyperdynamic phase of septic shock. Which medication does the nurse expect to be prescribed?
a.
Heparin sodium
b.
Vitamin K
c.
Corticosteroids
d.
Hetastarch (Hespan)

a.
Heparin sodium

During the hyperdynamic phase of septic shock, because of alterations in the clotting cascade, clients begin to form numerous small clots. Heparin is administered to limit clotting and prevent consumption of clotting factors. The other medications would not be prescribed during the hyperdynamic phase of septic shock.

306

The nurse is planning care for a client with late-phase septic shock. All of the following treatments have been prescribed. Which prescription does the nurse question?
a.
Enoxaparin (Lovenox) 40 mg subcutaneous twice daily
b.
Transfusion of 2 units of fresh frozen plasma
c.
Regular insulin intravenous drip per protocol
d.
Cefazolin (Ancef) 1 g IV every 6 hours

a.
Enoxaparin (Lovenox) 40 mg subcutaneous twice daily

Therapy during the second (late) phase of septic shock is aimed at enhancing the blood’s ability to clot. Enoxaparin would increase the client’s risk of bleeding and therefore should not be administered during the last phase of septic shock. Administering clotting factors, plasma, platelets, and other blood products will assist the client’s blood to clot. Intravenous insulin to control hyperglycemia and antibiotic therapy would continue in the late phases of septic shock.

307

The nurse is assessing a client at risk for shock. The client’s systolic blood pressure is 20 mm Hg lower than baseline. Which intervention does the nurse perform first?
a.
Increase the IV fluid rate.
b.
Administer oxygen.
c.
Notify the health care provider.
d.
Place the client in high Fowler’s position.

b.
Administer oxygen.

Administration of oxygen for any type of shock is appropriate to help reduce potential damage from tissue hypoxia. The other interventions should be completed after oxygen is administered.

308

A client recovering from septic shock is preparing for discharge home. What priority information does the nurse include in the teaching plan for this client?
a.
“Clean your toothbrush with laundry bleach daily.”
b.
“Bathe every other day with antimicrobial soap.”
c.
“Wash your hands after changing pet litter boxes.”
d.
“Use an electric razor when you shave your face.”

a.
“Clean your toothbrush with laundry bleach daily.”

The client at risk for septic shock should be instructed to clean his or her toothbrush daily, either by running it through the dishwasher or by rinsing it in laundry bleach. Clients should be instructed to bathe daily and wash the armpits, the groin, and the rectal area. The client should refrain from cleaning pet litter boxes. Clients recovering from septic shock are not at higher risk for bleeding disorders.

309

The intensive care nurse is caring for an intubated client who has severe sepsis that led to acute respiratory distress. Which nursing intervention is most appropriate during this stage of sepsis?
a.
Check blood glucose levels every 4 hours.
b.
Monitor intake and urinary output twice each shift.
c.
Decrease ventilator rate and tidal volume.
d.
Administer prescribed low-dose corticosteroids.

d.
Administer prescribed low-dose corticosteroids.

During severe sepsis, interventions should focus on decreasing hypoxia, maintaining acid-base balance, keeping blood glucose levels as normal as possible, maintaining organ perfusion, minimizing adrenal insufficiency, and decreasing microemboli. Treatment should include administration of low-dose corticosteroids, insulin drip with blood glucose checks every 1 to 2 hours, hourly intake and output monitoring, and an increase in ventilator rate and tidal volume

310

The nurse is providing health education to a client on immunosuppressant therapy. Which instructions does the nurse include in this client’s teaching? (Select all that apply.)

a. “Wear a facemask at all times.”
b. “Take your temperature once a day.”
c. “Drink only bottled water.”
d. “Avoid any contact with pets.”
e. “Wash dishes with hot sudsy water.”
f. “Rinse your toothbrush in liquid laundry bleach.”

ANS: B, E, F

b. “Take your temperature once a day.
e. “Wash dishes with hot sudsy water.”
f. “Rinse your toothbrush in liquid laundry bleach.”

Daily temperatures, washing dishes in hot sudsy water or a dishwasher, and rinsing toothbrushes in liquid bleach or in the dishwasher are infection precautions for the immune compromised client. Clients at increased risk because of immune suppression need to wear a facemask when in large crowds or around ill people. Water need not be bottled but should not be used if it has been standing for longer than 15 minutes. This population is not restricted from pets but is only advised not to change pet litter boxes

311

A client has septic shock. Which hemodynamic parameters does the nurse correlate with this type of shock? (Select all that apply.)

a. Decreased cardiac output
b. Increased cardiac output
c. Increased blood glucose
d. Decreased blood glucose
e. Increased serum lactate
f. Decreased serum lactate

ANS: A, C, E

a. Decreased cardiac output
c. Increased blood glucose
e. Increased serum lactate

Septic shock manifests with decreased cardiac output, increased blood glucose, and increased serum lactate. The other parameters do not correlate with septic shock.

312

How should the nurse respond to a parent who asks, “How can I protect my baby from whooping cough?”

a. “Don’t worry; your baby will have maternal immunity to pertussis that will last until they are approximately 18 months old.”

b. “Make sure your child gets the pertussis vaccine.”

c. “See the doctor when the baby gets a respiratory infection.”

d. “Have your pediatrician prescribe erythromycin.”

ANS: B

b. “Make sure your child gets the pertussis vaccine.”

Primary prevention of pertussis can be accomplished through administration of the pertussis vaccine. 

313

What should be included in the care for a neonate who was diagnosed with pertussis?

a. Monitoring hemoglobin level
b. Hearing test before discharge
c. Serial platelet counts
d. Treatment of all close contacts with a prophylactic antibiotic

ANS: D

d. Treatment of all close contacts with a prophylactic antibiotic

Erythromycin, azithromycin, or clarithromycin is given to all close contacts for the child diagnosed with pertussis.

314

A hospitalized child has developed a methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse plans which interventions when caring for this child? Select all that apply.

a. Airborne isolation

b. Administration of vancomycin (Vancocin)

c. Contact isolation

d. Administration of mupirocin (Bactroban) ointment to the nares

e. Administration of cefotaxime (Cefotetan)

ANS: B, C, D

b. Administration of vancomycin (Vancocin)
c. Contact isolation
d. Administration of mupirocin (Bactroban) ointment to the nares

Correct: Vancomycin is used to treat MRSA along with mupirocin ointment to the nares. The patient is placed in contact isolation to prevent spread of the infection to other patients.
Incorrect: The infection is not transmitted by the airborne route so only contact isolation is required. This infection is resistant to cephalosporins.

315

Which statement by a school-age girl indicates the need for further teaching about the prevention of urinary tract infections (UTIs)?

a. “I always wear cotton underwear.”
b. “I really enjoy taking a bubble bath.”
c. “I go to the bathroom every 3 to 4 hours.”
d. “I drink four to six glasses of fluid every day.”

ANS: B

b. “I really enjoy taking a bubble bath.”

Bubble baths should be avoided because they tend to cause urethral irritation, which leads to UTI. 

316

Which diagnostic finding is present when a child has primary nephrotic syndrome?

a. Hyperalbuminemia
b. Positive ASO titer
c. Leukocytosis
d. Proteinuria

ANS: D

d. Proteinuria

Large amounts of protein are lost through the urine as a result of an increased permeability of the glomerular basement membrane.

317

Which finding indicates that a child receiving prednisone for primary nephrotic syndrome is in remission?

a. Urine is negative for casts for 5 days.
b. Urine is up to a trace for protein for 5 to 7 days.
c. Urine is positive for glucose for 1 week.
d. Urine is up to a trace for blood for 1 week.

ANS: B

b. Urine is up to a trace for protein for 5 to 7 days.

The child receiving steroids for the treatment of primary nephrotic syndrome is considered in remission when the urine is up to trace for protein for 5 to 7 days. 

318

A child with secondary enuresis who complains of dysuria or urgency should be evaluated for which condition?
a.
Hypocalciuria
b.
Nephrotic syndrome
c.
Glomerulonephritis
d.
UTI

d.
UTI

Complaints of dysuria or urgency from a child with secondary enuresis suggest the possibility of a UTI.

319

A true statement describing the differences in the pediatric genitourinary system compared with the adult genitourinary system is that

a. The young infant’s kidneys can more effectively concentrate urine than an adult’s kidneys.

b. After 6 years of age, kidney function is nearly like that of an adult.

c. Unlike adults, most children do not regain normal kidney function after acute renal failure.

d. Young children have shorter urethras, which can predispose them to UTIs.

ANS: D

d. Young children have shorter urethras, which can predispose them to UTIs.

Young children have shorter urethras, which can predispose them to UTIs.

320

Which factor predisposes the urinary tract to infection?

a. Increased fluid intake
b. Short urethra in young girls
c. Prostatic secretions in males
d. Frequent emptying of the bladder

ANS: B

b. Short urethra in young girls

The short urethra in females provides a ready pathway for invasions of organisms. 

321

A child with secondary enuresis who complains of dysuria or urgency should be evaluated for what condition? Select all that apply.

a. Hypocalciuria
b. Nephrotic syndrome
c. Glomerulonephritis
d. UTI
e. Diabetes mellitus

ANS: D, E

d. UTI
e. Diabetes mellitus

Complaints of dysuria or urgency from a child with secondary enuresis suggest the possibility of a UTI. If accompanied by excessive thirst and weight loss, these symptoms may indicate the onset of diabetes mellitus.

322

A nurse is assessing an infant for urinary tract infection (UTI). Which assessment findings should the nurse expect? Select all that apply.

a. Change in urine odor or color
b. Enuresis
c. Fever or hypothermia
d. Voiding urgency
e. Poor weight gain

ANS: A, C, E

a. Change in urine odor or color
c. Fever or hypothermia
e. Poor weight gain

Correct: The signs of a UTI in an infant include fever or hypothermia, irritability, dysuria as evidenced by crying when voiding, change in urine odor or color, poor weight gain, and feeding difficulties.
Incorrect: Enuresis and voiding urgency should be assessed in an older child.

323

A child has had cold symptoms for more than 2 weeks, a headache, nasal congestion with purulent nasal drainage, facial tenderness, and a cough that increases during sleep. The nurse recognizes that these symptoms are characteristic of which respiratory condition?

a. Allergic rhinitis
b. Bronchitis
c. Asthma
d. Sinusitis

ANS: D

d. Sinusitis

Sinusitis is characterized by signs and symptoms of a cold that do not improve after 14 days, a low-grade fever, nasal congestion and purulent nasal discharge, headache, tenderness, a feeling of fullness over the affected sinuses, halitosis, and a cough that increases when the child is lying down.

324

Which statement made by a parent indicates an understanding about treatment of streptococcal pharyngitis?

a. “I guess my child will need to have his tonsils removed.”

b. “A couple of days of rest and some ibuprofen will take care of this.”

c. “I should give the penicillin three times a day for 10 days.”

d. “I am giving my child prednisone to decrease the swelling of the tonsils.”

ANS: C

c. “I should give the penicillin three times a day for 10 days.”

Streptococcal pharyngitis is best treated with oral penicillin two to three times daily for 10 days.

325

The parent of a toddler calls the nurse, asking about croup. What is a distinguishing manifestation of spasmodic croup?

a. Wheezing is heard audibly.
b. It has a harsh, barky cough.
c. It is bacterial in nature.
d. The child has a high fever.

ANS: B

b. It has a harsh, barky cough.

Spasmodic croup is viral in origin; is usually preceded by several days of symptoms of upper respiratory tract infection; often begins at night; and is marked by a harsh, metallic, barky cough; sore throat; inspiratory stridor; and hoarseness.

326

Which intervention for treating croup at home should be taught to parents?
a.
Have a decongestant available to give the child when an attack occurs.
b.
Have the child sleep in a dry room.
c.
Take the child outside.
d.
Give the child an antibiotic at bedtime.

c.
Take the child outside.

Taking the child into the cool, humid, night air may relieve mucosal swelling and improve symptoms.

327

. What intervention can be taught to the parents of a 3-year-old child with pneumonia who is not hospitalized?
a.
Offer the child only cool liquids.
b.
Offer the child her favorite warm liquid drinks.
c.
Use a warm mist humidifier.
d.
Call the physician for a respiratory rate less than 28 breaths/min.

b.
Offer the child her favorite warm liquid drinks.

Offering the child fluids that she likes will facilitate oral intake. Warm liquids help loosen secretions.

328

What sign is indicative of respiratory distress in infants?
a.
Nasal flaring
b.
Respiratory rate of 55 breaths/min
c.
Irregular respiratory pattern
d.
Abdominal breathing

a.
Nasal flaring'

Infants have difficulty breathing through their mouths; therefore nasal flaring is usually accompanied by extra respiratory efforts. It also allows more air to enter as the nares flare.

329

What is an appropriate beverage for the nurse to give to a child who had a tonsillectomy earlier in the day?
a.
Chocolate ice cream
b.
Orange juice
c.
Fruit punch
d.
Apple juice

d.
Apple juice

The child can have clear, cool liquids when fully awake.

330

. Which type of croup is always considered a medical emergency?
a.
Laryngitis
b.
Epiglottitis
c.
Spasmodic croup
d.
Laryngotracheobronchitis (LTB)

b.
Epiglottitis

Epiglottitis is always a medical emergency that requires antibiotics and airway support for treatment.

331

What information should the nurse teach workers at a daycare center about RSV?
a.
RSV is transmitted through particles in the air.
b.
RSV can live on skin or paper for up to a few seconds after contact.
c.
RSV can survive on nonporous surfaces for about 60 minutes.
d.
Frequent handwashing can decrease the spread of the virus.

d.
Frequent handwashing can decrease the spread of the virus.

Meticulous handwashing can decrease the spread of organisms.

332

Which intervention is appropriate for the infant hospitalized with bronchiolitis?
a.
Position on the side with neck slightly flexed.
b.
Administer antibiotics as ordered.
c.
Restrict oral and parenteral fluids if tachypneic.
d.
Give cool, humidified oxygen.

d.
Give cool, humidified oxygen.

Cool, humidified oxygen is given to relieve dyspnea, hypoxemia, and insensible fluid loss from tachypnea.

333

The nurse encourages the mother of a toddler with acute LTB to stay at the bedside as much as possible. The nurse’s rationale for this action is primarily that
a.
Mothers of hospitalized toddlers often experience guilt.
b.
The mother’s presence will reduce anxiety and ease child’s respiratory efforts.
c.
Separation from mother is a major developmental threat at this age.
d.
The mother can provide constant observations of the child’s respiratory efforts.

b.
The mother’s presence will reduce anxiety and ease child’s respiratory efforts.

The family’s presence will decrease the child’s distress.

334

A school-age child had an upper respiratory tract infection for several days and then began having a persistent dry, hacking cough that was worse at night. The cough has become productive in the past 24 hours. This is most suggestive of
a.
Bronchitis
b.
Bronchiolitis
c.
Viral-induced asthma
d.
Acute spasmodic laryngitis

a.
Bronchitis

Bronchitis is characterized by these symptoms and occurs in children older than 6 years.

335

The infant with bronchopulmonary dysplasia (BPD) who has RSV bronchiolitis is a candidate for which treatment?
a.
Pancreatic enzymes
b.
Cool humidified oxygen
c.
Erythromycin intravenously
d.
Intermittent positive pressure ventilation

b.
Cool humidified oxygen

Humidified oxygen is delivered if the oxygen saturation level drops to less than 90%.

336

Why do infants and young children quickly have respiratory distress in acute and chronic alterations of the respiratory system?

a. They have a widened, shorter airway.
b. There is a defect in their sucking ability.
c. The gag reflex increases mucus production.
d. Mucus and edema obstruct small airways.

ANS: D

d. Mucus and edema obstruct small airways.

The airway in infants and young children is narrower, and respiratory distress can occur quickly because mucus and edema can cause obstruction to their small airways

337

The nurse is caring for a child with acute respiratory distress syndrome (ARDS) associated with sepsis. Nursing actions should include:

a. Forcing fluids
b. Monitoring pulse oximetry
c. Instituting seizure precautions
d. Encouraging a high-protein diet

ANS: B

b. Monitoring pulse oximetry

Monitoring cardiopulmonary status is an important evaluation tool in the care of the child with ARDS.

338

As a child with asthma struggles to get enough air, the respiratory rate increases (tachypnea). Tachypnea lowers the carbon dioxide levels in the blood. This is known as _____________.

ANS: hypocapnia

As the child tires from the increased work of breathing, hyperventilation occurs and carbon dioxide levels increase. Increased levels of carbon dioxide in the blood (hypercapnia) during an asthma episode may be a sign of severe airway obstruction and impending respiratory failure.

339

. Which information should the nurse give to a child who is to have magnetic resonance imaging (MRI) of the brain?

a. “Your head will be restrained during the procedure.”

b. “You will have to drink a special fluid before the test.”

c. “You will have to lie flat after the test is finished.”

d. “You will have electrodes placed on your head with glue.”

ANS: A

a. “Your head will be restrained during the procedure.”

To reduce fear and enhance cooperation during the MRI, the child should be made aware that the head will be restricted to obtain accurate information.

340

Which term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation?

a. Coma
b. Stupor
c. Obtundation
d. Persistent vegetative state

ANS: B

b. Stupor

Stupor exists when the child remains in a deep sleep, responsive only to vigorous and repeated stimulation

341

The Glasgow Coma Scale consists of an assessment of

a. Pupil reactivity and motor response
b. Eye opening and verbal and motor responses
c. Level of consciousness and verbal response
d. ICP and level of consciousness

ANS: B

b. Eye opening and verbal and motor responses

The Glasgow Coma Scale assesses eye opening, and verbal and motor responses.

342

Which finding in an analysis of cerebrospinal fluid (CSF) is consistent with a diagnosis of bacterial meningitis?

a. CSF appears cloudy.
b. CSF pressure is decreased.
c. Few leukocytes are present.
d. Glucose level is increased compared with blood.

ANS: A

a. CSF appears cloudy.

In acute bacterial meningitis, the CSF is cloudy to milky or yellowish in color.

343

How should the nurse explain positioning for a lumbar puncture to a 5-year-old child?

a. “You will be on your knees with your head down on the table.”

b. “You will be able to sit up with your chin against your chest.”

c. “You will be on your side with the head of your bed slightly raised.”

d. “You will lie on your side and bend your knees so that they touch your chin.”

ANS: D

d. “You will lie on your side and bend your knees so that they touch your chin.”

The child should lie on her side with knees bent and chin tucked in to the knees. This position exposes the area of the back for the lumbar puncture.

344

A mother reports that her child has episodes where he appears to be staring into space. This behavior is characteristic of which type of seizure?

a. Absence
b. Atonic
c. Tonic-clonic
d. Simple partial

ANS: A

a. Absence

Absence seizures are very brief episodes of altered awareness. The child has a blank expression.

345

What is the best response to a father who tells the nurse that his son “daydreams” at home and his teacher has observed this behavior at school?

a. “Your son must have an active imagination.”

b. “Can you tell me exactly how many times this occurs in one day?”

c. “Tell me about your son’s activity when you notice the daydreams.”

d. “He is probably overtired and needs more rest.”

ANS: C

c. “Tell me about your son’s activity when you notice the daydreams.”

The daydream episodes are suggestive of absence seizures, and data about activity associated with the daydreams should be obtained.

346

The nurse teaches parents to alert their health care provider about which adverse effect when a child receives valproic acid (Depakene) to control generalized seizures?

a. Weight loss
b. Bruising
c. Anorexia
d. Drowsiness

ANS: B

b. Bruising

Thrombocytopenia is an adverse effect of valproic acid. Parents should be alert for any unusual bruising or bleeding.

347

. Which type of seizures involves both hemispheres of the brain?

a. Focal
b. Partial
c. Generalized
d. Acquired

ANS: C

c. Generalized

Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres.

348

. What is the most appropriate nursing action when a child is in the tonic phase of a generalized tonic-clonic seizure?
a.
Guide the child to the floor if standing and go for help.
b.
Turn the child’s body on the side.
c.
Place a padded tongue blade between the teeth.
d.
Quickly slip soft restraints on the child’s wrists.

b.
Turn the child’s body on the side.

Positioning the child on his side will prevent aspiration.

349

After a tonic-clonic seizure, it would not be unusual for a child to display

a. Irritability and hunger
b. Lethargy and confusion
c. Nausea and vomiting
d. Nervousness and excitability

ANS: B

b. Lethargy and confusion

In the period after a tonic-clonic seizure, the child may be confused and lethargic. Some children may sleep for a period of time.

350

What should the nurse teach parents when the child is taking phenytoin (Dilantin) to control seizures?

a. The child should use a soft toothbrush and floss the teeth after every meal.

b. The child will require monitoring of renal function while taking this medication.

c. Dilantin should be taken with food because it causes gastrointestinal distress.

d. The medication can be stopped when the child has been seizure free for 1 month.

ANS: A

a. The child should use a soft toothbrush and floss the teeth after every meal.

A side effect of Dilantin is gingival hyperplasia. Good oral hygiene will minimize this adverse effect.

351

A child is brought to the emergency department in generalized tonic-clonic status epilepticus. Which medication should the nurse expect to be given initially in this situation?

a. Clorazepate dipotassium (Tranxene)
b. Fosphenytoin (Cerebyx)
c. Phenobarbital
d. Lorazepam (Ativan)

ANS: D

d. Lorazepam (Ativan)

Lorazepam (Ativan) or diazepam (Valium) is given intravenously to control generalized tonic-clonic status epilepticus and may also be used for seizures lasting more than 5 minutes.

352

A nurse is explaining to parents how the central nervous system of a child differs from that of an adult. Which statement accurately describes these differences?

a. The infant has 150 mL of CSF compared with 50 mL in the adult.

b. Papilledema is a common manifestation of ICP in the very young child.

c. The brain of a term infant weighs less than half of the weight of the adult brain.

d. Coordination and fine motor skills develop as myelinization of peripheral nerves progresses.

ANS: D

d. Coordination and fine motor skills develop as myelinization of peripheral nerves progresses.

Peripheral nerves are not completely myelinated at birth. As myelinization progresses, so does the child’s coordination and fine muscle movements.

353

The nurse is preparing a school-age child for computed tomography (CT scan) to assess cerebral function. Which statement should the nurse include when preparing the child?

a. “Pain medication will be given.”

b. “The scan will not hurt.”

c. “You will be able to move once the equipment is in place.”

d. “Unfortunately no one can remain in the room with you during the test.”

ANS: B

b. “The scan will not hurt.”

For CT scans, the child must be immobilized. It is important to emphasize to the child that at no time is the procedure painful.

354

Which neurologic diagnostic test gives a visualized horizontal and vertical cross section of the brain at any axis?

a. Nuclear brain scan
b. Echoencephalography
c. CT scan
d. MRI

ANS: C

c. CT scan

A CT scan provides a visualization of the horizontal and vertical cross sections of the brain at any axis.

355

What nursing actions are indicated when the nurse is administering phenytoin (Dilantin) by the intravenous route to control seizures? Select all that apply.

a. It must be given with D51/2NS.

b. The child will require monitoring of therapeutic serum levels while taking this medication.

c. Dilantin should be given with food because it causes gastrointestinal distress.

d. It must be given in normal saline.

e. It must be filtered.

ANS: B, D, E

b. The child will require monitoring of therapeutic serum levels while taking this medication.

d. It must be given in normal saline.

e. It must be filtered.

The child should have serum levels drawn to monitor for optimal therapeutic levels. In addition, liver function studies should be monitored because this anticonvulsant may cause hepatic dysfunction. The IV dose must be given in normal saline, not D51/2NS. The IV dose must be filtered.

356

A nurse should expect which cerebral spinal fluid (CSF) laboratory results on a child diagnosed with bacterial meningitis? Select all that apply.

a. Elevated white blood count (WBC)
b. Decreased protein
c. Decreased glucose
d. Cloudy in color
e. Increase in red blood cells (RBC)

ANS: A, C, D

a. Elevated white blood count (WBC)
c. Decreased glucose
d. Cloudy in color

The CSF laboratory results for bacterial meningitis include elevated WBC counts, cloudy or milky in color, and decreased glucose.

357

Prolonged seizure activity, in the form of either a single seizure lasting 30 minutes or recurrent seizures lasting more than 30 minutes, with no return to a normal level of consciousness is known as _________________.

ANS: status epilepticus

The nurse caring for this patient should be aware that the causes of status epilepticus are many. Acute CNS injury from head trauma, meningitis, or electrolyte imbalance frequently precipitate status epilepticus.

358

The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize that this breaks the chain of infection by eliminating which element?

a. Host
b. Mode of transmission
c. Portal of entry
d. Reservoir

C

c. Portal of entry

Broken or impaired skin creates a portal of entry for pathogens. By maintaining intact tissue, the patient and the nurse have broken the chain of infection by eliminating a portal of entry. Host is incorrect because you are not eliminating the person or organism. Intact tissue does not eliminate the mode of transmission. Skin can still be used to transfer pathogens regardless of it being intact or broken. Intact skin does not eliminate the location for pathogens to live and grow.

359

While reviewing the complete blood count (CBC) of a patient on her unit, the nurse notes elevated basophil and eosinophil readings. The nurse realizes that this is most indicative of which type of infection?
a. Bacterial
b. Fungal
c. Parasitic
d. Viral

C

c. Parasitic

Parasitic infections are frequently indicated on a CBC by elevated basophil and eosinophil levels. Bacterial infections do not lead to elevated basophil and eosinophil levels but elevated B and T lymphocytes, neutrophils, and monocytes. Fungal infections do not lead to elevated basophil and eosinophil levels. Viral infections create elevations in B and T lymphocytes, neutrophils, and monocytes.

360

Which set of assessment data is consistent for a patient with severe infection that could lead to system failure?

a. Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours

b. BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours

c. BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours

d. BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours

ANS: B

b. BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours

The patient with severe infection presents with low BP and compensating elevations in pulse to move lower volumes of blood more rapidly and respiration to increase access to oxygen. Urine output decreases to counteract the decreased circulating blood volume and hypotension. These vital signs are all too low: Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours. The patient with severe infection does have a low BP, but the pulse and respiratory rate increase to compensate. This data is all within normal limits: BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours. This set of data reflects an elevated BP with a decrease in pulse and respiratory rates along with normal urine output: BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours. None of these is a typical response to severe infection.

361

The patient has a temperature of 105.2° F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient’s temperature?

a. Radiation
b. Conduction
c. Convection
d. Evaporation

ANS: B

b. Conduction

Applying an ice pack or bathing a patient with a cool cloth increases conductive heat loss because of the direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas. Convection is the transfer of heat away from the body by air movement.

362

The nurse is working the night shift on a surgical unit and is making 4:00 AM rounds. The nurse notices that the patient’s temperature is 96.8° F (36° C), whereas at 4:00 PM the preceding day, it was 98.6° F (37° C). What should the nurse do?

a. Call the health care provider immediately to report a possible infection.

b. Administer medication to lower the temperature further.

c. Provide another blanket to conserve body temperature.

d. Realize that this is a normal temperature variation.

ANS: D

d. Realize that this is a normal temperature variation.

Body temperature normally changes 0.5° to 1° C (0.9° to 1.8° F) during a 24-hour period and is usually lowest between 1:00 and 4:00 AM, with a maximum temperature at 4:00 PM, making this variation normal for the time of day. Unless the patient reports being cold, there is no physiological need for providing an extra blanket or medication to lower the body temperature further. There is also no need to call a health care provider to report a normal temperature variation.

363

The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). The patient’s last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). Which action will the nurse take?

a. Wait 30 minutes and recheck the patient’s temperature.

b. Assume that the patient has an infection and order blood cultures.

c. Encourage the patient to move around to increase muscular activity.

d. Be aware that temperatures this high are harmful and affect patient safety.

ANS: A

a. Wait 30 minutes and recheck the patient’s temperature.

Waiting 30 minutes and rechecking the patient’s temperature would be the most appropriate action in this case. A fever is usually not harmful if it stays below 102.2° F (39° C), and a single temperature reading does not always indicate a fever. In addition to physical signs and symptoms of infection, a fever determination is based on several temperature readings at different times of the day compared with the usual value for that person at that time. Nurses should base actions on knowledge, not on assumptions. Encouraging the patient to increase muscular activity will cause heat production to increase up to 50 times normal. The temperature has decreased and a symptom of infection would be an increase in temperature.

364

The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse use to obtain the patient’s temperature?

a. Oral
b. Rectal
c. Axillary
d. Tympanic

ANS: D

d. Tympanic

The tympanic route is easily accessible, requires minimal patient repositioning, and often can be used without disturbing the patient. It also has a very rapid measurement time. Oral temperatures require patient cooperation and are not recommended for patients with a history of seizures. Rectal temperatures require positioning and may increase patient agitation. Axillary temperatures need long measurement times and continuous positioning. The patient’s agitation state may not allow for long periods of attention.