Exam 2 Flashcards
(100 cards)
1
Q
Patient complains of feeling weak. What will the nurse do?
A
Ask which drug the client takes from arthritis
2
Q
When the nurse is admitting a patient who has acute rejection of an organ transplant, which of these already admitting patients will be the most appropriate roommate?
a. A patient who has viral pneumonia
b. A patient with second degree burns
c. A patient who is recovering from an anaphylactic reaction to a bee sting
d. A patient with graft-versus-host disease after a recent bone marrow
transplant
A
c. A patient who is recovering from an anaphylactic reaction to a bee sting
3
Q
A nurse is performing teaching with a female client who was newly diagnosed with SLE. The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that may exacerbate SLE?
a. Sunlight
b. Pregnancy
c. Infection
d. Exercise
A
d. Exercise
4
Q
Which statement by a client who has undergone renal transplantation indicates a need for further teaching?
A
My new kidney is working fine. I do not need to take medication any longer.
5
Q
The nurse teaches the client with vena cava syndrome that improvement is characterized by which clinal manifestation?
A
The client’s hands are less swollen.
6
Q
A patient is receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick ropey saliva. Which instructions would the nurse give to this patient?
A
Rinse the mouth before and after each meal and at bedtime with saline solution.
7
Q
Which intervention is most important for the nurse to implement to prevent complications from tumor lysis syndrome during chemotherapy?
A
Ensures that the client has a fluid intake of 3000 to 5000 mL/day.
8
Q
The nurse teaching a young women’s community service group about breast self-examination will include that
a. Performing BSE after the menstrual period is more comfortable
b. annual mammograms should be scheduled in addition to BSE
c. BSE should be done daily while taking a bath or shower
d. BSE will reduce the risk of dying from breast cancer
A
a. Performing BSE after the menstrual period is more comfortable
9
Q
A patient returns to the surgical unit following a modified radical mastectomy with dissection of axillary lymph nodes. Which nursing action should be included in the plan of care?
a. Insist that the patient examine the surgical incision when the dressings are
removed
b. Teach the patient to use the ordered patient-controlled analgesia (PCA)
every 10 minutes
c. Post a sign at the bedside warning against blood pressures or venipunctures
in the right arm
d. Obtain a permanent breast prosthesis for the patient before she is
discharged from the hospital
A
c. Post a sign at the bedside warning against blood pressure or venipuncture in the right arm.
10
Q
After change-of-shift report on the oncology unit, which patient should the nurse assess first?
a. Patient who has a platelet count of 130,000/uL after chemotherapy
b. Patient who has xerostomia after receiving head and neck radiation
c. A 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
A
c. Patient who is neutropenic and has a temperature of 100.5.
11
Q
What information must the nurse include about risk factors for the development of breast cancer?
A
a. Late menopause
b. Multiparity
c. Breast cancer in the first degree relative
12
Q
A nurse discusses the self-care guidelines to minimize the side effects of radiation on the skin. Which actions to reduce radiation skin reaction should the nurse explain to the client?
a. Wear loose-fitting, soft clothing over the treated skin
b. Use a straightedged razor to shave the hair in the treated area
c. Swim only in swimming pools to avoid stagnant water
d. Apply skin products immediately before radiation treatment
e. Wash treated area gently with lukewarm water and mild soap
A
a. Wear loose-fitting soft clothing over the treated skin
e. Wash treated area gently with lukewarm water and mild soap
13
Q
Which teaching will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk?
A
a. Sunscreen UV
b. Mammography
c. Colorectal screening
14
Q
A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan?
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 done
A
a. Cook food thoroughly before eating
c. Avoid public transportation such as busses
e. Talk to the oncologist before having any dental work
15
Q
A client is taking prednisone for the management of rheumatoid arthritis. The nurse identifies which of the following as potential adverse effects of this medication?
a. Potassium 3.9 mmol/L
b. Glucose 189 mg/dL
c. Blood in the stool
d. Blood pressure 90/40
e. Ecchymosis
A
b. Glucose 189 (high glucose)
c. Blood in the stool
d. Blood pressure 90/40
e. Ecchymosis
16
Q
A nurse is caring for a client with lupus who has end stage renal disease (ESRD). Which of the following findings will the nurse monitor for?
a. Hyperkalemia
b. Metabolic alkalosis
c. Tachypnea
d. Anemia
e. Hyperphosphatemia
A
a. Hyperkalemia
c. Tachypnea
d. Anemia
e. Hyperphosphatemia
17
Q
A client that has obsessive-compulsive personality disorder is admitted to the hospital for the management of a GI bleed. The nurse recognizes which of the following are clinical manifestations of obsessive-compulsive personality disorder?
a. Arrogance and inflated view of self
b. Suspicious and paranoid behavior
c. Completion of activities is hammered by perfection
d. Unstable emotions and impulsivity
A
c. Completion of activities is hampered by perfectionism.
18
Q
In prioritizing and planning care for a client with avoidant personality disorder, the nurse notes that the best intervention is to
a. Allow the client to take time alone and initiate contact with the nurse when
comfortable
b. Acknowledge goals that are achieved by the client to promote self esteem
c. Encourage the client to be independent and goal setting and planning
d. Create a large healthcare team to assist the client with hearing multiple
perspectives
A
b. Acknowledge goals that are achieved by the client to promote self-esteem.
19
Q
The RN is assisting clients in a behavioral health unit. Which of the following client assignments does the RN appropriately delegate to the LVN?
a. Develop a plan of care for a client with a narcissistic personality disorder
b. Initiate a leading plan for a client with schizoid personality disorder
c. Assess a client with a paranoid personality disorder for suicide risk
d. Assist a client with borderline personality or disorder to walk around the unit
A
d. Assist clients with borderline personality disorder to walk around the unit.
20
Q
The nurse is completing a health history on a client with narcissistic personality disorder. Which of the following assessments must they expect to find?
a. Inability to distinguish between rational and irrational thoughts
b. Arrogance and lack of empathy for others
c. Emotional speech that lacks detail
d. A focus on relationships with others and dependency on others
A
b. Arrogance and lack of empathy for others
21
Q
The nurse is caring for a client with borderline personality disorder and diabetes. The nurse prioritizes the assessment to include which of the following?
a. Questions about self-mutilation
b. Questions about relationships with others
c. Questions about self-esteem
d. Questions about speech issues
A
a. Questions about self-mutilation
22
Q
The nurse is caring for a client hospitalized with heart failure. The client has a history of borderline personality disorder. The nurse is planning care for the client and recognizes that which of the following must be considered related to the client’s borderline personality disorder?
a. The client’s desire to be the center of attention
b. The client’s avoidance of the nurse
c. The client’s fear of abandonment
d. The client’s blatant disregard for others
A
c. The client’s fear of abandonment
23
Q
A client with a histrionic personality disorder dresses provocatively and walks around the unit. The client is dramatic and strays from topics frequently making client teaching difficult. The nurse should use which of the following interventions to create therapeutic communication?
a. Encourage your client to remain in their room alone
b. Tell the client that the behavior is unacceptable and will not be tolerated
c. Address the client directly with specific questions and encourage pertinent
responses
d. Avoid eye contact with the client and do not speak to the client until the
behavior stops
A
c. Address the client directly with specific questions and encourage pertinent responses
24
Q
The client states that people are watching her. What is the best response from the nurses?
A
I can tell that what you’re seeing scares you, how can I help to make you more comfortable?
25
The nurse is assessing a client on a medical surgical unit that is suspicious and hypersensitive to criticism. The client shares many stories of being followed or watched by the nurse and other healthcare providers. The nurse suspects that the
client has which of the following personality disorder?
a. Paranoid personality disorder
b. Schizoid personality disorder
c. Histrionic personality disorder
d. Borderline personality disorder
a. Paranoid personality disorder
26
A client with schizoid personality disorder is admitted to the medical-surgical unit with coexisting medical issues. The nurse is planning care for the client and the nurse considers which of the following as characteristics of this personality disorder?
a. The client quickly becomes attached to the nurse and healthcare team
b. The client displays the behavior lacking social tact or grace
c. The client attempts to build intimate relationships with members of the
healthcare team
d. The client becomes overly emotional when approached by the healthcare
team
b. The client displays behavior lacking social tact or grace
27
The nurse conducting an interview and medical history on an adult client admitted to the hospital with a personality disorder. Which of the following clinical manifestations does the nurse expect to be present in a client with a personality disorder?
a. Changes in personality from a recent stressful event
b. Personality traits that have changed with advanced age
c. Personality traits that are beyond the range of those found in most people
d. Changes in personality that differ based on the situation
c. Personality traits that are beyond the range of those found in most people
28
Which of the following will the nurse include when preparing to conduct education for a client with schizoid personality disorder?
a. Deliver the education individually in a clear, concise way
b. Use a theoretical and dramatic format to present the information
c. Provide education in a large group setting and encourage socialization
d. Ensure that the client has developed a close, therapeutic relationship before
any education is done
a. Deliver the education individually in a clear, concise way
29
The nurse is caring for a client with a dependent personality disorder. The nurse includes which of the following interventions in the plan of care for this client?
Acknowledge the clients situation with empathy while encouraging independence
30
The nurse is caring for a client with ovarian cancer who is receiving chemotherapy. Which of the following lab results suggest that the client may be experiencing renal insufficiency?
a. Calcium 6.9mg/dl, Creatinine 1.7mg/dl
b. Magnesium 2.0 meq/l, Potassium 4.3 meq/l
c. Potassium 3.7 meq/l, hemoglobin 11.8 g/dl
d. Platelets 300,000/uL, hemoglobin 15.1 g/dl
a. Calcium 6.9mg/dl, Creatinine 1.7mg/dl
31
A client is diagnosed with stage IV lung cancer. Which of the following assessment findings suggest a serious complication?
a. Client reports fatigue
b. Client reports pain 4/10
c. Client is hypertensive
d. Client has fixed dilated pupils
d. Client has fixed dilated pupils
32
A nurse is asked to prepare an educational program on testicular cancer. The nurse should present the program to which group?
a. High school males
b. Males over the age of 50
c. Males over the age of 21 who have fathered a child
d. Males over the age of 30 that have never fathered a child
a. High school males
33
The client who is being treated with radiation for cervical cancer asks if she should have a mammogram. What is the nurse's best response?
a. “You must delay the mammogram until your therapy is finished, perform a breast examination monthly.”
b. “Being treated for one kind of cancer does not prevent the development of
another type of cancer. Have the mammogram.”
c. “Absolutely do not have the mammogram this year, because you are already
over the limit for safe exposure levels to radiation.”
d. “The radiation therapy you're receiving will protect you against other cancer
development, so it is okay to skip the mammogram this year.”
b. “Being treated for one kind of cancer does not prevent the development of another type of cancer. Have the mammogram.”
34
An older client says that she does not perform breast examination because there is no history of breast cancer in her family. What is the nurse's best response?
a. “You are correct. Breast cancer is an inherited type of malignancy and your
family history indicates a low risk for you to develop it.”
b. “Breast cancer can be found more frequently in families. However, the risk
for general nonfamilial breast cancer increases with age.”
c. “Because your breasts are no longer as dense as they were when you were
younger, your risk for breast cancer is now decreased.”
d. “Examining your breasts once a year when you have your mammogram is
sufficient screening for someone with your history.”
b. “Breast cancer can be found more frequently in families. However, the risk for general nonfamilial breast cancer increases with age.”
35
The client states that the brain tumor is benign and does not need to be removed. What is the nurse's best response?
a. “Because benign tumors continue to get larger, when they are in a place that could damage normal tissue, they need to be removed.”
b. “Because benign tumors are composed of completely normal cells, removal is only done for cosmetic purposes.”
c. “Because benign tumors can easily become malignant, they should be removed before cancer develops.”
d. “Because benign tumors can migrate, they should be removed before they spread.”
a. “Because benign tumors continue to get larger, when they are in a place that could damage normal tissue, they need to be removed.”
36
While being prepared for a examine of a lump. The patient asks the nurse the difference between a benign and malignant tumor. Which response 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 slowly than normal cells.”
c. “Malignant tumors may spread to other tissues or organs.”
37
Which of the following cancer clients is presenting a complication and requires immediate attention?
a. Newly diagnosed colon cancer patient with cramping abdominal pain, highly pitched bowel sounds in the upper abdomen and projectile vomiting
b. One day postoperative patient whose colostomy stoma is red, swollen, and projecting out about 1 inch from the abdominal wall
c. 2-day post-operative patient who still has not regained the return of bowel sounds and is using patient controlled analgesia prior to activity such as ambulation
d. 3-day postoperative patient who is having difficulty looking at the colostomy stoma and is not willing to learn how to change your stool collection pouch at this time
a. Newly diagnosed colon cancer patient with cramping abdominal pain, highly pitched bowel sounds in the upper abdomen and projectile vomiting
38
When caring for a patient with a temporary radioactive cervical implant, which action by nursing assistive personnel (NAP) indicates that the RN should immediately intervene?
a. The NAP assists the patient with emptying a bedpan
b. The NAP stands by the patient's bed for 30 minutes talking with the patient
c. The NAP places the patient’s bedding in the laundry container in the room
d. The NAP gives the patient an alcohol containing mouthwash to use for oral
care
b. The NAP stands by the patient bed for 30 minutes talking with the patient
39
The nurse is screening clients at a community health fair. Which person is at least risk of developing colorectal cancer at this time?
a. A 20-year-old woman who drinks eight cups of coffee every day
b. A 56-year-old woman with a history of inflammatory bowel disease
c. A 60-year-old man with a BMI of 19.2 who leads a sedentary lifestyle
d. A 51-year-old man who travels extensively and eats fast food frequently
a. A 20-year-old women who drinks eight cups of coffee every day
40
After receiving the change of shift report, which of these patients should the nurse assess first?
a. 35-year-old who is receiving abdominal radiation for ovarian cancer and has skin redness and itchy, irritation to the abdomen
b. 52-year-old who is sobbing after receiving a new diagnosis of lung cancer
c. 24-year-old with lymphoma who is receiving neck radiation, develops a cough, and blood-tinged sputum
d. 56-year-old with lung cancer who has chest tenderness after receiving chest radiation
c. 24-year-old with lymphoma who is receiving neck radiation, develops a cough, and blood-tinged sputum
41
A 21-year-old client at the health client for a routine check up. Which question should the nurse ask the client whether a pap test is needed?
a. “Have you performed a self breast exam this month?”
b. “Do you use any illegal substances?”
c. “Have you had a Pap test in the past?”
d. “At what age did your menstrual period start?”
c. “Have you had a Pap test in the past?”
42
A chemotherapeutic agent known to cause alopecia is prescribed for a patient. To ensure the patient's self-esteem, the nurse plans to
a. Suggest that the patient limits social contacts until regrowth of the hair occurs
b. Encourage the patient to purchase a wig or hat and wear it once hair loss begins
c. Have the patient wash their hair gently with a mild shampoo to minimize hair loss
d. Inform the patient that the hair will grow back once the chemotherapy is complete
b. Encourage the patient to purchase a wig or hat and wear it once hair loss begins
43
The nurse prioritized which intervention in the client with xerostomia secondary to radiation therapy to the neck area?
a. Applying lotions and oils to affected areas
b. Wearing a scarf to protect the area
c. Carrying out oral care after every meal and at hour of sleep
d. Monitoring vital signs every 4 hours
c. Carrying out oral care after every meal and at hour of sleep
44
Several patients called the urology clinic requesting appointments with the health care provider as soon as possible. Which patient will the nurse schedule to be seen first?
a. 22-year-old who has noticed a firm, nontender lump on his scrotum
b. 35-year-old who is concerned about increased flatulence and diarrhea
c. 40-year-old who has pelvic pain while being treated for chronic prostatitis
d. 70-year-old who is reporting frequent urinary dribbling after a prostatectomy
a. 22-year-old who has noticed a firm, nontender lump on his scrotum
45
When the nurse is assessing the breasts of a 31 year old, which finding is the most indicative of a need for further evaluation?
a. Bilateral nodules that are tender with palpitation
b. A nodule that is 1 cm in size, painless, and fixed
c. A lump that increases in size before the menstrual period
d. A lump that is small, mobile, and has a rubbery consistency
b. A nodule that is 1 cm in size, painless, and fixed
46
31-year-old patient who has been diagnosed with HPV infection gives a health history that includes smoking tobacco taking oral contraceptions, and having been treated twice for vaginal candidiasis. Which topic will the nurse include in patient teaching?
a. Risk factors for colorectal cancer
b. Risk factors for cervical cancer
c. Risk factors for ovarian cancer
d. Risk factors for breast cancer
b. Risk factor for cervical cancer
47
Which nursing action will be most effective in improving oral intake for a cancer patient receiving cyclophosphamide and with the nursing diagnosis of imbalanced nutrition less than body requirements related to painful oral ulcers?
a. Offer the patient frequent small snacks between meals
b. Assist the patient to choose favorite foods from the menu
c. Provide education about the importance of nutritional intake
d. Apply the ordered anesthetic gel to oral lesions before meals
d. Apply the ordered anesthetic gel to oral lesions before meals
48
All these patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first?
a. 19-year-old with no previous health problems who has a nontender lump in
the right axile
b. 46-year-old with sickle cell anemia who says “that my eyes always look sort
of yellow”
c. 21-year-old with lymphoma who wants to learn how to self-administer
insulin therapy
d. 50-year-old with early-stage chronic lymphocytic leukemia who has
complaints of chronic fatigue
a. 19-year-old with no previous health problems who has a non-tender lump in the right axilla
49
After the nurse determines that a patient has the following risk factors for melanoma, which risk factor should be the focus of patient teaching related to prevention?
a. The patient has multiple dysplastic nevi
b. The patient is fair skinned and has blue eyes
c. The patient's mother died of a malignant melanoma
d. The patient uses a tanning booth throughout the winter
d. The patient uses a tanning booth throughout the winter
50
The client is experiencing lymphedema in the arm on the operative side after a modified radical mastectomy. Which statement indicates the correct understanding for managing this problem?
a. “I will reduce my intake of salt”
b. “I will elevate my arm on a pillow at night”
c. “I will try to drink at least 3 L of water each day”
d. “I will wear long sleeves to protect sun exposure to that area”
b. “I will elevate my arm on a pillow at night”
51
The nurse is caring for a client who has undergone removal of a benign colonic polyp. The client asks the nurse why a follow-up colonoscopy is necessary. Which is the nurse's best response?
a. “You are at risk for developing more polyps in the future”
b. “You may have other cancerous lesions that could not be seen right now”
c. “The doctor can only remove a few of the polyps during each colonoscopy”
d. “This test will ensure that healing has occurred where the polyp has been
removed”
a. “You are at risk for developing more polyps in the future”
52
The nurse is planning chemotherapy treatment with a 58-year-old post-menopausal female diagnosed with stage 3 cervical cancer. The nurse recognizes that the patient understands the definition of the diagnosis by which of the following correct statement?
a. “Thankfully, the cancer is localized to my cervix only”
b. “I regret not taking this time to get my annual pap smear. Maybe with early
detection it wouldn't have spread to my brain”
c. "I know that my treatment plan will be multimodal and include surgery,
chemotherapy and, most likely, radiation due to the extent of the disease”
d. I'm so happy that the cancer is localized to my cervix and upper third of the
vagina and doesn't have the potential for metastasis”
c. "I know that my treatment plan will be multimodal and include surgery, chemotherapy and, most likely, radiation due to the extent of the disease”
53
The nurse is caring for a client with OCD. The nurse anticipates which of the following findings when assessing the client?
a. Reluctant to relinquish control
b. Inattention to details
c. Oftens asks for help with tasks
d. Excessively devoted to tasks
e. Constant drive for perfectionism
a. Reluctant to relinquish control
d. Excessively devoted to tasks
e. Constant drive for perfectionism
54
The nurse is working on the care plan for a client with antisocial personality disorder. The nurse recognizes that which of the following client behaviors are associated with an antisocial personality disorder?
a. Verbalizes a lack of sympathy for situations
b. Reacts dramatically and emotionally to situations
c. Self-harms with frequent suicide attempts
d. Acts impulsively and without concern for consequences
e. Has a blatant disregard for feelings of others
a. Verbalizes a lack of sympathy for situation
d. Acts impulsively and without concern for consequences
e. Has a blatant disregard for the feelings of others
55
The nurse is caring for a client with borderline personality disorder. Upon assessment, the nurse identifies which of the following behaviors are associated with borderline personality disorder?
a. Excessive attention to appearance
b. Chronic feelings of emptiness
c. Unstable interpersonal relationships
d. Submissive behaviors
e. Self-mutilations
b. Chronic feelings of emptiness
c. Unstable interpersonal relationships
d. Submissive behaviors
56
The nurse is assessing a client with an antisocial personality disorder. The nurse experts which of the following behaviors to be present?
a. Disregards the rights of others
b. Displays deceitful behaviors
c. Avoids all interactions with the nurse and the healthcare team
d. Shows dramatic emotions that do not fit the situation
e. Voices of lack of responsibility for situations
a. Disregards the right of others
b. Displays deceitful behaviors
c. Avoids all interactions with the nurse and the healthcare team
e. Voices a lack of responsibility for situation
57
The nurse is caring for a client on a telemetry unit with heart failure and a schizoid personality disorder. The nurse assesses the client and expects which of the following clinical manifestations related to the schizoid personality disorder?
a. Peculiar behavior and extreme social anxiety
b. Indifferent to praise and encouragement
c. Social isolation and restricted emotions
d. Grandiosity and lack of empathy
e. Intentional deceit of others
a. Peculiar behavior and extreme social anxiety
b. Indifferent to praise and encouragement
c. Social isolation and restricted emotions
d. Grandiosity and lack of empathy
58
A client is admitted to the behavior health unit with a histrionic personality disorder. The nurse assesses the client and identifies which of the following clinical manifestations of histrionic personality disorder?
a. Verbalizes the grand things done and planned
b. Concerned about appearance
c. Compliment seeking behavior
d. Idealizes the nurse and then devalues the nurse
e. Has rapid shifts of emotion
b. Concerned about appearance
c. Compliment seeking behavior
d. Idealizes the nurse and then devalues the nurse
59
The home health nurse visits a 40-year-old patient with metastatic breast cancer who is receiving palliative care. The patient is experiencing pain at a level of 7-10. In prioritizing activities for the client, what should the nurse do first?
a. Ausculate for breath sounds
b. Administer PRN pain medication
c. Check pressure points for skin breakdown
d. Ask family about patient's food and fluid intake
b. Administer PRN pain medication
60
A patient with rheumatoid arthritis is experiencing articular involvement. The nurse recognizes these characteristic changes include
a. bamboo shaped fingers
b. metatarsal head dislocation in feet
c. non inflammatory pain in large joints
d. asymmetric involvement of small joints
e. morning stiffness lasting 60 minutes or more
b. Metatarsal head dislocation in feet
e. Morning stiffness lasting 60 minutes or more
61
In teaching a patient with systemic lupus erythematous about the disorder, the nurse knows the pathophysiology of SLE includes
a. circulating immune complexes formed from IgG autoantibodies reacting
with IgG
b. an autoimmune T-cell reaction that results in destruction of the deep dermal skin layer
c. immunologic dysfunction leading to chronic inflammation in the cartilage and muscles
d. the production of a variety of auto antibodies directed against components of the cell nucleus
d. the production of a variety of auto antibodies directed against components of the cell nucleus
62
The nurse is initiating an IV infusion of lactated ringer’s (LR) For a post-operative oncology patient in hypovolemic shock. The nurse understands that the purpose of initiating A crystalloid is to:
a. Replace potassium and magnesium for cardiac stabilization
b. Provide dextrose and nutrients to prevent apoptosis
c. Draw water from the interstitium to jump to the intravascular space
d. Increased fluid volume and urinary output
d. Increased fluid volume and urinary output
63
The nurse is assessing a client with an autoimmune condition. Which finding indicates that the client may be experiencing physical changes from long-term use of prednisone?
a. Weight gain
b. Increased skeletal muscle mass
c. Thin, fragile skin
d. Acne vulgaris
e. Alopecia
a. Weight gain
c. Thin, fragile skin
d. Acne vulgaris
64
Given the information provided in the client chart, the nurse is most concerned about which of the following complications of chemotherapy?
a. Hyperkalemia and tumor lysis syndrome
b. bleeding and infection
c. hypokalemia and bradycardia
d. low platelet counts and oozing blood
e. sudden cardiac death and ventricular fibrillation
a. Hyperkalemia and tumor lysis syndrome
65
The patient is being treated with brachytherapy for cervical cancer. What factors must the nurse be aware of to protect herself when caring for this patient?
a. The time the nurse spends at what distance from the patient
b. the nutritional supplements that will help the patient
c. how much time is needed to provide the patient's care
d. the medications the patient is taking
a. The time the nurse spends at what distance from the patient
66
The nurse is teaching a wellness class to a group of women at their workplace. Which findings represent the highest risk for developing cancer?
a. Diabetes type II and smoking cigarettes for 20 years
b. High sodium consumption and has regular mammography and Pap
screenings
c. Family history of cervical cancer and does not consume alcohol
d. Exercises five times every week and eats low cholesterol diet
a. Diabetes type II and smoking cigarettes for 20 years
67
Josie, a 27-year-old patient, complains that most of the staff do not like her. She says she can tell that you are a caring person. Josie is unsure of what she wants to do with her life and her “mixed-up feelings” about relationships. When you tell her that you will be on vacation next week, she becomes very angry. Two hours later, she is found using a curling iron to burn her underarms and explains that it “makes the numbness stop.” Given this presentation, which personality disorder would you
suspect?
a. Obsessive-compulsive
b. Borderline
c. Antisocial
d. Schizotypal
b. Borderline
68
The nurse is assessing the lung sounds of a client with an apparent allergic reaction to an Adriamycin infusion. The nurse recognizes that the client’s respiratory status has deteriorated based on which of the following?
a. Inspiratory wheezing
b. Periorbital edema
c. Hives to the upper body and reports of itching
d. Stridor with chest retractions
d. Stridor with chest retractions
69
The nurse is caring for a patient with breast cancer status post 26 rounds of radiation to her chest. The patient is complaining of an 8/10 rating of pain to her chest that is improved placing her in the tripod position. The nurse Knows that it is important to monitor the patient for which of the following clinical manifestation(s) of cardiac tamponade?
a. Tinnitus
b. Juglar vein distention
c. Tachycardia
d. Hypertension
e. Muffled heart sounds
b. Juglar vein distention
c. Tachycardia
d. Hypertension
e. Muffled heart sounds
70
The nurse is reviewing the laboratory results for a patient who has acute leukemia and received aggressive chemotherapy 14 days ago. Which of the following hematologic laboratory values should the nurse expect to find on the complete blood count?
a. Leukocytosis
b. Increased hematocrit
c. Thrombocytopenia
d. Pancytopenia
e. Low blood glucose
c. Thrombocytopenia
d. Pancytopenia
71
The nurse is caring for a client with colon cancer who developed cardiogenic shock while receiving IV fluids following chemotherapy Winch of the following assessment findings indicate that the client is experiencing hypervolemia from fluid overload?
a. Hypertension
b. Elevated temperature
c. Peripheral edema
d. Frothy sputum production
e. Nausea and vomiting
f. Dyspnea
a. Hypertension
c. Peripheral edema
d. Frothy sputum production
f. Dyspnea
72
A nurse is caring for an older adult client who has RA and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?
a. Erythrocyte Sedimentation Rate
b. Antinuclear Antibody
c. Rheumatoid factor
d. White blood cell count
a. Erythrocyte Sedimentation Rate
73
A client is starting celecoxib to treat osteoarthritis. The nurse should instruct the client to watch for and report which of the following adverse effects?
a. Dry mouth
b. Bone pain
c. Black tarry stools
d. Polyuria
c. Black tarry stools
74
A nurse is teaching a client about risk factors for osteoporosis. Which of the following factors should the nurse include in the teaching?
a. BMI > 30
b. Aging
c. Sedentary lifestyle
d. Second-hand smoke
e. Caffeine intake
b. Aging
c. Sedentary lifestyle
75
A nurse is teaching a client who has chronic gout about his new prescription for allopurinol. The nurse should explain that the purpose of this medication is to reduce blood levels of which of the following substances?
a. Uric acid
b. Interleukin -1
c. Potassium
d. Chloride
a. Uric acid
76
A nurse is caring for a client with bladder incontinence. Which of the following actions should the nurse take to prevent skin breakdown?
a. Minimize oral fluid intake
b. Cleanse skin with betadine and hot water
c. Dry between skin folds
d. Apply baby powder to the client's skin
c. Dry between skin folds
77
An oncology nurse tells another nurse that they are feeling overwhelmed after caring for multiple clients who are dying and reports having difficulty feeling sympathy for their clients. The nurse has manifestations of which of the following conditions?
a. PTSD
b. Compassion fatigue
c. Prolonged grief disorder
d. A normal response from a caregiver caring for terminally ill patients
b. Compassion fatigue
78
A nurse is caring for a client newly diagnosed with metastatic lung cancer. The client states, “My doctor was just here but I still do not understand my diagnosis.” The nurse contacts the provider to return to speak with the client. Which of the following principles is the nurse demonstrating?
a. Confidentiality
b. Fidelity
c. Accountability
d. Advocacy
d. Advocacy
79
A nurse is assessing a client who has RA and a suspected active infection. Which of the following findings is manifestations of sepsis?
a. Vomiting
b. Hypoglycemia
c. Hypertension
d. Altered mental status
e. Elevated white blood cell count
a. Vomiting
c. Hypertension
d. Altered mental status
e. Elevated WBC count
80
A severely neutropenic patient in septic shock receives 2 L of normal saline intravenously, the heart rate is 109 beats/min and the blood pressure is 82/40 mm Hg. What medication should the nurse anticipate will be administered next?
a. Lactated ringers
b. Metoprolol
c. Furosemide
d. Norepinephrine
e. Nitroglycerine
f. Nitroprusside
d. Norepinephrine
81
The nurse reviews the client's ECG rhythm strip, patient information, it reports a rhythm to the provider as
a. Ventricular tachycardia
b. Ventricular fibrillation
c. Atrial fibrillation
d. Normal sinus rhythm with PVCs
c. Atrial fibrillation
82
Which interventions should the nurse complete?
a. Begin CPR and call a code blue
b. Administer the scheduled dose of metoprolol
c. Administer atropine IVP
d. Apply a transcutaneous pacer
e. Have the patient perform the Valsalva maneuver
f. Prepare the patient for a pacemaker
c. Administer atropine IVP
d. Apply a transcutaneous pacer
f. Prepare the patient for a pacemaker
83
A nurse is caring for a client with dependent personality disorder. The nurse should identify which of the following between as a warning sign of suicide?
a. The client is giving away their possessions
b. The client states that they are stopping their medications
c. The client requests an appointment to discuss their depression
d. The client states they have been sleeping 12 hr a day
a. The client is giving away their possessions
84
Based on these findings, the nurse anticipates which of the following orders from the provider?
a. Start an amiodarone drip
b. Collect a CBC
c. Prepare for cardioversion
d. Prepare for defibrillation
e. Administer a liter of Lactated Ringers
f. Administer Ativan 1 mg IV Push
a. Start an amiodarone drip
c. Prepare for cardioversion
e. Administer a liter of lactated ringers
85
A nurse is caring for a client with a recent lung transplant who has a chest tube connected to a closed drainage system and needs to be transported to the X-ray department. Which of the following actions should the nurse take?
a. Clamp the chest tube prior to transferring the client to a wheelchair
b. Disconnect the chest tube from the drainage system during transport
c. Keep the drainage system below the level of the client's chest at all times
d. Empty the collection chamber prior to transport
c. Keep the drainage system below the level of the clients chest at all times
86
A nurse is caring for a client with rheumatoid arthritis and pleuritis who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration?
a. Continue to monitor the client
b. Immediately notify the provider
c. Reposition the client toward the left side
d. Clamp the chest tube near the water seal
a. Continue to monitor the client
87
A nurse is teaching a newly licensed nurse about pain manage- ment during the end of life. Which of the following statements should the nurse make?
a. Pain is expected in older adult clients
b. Discomfort is expected in clients who are at the end of life
c. Clients are often afraid that opioid narcotics can result in addiction
d. Opioid narcotics can cause loose stools and diarrhea in clients
c. Clients are often afraid that opioid narcotics can result in addiction
88
A nurse is caring for a client who has received hemodialysis. Which of the following assessment findings require follow ups?
a. Vital signs
b. Weight
c. Blood glucose level
d. Presence of bruit and thrill
e. Lung sounds
f. AV fistula site assessment
a. Vital signs
b. Weight
c. Blood glucose level
e. Lung sounds
f. AV fistula site assessment
89
There is one answer
a. Maintain a neutral demeanor
b. Avoid becoming defensive when the client makes disparaging remarks
c. Narcissistic personality disorder
d. Low self-esteem
e. Lack of social empathy
90
The nurse at the clinic is interviewing a 61-year-old woman who is 5 feet, 3 inches tall and weighs 125 lbs. The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine 2 or 3 times week, denies smoking you studied. Which topics will the nurse plan to include in patient teaching
about cancer screening and decreasing cancer risk?
a. Pap testing
b. Smoking cessation
c. Sunscreen use
d. Mammography
e. Colorectal screening
a. Pap testing
c. Sunscreen use
d. Mammography
e. Colorectal screening
91
The nurse is caring for a client with paranoid personality disorder that the states she sees UFOs and aliens following and watching her. What is the best response from the nurse?
a. “I don't know what you are talking about. I don't see any UFOs or aliens.”
b. “I don't see any UFOs or aliens.”
c. “I see the UFOs and aliens too and they scare me, what are we going to do?”
d. “I can tell that what you're seeing scares you, how can I help to make you
more comfortable?”
d. “I can tell that what you're seeing scares you, how can I help to make you more comfortable?”
92
A client who has fecal occult blood testing tells the nurse that the test was negative for colon cancer and wishes to cancel a colonoscopy scheduled for the next day.
Which is the nurse’s best response?
a. “I will call and cancel the test for tomorrow.”
b. “You will need two negative fecal occult blood tests.”
c. “This does not rule out the possibility of colon cancer.”
c. “This does not rule out the possibility of colon cancer.”
93
The nurse manager has delegated four clients to be cared for by a licensed practical/vocational nurse (LPN/LVN). Which action(s) by the LPN/LVN evaluated by the delegating nurse may indicate disciplinary action should be instituted?
a. Leaving dressing supplies in the client’s room that were not used.
b. A client refuses to take medication that is prescribed
c. Documentation of wound care that was not performed
d. A client’s BP is 220/114 mmHg and prescribed antihypertensive not
administered
e. The LPN/LVN takes an extra 15 minutes of lunchtime with a co-worker
c. Documentation of wound care that was not performed
d. A client’s BP is 220/114 mmHg and prescribed antihypertensive not administered
e. The LPN/LVN takes an extra 15 minutes of lunchtime with a co-worker
94
Which of the following is the nurses’ priority based on the information?
a. Institute falls prevention precautions
b. Initiate neutropenic precautions
c. Contact the healthcare provider for a Foley catheter order
d. Assess that the client is having regular bowel movements
a. Institute falls prevention precautions
95
You are the nurse caring for the client. Based on the information provided, which of the following is the priority to report immediately to the healthcare provider?
a. Tidaling in the suction control chamber of the best tube
b. Presence of drainage in the chest tube
c. Absence of bubbling in the suction control chamber of the chest tube
d. Bubbling in the water seal chamber of the chest tube
d. Bubbling in the water seal chamber of the chest tube
96
Based on the information provided, which of the following medications will the nurse administer first?
a. Normal saline IV infusion 150 ml/hour
b. Vancomycin 250mg IVPB
c. Heparin 10,000 units subcutaneously
d. Propranolol 80mg daily
e. Enalapril 5mg daily
c. Heparin 10,000 units subcutaneously
97
Which statements made by the psychiatric nurse demonstrates an accurate understanding of the factors that affect an individual’s personality?
a. “Therapy will help her identify that her problems are personality related.”
b. “I’ll need to learn more about this patient’s cultural beliefs.”
c. “It’s encouraging to know that personality disorders respond well to
treatment.”
d. “A person’s personality is fluid and adjusts to current social situations.”
b. “I’ll need to learn more about this patient’s cultural beliefs.”
98
The patient and his family are upset that the patient is going through procedures to diagnose cancer. What nursing actions should the nurse use first to facilitate their coping with this situation?
a. Maintain hope
b. Exhibit a caring attitude
c. Plan realistic long-term goals
d. Give them antianxiety medications
e. Be available to listen to fears and concerns
f. Teach them about the type of cancers that could be diagnosed
a. Maintain hope
b. Exhibit a caring attitude
e. Be available to listen to fears and concerns
99
The nursing diagnosis that is likely to be appropriate for a 67-year-old woman who has just been diagnosed with stage III ovarian cancer is
a. Sexual dysfunction related to loss of vaginal sensation
b. Risk for infection related to impaired immune function
c. Situational low self-esteem related to guilt about delaying medical care
d. Anxiety related to cancer diagnosis and need for treatment decisions
d. Anxiety related to cancer diagnosis and need for treatment decisions
100
A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observations by the RN caring for the patient indicates that the nurse should take action?
a. The patient ambulates several times a day in the room
b. The patient’s visitors bring in some fresh peaches from home
c. The patient cleans with a warm washcloth after having a stool
d. The patient uses soap and shampoo to shower every other day
b. The patient’s visitors bring in some fresh peaches from home
