- A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event?
a. Provide water and healthy snacks for energy throughout the event.
b. Schedule 16-hour shifts to allow for greater rest between shifts.
c. Encourage counseling upon deactivation of the emergency response plan. d. Assign staff to different roles and units within the medical facility.
ANS: A
To prevent staff post-traumatic stress disorder during a mass casualty event, the nurses should use available counseling, encourage and support co-workers, monitor each others stress level and performance, take breaks when needed, talk about feelings with staff and managers, and drink plenty of water and eat healthy snacks for energy. Nurses should also keep in touch with family, friends, and significant others, and not work for more than 12 hours per day. Encouraging counseling upon deactivation of the plan, or after the emergency response is over, does not prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may increase situational stress and is not an approach to prevent post-traumatic stress disorder.
- An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event?
a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims.
b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in.
c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED.
d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.
ANS: D
The ED charge nurse should direct additional nursing staff to help care for current ED clients while the ED staff prepares to receive mass casualty victims; however, they should not be assigned to the most critically ill or injured clients. The house supervisor and unit directors would collaborate to discharge stable clients. The hospital incident commander is responsible for mobilizing resources and would have the responsibility for calling in staff. The medical command physician would be the person best able to communicate with on-scene personnel regarding the ability to take more clients.
- The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation?
a. You are free to express your feelings; whatever is said here stays here.
b. Lets evaluate what went wrong and develop policies for future incidents.
c. This session is only for nursing and medical staff, not for
ancillary personnel.
d. Lets pass around the written policy
compliance form for everyone.
ANS: A
Strict confidentiality during stress debriefing is essential so that staff members can feel comfortable sharing their feelings, which should be accepted unconditionally. Brainstorming improvements and discussing policies would occur during an administrative review. Any employee present during a mass casualty situation is eligible for critical incident stress management services.
- A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select all that apply.)
a. Paramedic Decides the number, acuity, and resource needs of clients
b. Hospital incident commander Assumes overall leadership for implementing the emergency plan
c. Public information officer Provides advanced life support during transportation to the hospital
d. Triage officer Rapidly evaluates each client to determine priorities for treatment
e. Medical command physician Serves as a liaison between the health care facility and the media
ANS: B, D
The hospital incident commander assumes overall leadership for implementing the emergency plan. The triage officer rapidly evaluates each client to determine priorities for treatment. The paramedic provides advanced life support during transportation to the hospital. The public information officer serves as a liaison between the health care facility and the media. The medical command physician decides the number, acuity, and resource needs of clients.
7. A hospital unit is participating in a bioterrorism drill. A client
is admitted with inhalation anthrax. Under
what type of
precautions does the charge nurse admit the client?
a. Airborne
Precautions
b. Contact Precautions
c. Droplet
Precautions
d. Standard Precautions
ANS: D
Only Standard Precautions are needed. No other special
precautions are required for the client because
inhalation
anthrax is not spread person to person.
9. A client is admitted with fever, myalgia, and a papular rash on
the face, palms, and soles of the feet. What
action should the
nurse take first?
a. Obtain cultures of the lesions.
b.
Place the client on Airborne Precautions.
c. Prepare to
administer antibiotics.
d. Provide comfort measures for the rash.
ANS: B
This client has manifestations of smallpox, a public
health emergency, and should be placed on Airborne
Precautions
first before other care measures are implemented.
6. After teaching a client who is prescribed voice rest therapy for
vocal cord polyps, a nurse assesses the clients
understanding.
Which statement indicates the client needs further teaching?
a. I
will stay away from smokers to minimize inhalation of secondhand
smoke.
b. When I speak, I will whisper rather than use a normal
tone of voice.
c. For the next several weeks, I will not lift
more than 10 pounds.
d. I will drink at least three quarts of
water each day to stay hydrated.
ANS: B
Treatment for vocal cord polyps includes no speaking, no
lifting, and no smoking. The client has to be
educated not to
even whisper when resting the voice. It is also appropriate for the
client to stay out of rooms
where people are smoking, to stay
hydrated, and to use stool softeners.
8. A nurse cares for a client after radiation therapy for lung
cancer. The client reports a sore throat. Which
action should the
nurse take first?
a. Ask the client to gargle with mouthwash
containing lidocaine.
b. Administer prescribed intravenous pain
medications.
c. Explain that soreness is normal and will improve
in a couple days.
d. Assess the clients neck for redness and swelling.
ANS: A
Mouthwashes and throat sprays containing a local
anesthetic agent such as lidocaine or diphenhydramine can
provide
relief from a sore throat after radiation therapy. Intravenous pain
medications may be used if local
anesthetics are unsuccessful.
The nurse should explain to the client that this is normal and assess
the clients
neck, but these options do not decrease the clients discomfort.
9. A nurse cares for a client who had a partial laryngectomy 10 days
ago. The client states that all food tastes
bland. How should the
nurse respond?
a. I will consult the speech therapist to ensure
you are swallowing properly.
b. This is normal after surgery.
What types of food do you like to eat?
c. I will ask the
dietitian to change the consistency of the food in your diet.
d.
Replacement of protein, calories, and water is very important after surgery.
ANS: B
Many clients experience changes in taste after surgery.
The nurse should identify foods that the client wants to
eat to
ensure the client maintains necessary nutrition. Although the nurse
should collaborate with the speech
therapist and dietitian to
ensure appropriate replacement of protein, calories, and water, the
other responses do
not address the clients concerns.
10. A nurse cares for a client who is scheduled for a total
laryngectomy. Which action should the nurse take
prior to
surgery?
a. Assess airway patency, breathing, and
circulation.
b. Administer prescribed intravenous pain
medication.
c. Assist the client to choose a communication
method.
d. Ambulate the client in the hallway to assess gait.
ANS: C
The client will not be able to speak after surgery. The
nurse should assist the client to choose a communication
method
that he or she would like to use after surgery. Assessing the clients
airway and administering IV pain
medication are done after the
procedure. Although ambulation promotes health and decreases
the
complications of any surgery, this clients gait should not be
impacted by a total laryngectomy and therefore is
not a priority.
14. A nurse teaches a client to use a room humidifier after a
laryngectomy. Which statement should the nurse
include in this
clients teaching?
a. Add peppermint oil to the humidifier to
relax the airway.
b. Make sure you clean the humidifier to
prevent infection.
c. Keep the humidifier filled with water at
all times.
d. Use the humidifier when you sleep, even during
daytime naps.
ANS: B
Priority teaching related to the use of a room humidifier
focuses on infection control. Clients should be taught
to
meticulously clean the humidifier to prevent the spread of mold or
other sources of infection. Peppermint oil
should not be added to
a humidifier. The humidifier should be refilled with water as needed
and should be used
while awake and asleep.
4. A registered nurse (RN) cares for clients on a surgical unit.
Which clients should the RN delegate to a
licensed practical
nurse (LPN)? (Select all that apply.)
a. A 32-year-old who had a
radical neck dissection 6 hours ago
b. A 43-year-old diagnosed
with cancer after a lung biopsy 2 days ago
c. A 55-year-old who
needs discharge teaching after a laryngectomy
d. A 67-year-old
who is awaiting preoperative teaching for laryngeal cancer
e. An
88-year-old with esophageal cancer who is awaiting gastric tube placement
ANS: B, E
The nurse can delegate stable clients to the LPN. The
client who had a biopsy 2 days ago and the client who is
awaiting
gastric tube placement are stable. The client who is 6 hours
post-surgery is not yet stable. The RN is
the only one who can
perform discharge and preoperative teaching; teaching cannot be delegated.
5. A nurse cares for a client who has developed esophagitis after
undergoing radiation therapy for lung cancer.
Which diet
selection should the nurse provide for this client?
a. Spaghetti
with meat sauce, ice cream
b. Chicken soup, grilled cheese
sandwich
c. Omelet, soft whole wheat bread
d. Pasta salad,
custard, orange juice
ANS: C
Side effects of radiation therapy may include
inflammation of the esophagus. Clients should be taught
that
bland, soft, high-calorie foods are best, along with liquid
nutritional supplements. Tomato sauce may prove too
spicy for a
client with esophagitis. A grilled cheese sandwich is too difficult to
swallow with this condition,
and orange juice and other foods
with citric acid are too caustic.
6. The nurse is caring for a client with lung cancer who states, I
dont want any pain medication because I am
afraid Ill become
addicted. How should the nurse respond?
a. I will ask the
provider to change your medication to a drug that is less
potent.
b. Would you like me to use music therapy to distract you
from your pain?
c. It is unlikely you will become addicted when
taking medicine for pain.
d. Would you like me to give you
acetaminophen (Tylenol) instead?
ANS: C
Clients should be encouraged to take their pain
medications; addiction usually is not an issue with a client
in
pain. The nurse would not request that the pain medication be
changed unless it was not effective. Other
methods to decrease
pain can be used, in addition to pain medication.
10. While assessing a client who is 12 hours postoperative after a
thoracotomy for lung cancer, a nurse notices
that the lower chest
tube is dislodged. Which action should the nurse take first?
a.
Assess for drainage from the site.
b. Cover the insertion site
with sterile gauze.
c. Contact the provider and obtain a suture
kit.
d. Reinsert the tube using sterile technique.
ANS: B
Immediately covering the insertion site helps prevent air
from entering the pleural space and causing a
pneumothorax. The
area will not reseal quickly enough to prevent air from entering the
chest. The nurse should
not leave the client to obtain a suture
kit. An occlusive dressing may cause a tension pneumothorax. The
site
should only be assessed after the insertion site is covered.
The provider should be called to reinsert the chest
tube or
prescribe other treatment options.
13. A nurse cares for a client who had a chest tube placed 6 hours
ago and refuses to take deep breaths because
of the pain. Which
action should the nurse take?
a. Ambulate the client in the
hallway to promote deep breathing.
b. Auscultate the clients
anterior and posterior lung fields.
c. Encourage the client to
take shallow breaths to help with the pain.
d. Administer pain
medication and encourage the client to take deep breaths.
ANS: D
A chest tube is placed in the pleural space and may be
uncomfortable for a client. The nurse should provide
pain
medication to minimize discomfort and encourage the client to take
deep breaths. The other responses do
not address the clients
discomfort and need to take deep breaths to prevent complications.
14. A nurse cares for a client who has a chest tube. When would this
client be at highest risk for developing a
pneumothorax?
a.
When the insertion site becomes red and warm to the touch
b. When
the tube drainage decreases and becomes sanguineous
c. When the
client experiences pain at the insertion site
d. When the tube
becomes disconnected from the drainage system
ANS: D
Intrathoracic pressures are less than atmospheric
pressures; therefore, if the chest tube becomes disconnected
from
the drainage system, air can be sucked into the pleural space and
cause a pneumothorax. A red, warm,
and painful insertion site
does not increase the clients risk for a pneumothorax. Tube drainage
should decrease
and become serous as the client heals.
Sanguineous drainage is a sign of bleeding but does not increase
the
clients risk for a pneumothorax.
2. A nurse assesses a client who has a mediastinal chest tube. Which
symptoms require the nurses immediate
intervention? (Select all
that apply.)
a. Production of pink sputum
b. Tracheal
deviation
c. Pain at insertion site
d. Sudden onset of
shortness of breath
e. Drainage greater than 70 mL/hr
f.
Disconnection at Y site
ANS: B, D, E, F
Immediate intervention is warranted if the
client has tracheal deviation because this could indicate a
tension
pneumothorax. Sudden shortness of breath could indicate
dislodgment of the tube, occlusion of the tube, or
pneumothorax.
Drainage greater than 70 mL/hr could indicate hemorrhage.
Disconnection at the Y site could
result in air entering the
tubing. Production of pink sputum, oxygen saturation less than 95%,
and pain at the
insertion site are not signs/symptoms that would
require immediate intervention.
8. A nursing student is caring for a client with leukemia. The
student asks why the client is still at risk for
infection when
the clients white blood cell count (WBC) is high. What response by the
registered nurse is best?
a. If the WBCs are high, there already
is an infection present.
b. The client is in a blast crisis and
has too many WBCs.
c. There must be a mistake; the WBCs should be
very low.
d. Those WBCs are abnormal and dont provide protection.
ANS: D
In leukemia, the WBCs are abnormal and do not provide
protection to the client against infection. The other
statements
are not accurate.
10. A nurse is caring for a client who is about to receive a bone
marrow transplant. To best help the client cope
with the long
recovery period, what action by the nurse is best?
a. Arrange a
visitation schedule among friends and family.
b. Explain that
this process is difficult but must be endured.
c. Help the client
find things to hope for each day of recovery.
d. Provide plenty
of diversionary activities for this time.
ANS: C
Providing hope is an essential nursing function during
treatment for any disease process, but especially during
the
recovery period after bone marrow transplantation, which can take up
to 3 weeks. The nurse can help the
client look ahead to the
recovery period and identify things to hope for during this time.
Visitors are important
to clients, but may pose an infection
risk. Telling the client the recovery period must be endured does
not
acknowledge his or her feelings. Diversionary activities are
important, but not as important as instilling hope.
11. A nursing student is struggling to understand the process of
graft-versus-host disease. What explanation by the nurse instructor is
best?
a. Because of immunosuppression, the donor cells take
over.
b. Its like a transfusion reaction because no perfect
matches exist.
c. The clients cells are fighting donor cells for
dominance.
d. The donors cells are actually attacking the clients cells.
ANS: D
Graft versus host disease is an autoimmune-type process
in which the donor cells recognize the clients cells as
foreign
and begin attacking them. The other answers are not accurate.
12. The nurse is caring for a client with leukemia who has the
priority problem of fatigue. What action by the
client best
indicates that an important goal for this problem has been
met?
a. Doing activities of daily living (ADLs) using rest
periods
b. Helping plan a daily activity schedule
c.
Requesting a sleeping pill at night
d. Telling visitors to leave
when fatigued
ANS: A
Fatigue is a common problem for clients with leukemia.
This client is managing his or her own ADLs using
rest periods,
which indicates an understanding of fatigue and how to control it.
Helping to plan an activity
schedule is a lesser indicator.
Requesting a sleeping pill does not help control fatigue during the
day. Asking
visitors to leave when tired is another lesser
indicator. Managing ADLs using rest periods demonstrates the
most
comprehensive management strategy.
13. A nurse is caring for a young male client with lymphoma who is to
begin treatment. What teaching topic is
a priority?
a.
Genetic testing
b. Infection prevention
c. Sperm
banking
d. Treatment options
ANS: C
All teaching topics are important to the client with
lymphoma, but for a young male, sperm banking is of
particular
concern if the client is going to have radiation to the lower abdomen
or pelvis.
17. A client has a platelet count of 9000/mm3. The nurse finds the
client confused and mumbling. What action
takes priority?
a.
Calling the Rapid Response Team
b. Delegating taking a set of
vital signs
c. Instituting bleeding precautions
d. Placing
the client on bedrest
ANS: A
With a platelet count this low, the client is at high
risk of spontaneous bleeding. The most disastrous
complication
would be intracranial bleeding. The nurse needs to call the Rapid
Response Team as this client
has manifestations of a sudden
neurologic change. The nurse should not delegate the vital signs as
the client is no longer stable. Bleeding precautions will not address
the immediate situation. Placing the client on bedrest or
putting
the client back into bed is important, but the critical action is to
call for immediate medical attention.
21. A client has thrombocytopenia. What client statement indicates
the client understands self-management of this condition?
a. I
brush and use dental floss every day.
b. I chew hard candy for my
dry mouth.
c. I usually put ice on bumps or bruises.
d.
Nonslip socks are best when I walk.
ANS: C
The client should be taught to apply ice to areas of
minor trauma. Flossing is not recommended. Hard foods
should be
avoided. The client should wear well-fitting shoes when ambulating.
25. A nurse is caring for four clients with leukemia. After hand-off
report, which client should the nurse see
first?
a. Client
who had two bloody diarrhea stools this morning
b. Client who has
been premedicated for nausea prior to chemotherapy
c. Client with
a respiratory rate change from 18 to 22 breaths/min
d. Client
with an unchanged lesion to the lower right lateral malleolus
ANS: A
The client who had two bloody diarrhea stools that
morning may be hemorrhaging in the gastrointestinal (GI)
tract
and should be assessed first. The client with the change in
respiratory rate may have an infection or
worsening anemia and
should be seen next. The other two clients are not a priority at this time.
26. A client has frequent hospitalizations for leukemia and is
worried about functioning as a parent to four
small children.
What action by the nurse would be most helpful?
a. Assist the
client to make sick day plans for household responsibilities.
b.
Determine if there are family members or friends who can help the
client.
c. Help the client inform friends and family that they
will have to help out.
d. Refer the client to a social worker in
order to investigate respite child care
ANS: A
While all options are reasonable choices, the best option
is to help the client make sick day plans, as that is
more
comprehensive and inclusive than the other options, which focus on a
single item.
2. A student studying leukemias learns the risk factors for
developing this disorder. Which risk factors does
this include?
(Select all that apply.)
a. Chemical exposure
b. Genetically
modified foods
c. Ionizing radiation exposure
d.
Vaccinations
e. Viral infections
ANS: A, C, E
Chemical and ionizing radiation exposure and viral
infections are known risk factors for developing leukemia.
Eating
genetically modified food and receiving vaccinations are not known
risk factors
3. A client has Hodgkins lymphoma, Ann Arbor stage Ib. For what
manifestations should the nurse assess the
client? (Select all
that apply.)
a. Headaches
b. Night sweats
c. Persistent fever
d. Urinary frequency
e. Weight loss
ANS: B, C, E
In this stage, the disease is located in a single
lymph node region or a single nonlymph node site. The
client
displays night sweats, persistent fever, and weight loss.
Headache and urinary problems are not related.
4. A client has a platelet count of 25,000/mm3. What actions does the
nurse delegate to the unlicensed assistive
personnel (UAP)?
(Select all that apply.)
a. Assist with oral hygiene using a firm
toothbrush.
b. Give the client an enema if he or she is
constipated.
c. Help the client choose soft foods from the
menu.
d. Shave the male client with an electric razor.
e.
Use a lift sheet when needed to re-position the client.
ANS: C, D, E
This client has thrombocytopenia and requires
bleeding precautions. These include oral hygiene with a
soft-
bristled toothbrush or swabs, avoiding rectal trauma,
eating soft foods, shaving with an electric razor, and
using a
lift sheet to re-position the client.
10. A client has received a bone marrow transplant and is waiting for
engraftment. What actions by the nurse
are most appropriate?
(Select all that apply.)
a. Not allowing any visitors until
engraftment
b. Limiting the protein in the clients diet
c.
Placing the client in protective precautions
d. Teaching visitors
appropriate hand hygiene
e. Telling visitors not to bring live
flowers or plants
ANS: C, D, E
The client waiting for engraftment after bone
marrow transplant has no white cells to protect him or her
against
infection. The client is on protective precautions and
visitors are taught hand hygiene. No fresh flowers or
plants are
allowed due to the standing water in the vase or container that may
harbor organisms. Limiting
protein is not a healthy option and
will not promote engraftment.
1. A client is admitted with Guillain-Barr syndrome (GBS). What
assessment takes priority?
a. Bladder control
b. Cognitive
perception
c. Respiratory system
d. Sensory functions
ANS: C
Clients with GBS have muscle weakness, possibly to the
point of paralysis. If respiratory muscles are
paralyzed, the
client may need mechanical ventilation, so the respiratory system is
the priority. The nurse will
complete urinary, cognitive, and
sensory assessments as part of a thorough evaluation.
2. The nurse learns that the pathophysiology of Guillain-Barr
syndrome includes segmental demyelination. The
nurse should
understand that this causes what?
a. Delayed afferent nerve
impulses
b. Paralysis of affected muscles
c. Paresthesia in
upper extremities
d. Slowed nerve impulse transmission
ANS: D
Demyelination leads to slowed nerve impulse transmission.
The other options are not correct.
3. A client with Guillain-Barr syndrome is admitted to the hospital.
The nurse plans caregiving priority to
interventions that address
which priority client problem?
a. Anxiety
b. Low fluid
volume
c. Inadequate airway
d. Potential for skin breakdown
ANS: C
Airway takes priority. Anxiety is probably present, but a
physical diagnosis takes priority over a psychosocial
one. The
client has no reason to have low fluid volume unless he or she has
been unable to drink for some time.
If present, airway problems
take priority over a circulation problem. An actual problem takes
precedence over
a risk for a problem.
11. A client is receiving plasmapheresis. What action by the nurse
best prevents infection in this client?
a. Giving antibiotics
prior to treatments
b. Monitoring the clients vital signs
c. Performing
appropriate hand hygiene
d. Placing the client in protective isolation
ANS: C
Plasmapheresis is an invasive procedure, and the nurse
uses good hand hygiene before and after client contact
to prevent
infection. Antibiotics are not necessary. Monitoring vital signs does
not prevent infection but could
alert the nurse to its
possibility. The client does not need isolation.
12. An older client is hospitalized with Guillain-Barr syndrome. A
family member tells the nurse the client is
restless and seems
confused. What action by the nurse is best?
a. Assess the clients
oxygen saturation.
b. Check the medication list for
interactions.
c. Place the client on a bed alarm.
d. Put the
client on safety precautions.
ANS: A
In the older adult, an early sign of hypoxia is often
confusion and restlessness. The nurse should first assess
the
clients oxygen saturation. The other actions are appropriate,
but only after this assessment occurs.
4. An older adult client is hospitalized with Guillain-Barr syndrome.
The client is given amitriptyline (Elavil).
After receiving the
hand-off report, what actions by the nurse are most important? (Select
all that apply.)
a. Administering the medication as
ordered
b. Advising the client to have help getting up
c.
Consulting the provider about the drug
d. Cutting the dose of the
drug in half
e. Placing the client on safety precautions
ANS: B, C, E
Amitriptyline is a tricyclic antidepressant and is
considered inappropriate for use in older clients due to
concerns
of anticholinergic effects, confusion, and safety risks. The nurse
should tell the client to have help
getting up, place the client
on safety precautions, and consult the provider. Since this drug is
not appropriate
for older clients, cutting the dose in half is
not warranted.
5. The nurse caring for a client with Guillain-Barr syndrome has
identified the priority client problem of
decreased mobility for
the client. What actions by the nurse are best? (Select all that
apply.)
a. Ask occupational therapy to help the client with
activities of daily living.
b. Consult with the provider about a
physical therapy consult.
c. Provide the client with information
on support groups.
d. Refer the client to a medical social worker
or chaplain.
e. Work with speech therapy to design a high-protein diet.
ANS: A, B, E
Improving mobility and strength involves the
collaborative assistance of occupational therapy,
physical
therapy, and speech therapy. While support groups,
social work, or chaplain referrals may be needed, they do
not
help with mobility.
5. A client is being taught about drug therapy for Helicobacter
pylori infection. What assessment by the nurse
is most
important?
a. Alcohol intake of 1 to 2 drinks per week
b.
Family history of H. pylori infection
c. Former smoker still
using nicotine patches
d. Willingness to adhere to drug therapy
ANS: D
Treatment for this infection involves either triple or
quadruple drug therapy, which may make it difficult for
clients
to remain adherent. The nurse should assess the clients willingness
and ability to follow the regimen.
The other assessment findings
are not as critical.
10. A client is scheduled for a total gastrectomy for gastric cancer.
What preoperative laboratory result should
the nurse report to
the surgeon immediately?
a. Albumin: 2.1 g/dL
b. Hematocrit:
28%
c. Hemoglobin: 8.1 mg/dL
d. International normalized
ratio (INR): 4.2
ANS: D
An INR as high as 4.2 poses a serious risk of bleeding
during the operation and should be reported. The
albumin is low
and is an expected finding. The hematocrit and hemoglobin are also
low, but this is expected in
gastric cancer.
11. A client has a recurrence of gastric cancer and is in the
gastrointestinal clinic crying. What response by the nurse is most
appropriate?
a. Do you have family or friends for
support?
b. Id like to know what you are feeling now.
c.
Well, we knew this would probably happen.
d. Would you like me to
refer you to hospice?
ANS: B
The nurse assesses the clients emotional state with
open-ended questions and statements and shows a
willingness to
listen to the clients concerns. Asking about support people is very
limited in nature, and yes-or-
no questions are not therapeutic.
Stating that this was expected dismisses the clients concerns. The
client may
or may not be ready to hear about hospice, and this is
another limited, yes-or-no question.
15. A client has dumping syndrome after a partial gastrectomy. Which
action by the nurse would be most
helpful?
a. Arrange a
dietary consult.
b. Increase fluid intake.
c. Limit the
clients foods.
d. Make the client NPO.
ANS: A
The client with dumping syndrome after a gastrectomy has
multiple dietary needs. A referral to the registered
dietitian
will be extremely helpful. Food and fluid intake is complicated and
needs planning. The client should
not be NPO.
16. An older client has gastric cancer and is scheduled to have a
partial gastrectomy. The family does not want
the client told
about her diagnosis. What action by the nurse is best?
a. Ask the
family why they feel this way.
b. Assess family concerns and
fears.
c. Refuse to go along with the familys wishes.
d.
Tell the family that such secrets cannot be kept.
ANS: B
The nurse should use open-ended questions and statements
to fully assess the familys concerns and fears.
Asking why
questions often puts people on the defensive and is considered a
barrier to therapeutic
communication. Refusing to follow the
familys wishes or keep their confidence will not help move this
family
from their position and will set up an adversarial relationship.
3. The student nurse learns about risk factors for gastric cancer.
Which factors does this include? (Select all
that apply.)
a.
Achlorhydria
b. Chronic atrophic gastritis
c. Helicobacter
pylori infection
d. Iron deficiency anemia
e. Pernicious anemia
ANS: A, B, C, E
Achlorhydria, chronic atrophic gastritis, H.
pylori infection, and pernicious anemia are all risk factors
for
developing gastric cancer. Iron deficiency anemia is not a
risk factor.
4. A client has dumping syndrome. What menu selections indicate the
client understands the correct diet to
manage this condition?
(Select all that apply.)
a. Canned unsweetened apricots
b.
Coffee cake
c. Milk shake
d. Potato soup
e. Steamed broccoli
ANS: A, D
Canned apricots and potato soup are appropriate
selections as they are part of a high-protein, high-fat, low-
to
moderate-carbohydrate diet. Coffee cake and other sweets must
be avoided. Milk products and sweet drinks
such as shakes must be
avoided. Gas-forming foods such as broccoli must also be avoided.
6. A client who had a partial gastrectomy has several expected
nutritional problems. What actions by the nurse
are best to
promote better nutrition? (Select all that apply.)
a. Administer
vitamin B12 injections.
b. Ask the provider about folic acid
replacement.
c. Educate the client on enteral feedings.
d.
Obtain consent for total parenteral nutrition.
e. Provide iron
supplements for the client.
ANS: A, B, E
After gastrectomy, clients are at high risk for
anemia due to vitamin B12 deficiency, folic acid deficiency,
or
iron deficiency. The nurse should provide supplements for all
these nutrients. The client does not need enteral
feeding or
total parenteral nutrition.
5. A nurse assesses clients at a community health center. Which
client is at highest risk for the development of
colorectal
cancer?
a. A 37-year-old who drinks eight cups of coffee
daily
b. A 44-year-old with irritable bowel syndrome
(IBS)
c. A 60-year-old lawyer who works 65 hours per week
d.
A 72-year-old who eats fast food frequently
ANS: D
Colon cancer is rare before the age of 40, but its
incidence increases rapidly with advancing age. Fast food
tends
to be high in fat and low in fiber, increasing the risk for colon
cancer. Coffee intake, IBS, and a heavy
workload do not increase
the risk for colon cancer.
6. A nurse assessing a client with colorectal cancer auscultates
high-pitched bowel sounds and notes the
presence of visible
peristaltic waves. Which action should the nurse take?
a. Ask if
the client is experiencing pain in the right shoulder.
b. Perform
a rectal examination and assess for polyps.
c. Contact the
provider and recommend computed tomography.
d. Administer a
laxative to increase bowel movement activity.
ANS: C
The presence of visible peristaltic waves, accompanied by
high-pitched or tingling bowel sounds, is indicative
of partial
obstruction caused by the tumor. The nurse should contact the provider
with these results and
recommend a computed tomography scan for
further diagnostic testing. This assessment finding is
not
associated with right shoulder pain; peritonitis and
cholecystitis are associated with referred pain to the
right
shoulder. The registered nurse is not qualified to complete
a rectal examination for polyps, and laxatives would
not help
this client.
7. A nurse prepares a client for a colonoscopy scheduled for
tomorrow. The client states, My doctor told me
that the fecal
occult blood test was negative for colon cancer. I dont think I need
the colonoscopy and would
like to cancel it. How should the nurse
respond?
a. Your doctor should not have given you that
information prior to the colonoscopy.
b. The colonoscopy is
required due to the high percentage of false negatives with the blood
test.
c. A negative fecal occult blood test does not rule out the
possibility of colon cancer.
d. I will contact your doctor so
that you can discuss your concerns about the procedure.
ANS: C
A negative result from a fecal occult blood test does not
completely rule out the possibility of colon cancer. To determine
whether the client has colon cancer, a colonoscopy should be performed
so the entire colon can be
visualized and a tissue sample taken
for biopsy. The client may want to speak with the provider, but the
nurse
should address the clients concerns prior to contacting the provider.
8. A nurse cares for a client newly diagnosed with colon cancer who
has become withdrawn from family
members. Which action should the
nurse take?
a. Contact the provider and recommend a psychiatric
consult for the client.
b. Encourage the client to verbalize
feelings about the diagnosis.
c. Provide education about new
treatment options with successful outcomes.
d. Ask family and
friends to visit the client and provide emotional support.
ANS: B
The nurse recognizes that the client may be expressing
feelings of grief. The nurse should encourage the client
to
verbalize feelings and identify fears to move the client through the
phases of the grief process. A psychiatric
consult is not
appropriate for the client. The nurse should not brush aside the
clients feelings with discussions
related to cancer prognosis and
treatment. The nurse should not assume that the client desires family
or friends
to visit or provide emotional support.
9. A nurse cares for a client with colon cancer who has a new
colostomy. The client states, I think it would be
helpful to talk
with someone who has had a similar experience. How should the nurse
respond?
a. I have a good friend with a colostomy who would be
willing to talk with you.
b. The enterostomal therapist will be
able to answer all of your questions.
c. I will make a referral
to the United Ostomy Associations of America.
d. Youll find that
most people with colostomies dont want to talk about them.
ANS: C
Nurses need to become familiar with community-based
resources to better assist clients. The local chapter of he United
Ostomy Associations of America has resources for clients and their
families, including Ostomates
(specially trained visitors who
also have ostomies). The nurse should not suggest that the client
speak with a personal contact of the nurse. Although the enterostomal
therapist is an expert in ostomy care, talking with him
or her is
not the same as talking with someone who actually has had a colostomy.
The nurse should not brush aside the clients request by saying that
most people with colostomies do not want to talk about them. Many
people are willing to share their ostomy experience in the hope of
helping others.
11. A nurse cares for a client who states, My husband is repulsed by
my colostomy and refuses to be intimate
with me. How should the
nurse respond?
a. Lets talk to the ostomy nurse to help you and
your husband work through this.
b. You could try to wear longer
lingerie that will better hide the ostomy appliance.
c. You
should empty the pouch first so it will be less noticeable for your
husband.
d. If you are not careful, you can hurt the stoma if you
engage in sexual activity.
ANS: A
The nurse should collaborate with the ostomy nurse to
help the client and her husband work through intimacy
issues. The
nurse should not minimize the clients concern about her husband with
ways to hide the ostomy.
The client will not hurt the stoma by
engaging in sexual activity.
15. A nurse assesses a client who is prescribed 5-fluorouracil (5-FU)
chemotherapy intravenously for the
treatment of colon cancer.
Which assessment finding should alert the nurse to contact the health
care provider?
a. White blood cell (WBC) count of
1500/mm3
b. Fatigue
c. Nausea and diarrhea
d. Mucositis
and oral ulcers
ANS: A
Common side effects of 5-FU include fatigue, leukopenia,
diarrhea, mucositis and mouth ulcers, and peripheral neuropathy.
However, the clients WBC count is very low (normal range is 5000 to
10,000/mm3), so the provider should be notified. He or she may want to
delay chemotherapy by a day or two. Certainly the client is at high
risk for infection. The other assessment findings are consistent with
common side effects of 5-FU that would not need to be reported immediately.
16. A nurse cares for a client who had a colostomy placed in the
ascending colon 2 weeks ago. The client
states, The stool in my
pouch is still liquid. How should the nurse respond?
a. The stool
will always be liquid with this type of colostomy.
b. Eating
additional fiber will bulk up your stool and decrease
diarrhea.
c. Your stool will become firmer over the next couple
of weeks.
d. This is abnormal. I will contact your health care provider.
ANS: A
The stool from an ascending colostomy can be expected to
remain liquid because little large bowel is available
to reabsorb
the liquid from the stool. This finding is not abnormal. Liquid stool
from an ascending colostomy
will not become firmer with the
addition of fiber to the clients diet or with the passage of time.
18. A nurse teaches a client who is recovering from a colon
resection. Which statement should the nurse
include in this
clients plan of care?
a. You may experience nausea and vomiting
for the first few weeks.
b. Carbonated beverages can help
decrease acid reflux from anastomosis sites.
c. Take a stool
softener to promote softer stools for ease of defecation.
d. You
may return to your normal workout schedule, including weight lifting.
ANS: C
Clients recovering from a colon resection should take a
stool softener as prescribed to keep stools a soft
consistency
for ease of passage. Nausea and vomiting are symptoms of intestinal
obstruction and perforation
and should be reported to the
provider immediately. The client should be advised to avoid
gas-producing foods
and carbonated beverages, and avoid lifting
heavy objects or straining on defecation.
19. A nurse teaches a client who is at risk for colon cancer. Which
dietary recommendation should the nurse
teach this
client?
a. Eat low-fiber and low-residual foods.
b. White
rice and bread are easier to digest.
c. Add vegetables such as
broccoli and cauliflower to your new diet.
d. Foods high in
animal fat help to protect the intestinal mucosa.
ANS: C
The client should be taught to modify his or her diet to
decrease animal fat and refined carbohydrates. The
client should
also increase high-fiber foods and Brassica vegetables, including
broccoli and cauliflower, which
help to protect the intestinal
mucosa from colon cancer.
20. A nurse cares for a client who has a new colostomy. Which action
should the nurse take?
a. Empty the pouch frequently to remove
excess gas collection.
b. Change the ostomy pouch and wafer every
morning.
c. Allow the pouch to completely fill with stool prior
to emptying it.
d. Use surgical tape to secure the pouch and
prevent leakage.
ANS: A
The nurse should empty the new ostomy pouch frequently
because of excess gas collection, and empty the
pouch when it is
one-third to one-half full of stool. The ostomy pouch does not need to
be changed every
morning. Ostomy wafers with paste should be used
to secure and seal the ostomy appliance; surgical tape
should not
be used.
21. A nurse cares for a client who has a family history of colon
cancer. The client states, My father and my
brother had colon
cancer. What is the chance that I will get cancer? How should the
nurse respond?
a. If you eat a low-fat and low-fiber diet, your
chances decrease significantly.
b. You are safe. This is an
autosomal dominant disorder that skips generations.
c. Preemptive
surgery and chemotherapy will remove cancer cells and prevent
cancer.
d. You should have a colonoscopy more frequently to
identify abnormal polyps early.
ANS: D
The nurse should encourage the client to have frequent
colonoscopies to identify abnormal polyps and
cancerous cells
early. The abnormal gene associated with colon cancer is an autosomal
dominant gene
mutation that does not skip a generation and places
the client at high risk for cancer. Changing the clients
diet,
preemptive chemotherapy, and removal of polyps will
decrease the clients risk but will not prevent cancer.
However, a
client at risk for colon cancer should eat a low-fat and high-fiber diet.
2. After teaching a client who is recovering from a colon resection,
the nurse assesses the clients
understanding. Which statements by
the client indicate a correct understanding of the teaching? (Select
all that
apply.)
a. I must change the ostomy appliance daily
and as needed.
b. I will use warm water and a soft washcloth to
clean around the stoma.
c. I might start bicycling and swimming
again once my incision has healed.
d. Cutting the flange will
help it fit snugly around the stoma to avoid skin breakdown.
e. I
will check the stoma regularly to make sure that it stays a deep red
color.
f. I must avoid dairy products to reduce gas and odor in
the pouch.
ANS: B, C, D
The ostomy appliance should be changed as needed
when the adhesive begins to decrease, placing the
appliance at
risk of leaking. Changing the appliance daily can cause skin breakdown
as the adhesive will still
be secured to the clients skin. The
client should avoid using soap to clean around the stoma because it
might
prevent effective adhesion of the ostomy appliance. The
client should use warm water and a soft washcloth
instead. The
tissue of the stoma is very fragile, and scant bleeding may occur when
the stoma is cleaned. The flange should be cut to fit snugly around
the stoma to reduce contact between excretions and the clients
skin.
Exercise (other than some contact sports) is important for
clients with an ostomy. The stoma should remain a
soft pink
color. A deep red or purple hue indicates ischemia and should be
reported to the surgeon right away.
Yogurt and buttermilk can
help reduce gas in the pouch, so the client need not avoid dairy products.
2. The nurse is examining a womans breast and notes multiple small
mobile lumps. Which question would be
the most appropriate for
the nurse to ask?
a. When was your last mammogram at the
clinic?
b. How many cans of caffeinated soda do you drink in a
day?
c. Do the small lumps seem to change with your menstrual
period?
d. Do you have a first-degree relative who has breast cancer?
ANS: C
The most appropriate question would be one that relates
to benign lesions that usually change in response to
hormonal
changes within a menstrual cycle. Reduction of caffeine in the diet
has been shown to give relief in
fibrocystic breast conditions,
but research has not found that it has a significant impact. Questions
related to the
clients last mammogram or breast cancer history
are not related to the nurses assessment.
4. Which finding in a female client by the nurse
would receive the highest priority of further diagnostics?
a.
Tender moveable masses throughout the breast tissue
b. A 3-cm firm, defined mobile mass in the lower quadrant of the
breast
c. Nontender immobile mass in the upper outer quadrant of
the breast
d. Small, painful mass under warm reddened skin
ANS: C
Malignant lesions are hard, nontender, and usually
located in the upper outer quadrant of the breast and would
be
the priority for further diagnostic study. The other lesions are
benign breast disorders. The tender moveable
masses throughout
the breast tissue could be a fibrocystic breast condition. A firm,
defined mobile mass in the
lower quadrant of the breast is a
fibroadenoma, and a painful mass under warm reddened skin could be a
local
abscess or ductal ectasia.
7. With a history of breast cancer in the family, a 48-year-old
female client is interested in learning about the
modifiable risk
factors for breast cancer. After the nurse explains this information,
which statement made by
the client indicates that more teaching
is needed?
a. I am fortunate that I breast-fed each of my three
children for 12 months.
b. It looks as though I need to start
working out at the gym more often.
c. I am glad that we can still
have wine with every evening meal.
d. When I have menopausal
symptoms, I must avoid hormone replacement therapy.
ANS: C
Modifiable risk factors can help prevent breast cancer.
The client should lessen alcohol intake and not have
wine 7 days
a week. Breast-feeding, regular exercise, and avoiding hormone
replacement are also strategies for
breast cancer prevention.
8. A 37-year-old Nigerian woman is at high risk for breast cancer and
is considering a prophylactic
mastectomy and oophorectomy. What
action by the nurse is most appropriate?
a. Discourage this
surgery since the woman is still of childbearing age.
b. Reassure
the client that reconstructive surgery is as easy as breast
augmentation.
c. Inform the client that this surgery removes all
mammary tissue and cancer risk.
d. Include support people, such
as the male partner, in the decision making.
ANS: D
The cultural aspects of decision making need to be
considered. In the Nigerian culture, the man often makes
the
decisions for care of the female. Women with a high risk for breast
cancer can consider prophylactic
surgery. If reconstructive
surgery is considered, the procedure is more complex and will have
more
complications compared to a breast augmentation. There is a
small risk that breast cancer can still develop in
the remaining
mammary tissue.
9. A 35-year-old woman is diagnosed with stage III breast cancer. She
seems to be extremely anxious. What
action by the nurse is
best?
a. Encourage the client to search the Internet for
information tonight.
b. Ask the client if sexuality has been a
problem with her partner.
c. Explore the idea of a referral to a
breast cancer support group.
d. Assess whether there has been any
mental illness in her past.
ANS: C
Support for the diagnosis would be best with a referral
to a breast cancer support group. The Internet may be a
good
source of information, but the day of diagnosis would be too soon. The
nurse could assess the frequency
and satisfaction of sexual
relations but should not assume that there is a problem in that area.
Assessment of
mental illness is not an appropriate action.
10. A client has just returned from a right radical mastectomy. Which
action by the unlicensed assistive
personnel (UAP) would the
nurse consider unsafe?
a. Checking the amount of urine in the
urine catheter collection bag
b. Elevating the right arm on a
pillow
c. Taking the blood pressure on the right arm
d.
Encouraging the client to squeeze a rolled washcloth
ANS: C
Health care professionals need to avoid the arm on the
side of the surgery for blood pressure measurement,
injections,
or blood draws. Since lymph nodes are removed, lymph drainage would be
compromised. The
pressure from the blood pressure cuff could
promote swelling. Infection could occur with injections and
blood
draws. Checking urine output, elevation of the affected arm
on a pillow, and encouraging beginning exercises
11. A client is discharged to home after a modified radical
mastectomy with two drainage tubes. Which
statement by the client
would indicate that further teaching is needed?
a. I am glad that
these tubes will fall out at home when I finally shower.
b. I
should measure the drainage each day to make sure it is less than an
ounce.
c. I should be careful how I lie in bed so that I will not
kink the tubing.
d. If there is a foul odor from the drainage, I
should contact my doctor.
ANS: A
The drainage tubes (such as a Jackson-Pratt drain) lie
just under the skin but need to be removed by the health
care
professional in about 1 to 3 weeks at an office visit. Drainage should
be less than 25 mL in a days time.
The client should be aware of
her positioning to prevent kinking of the tubing. A foul odor from the
drainage
may indicate an infection; the doctor should be
contacted immediately.
2. What comfort measure can only be performed by a nurse, as opposed
to an unlicensed assistive personnel
(UAP), for a client who
returned from a left modified radical mastectomy 4 hours ago?
a.
Placing the head of bed at 30 degrees
b. Elevating the left arm
on a pillow
c. Administering morphine for pain at a 4 on a
0-to-10 scale
d. Supporting the left arm while initially
ambulating the client
ANS: C
Only the nurse is authorized to administer medications,
but the UAP could inform the nurse about the rating of
pain by
the client. The UAP could position the bed to 30 degrees and elevate
the clients arm on a pillow to
facilitate lymphatic fluid
drainage return. The clients arm should be supported while walking at
first but then
allowed to hang straight by the side. The UAP
could support the arm while walking the client.
14. A client is starting hormonal therapy with tamoxifen (Nolvadex)
to lower the risk for breast cancer. What
information needs to be
explained by the nurse regarding the action of this drug?
a. It
blocks the release of luteinizing hormone.
b. It interferes with
cancer cell division.
c. It selectively blocks estrogen in the
breast.
d. It inhibits DNA synthesis in rapidly dividing cells.
ANS: C
Tamoxifen (Nolvadex) reduces the estrogen available to
breast tumors to stop or prevent growth. This drug
does not block
the release of luteinizing hormone to prevent the ovaries from
producing estrogen; leuprolide
(Lupron) does this. Chemotherapy
agents such as ixabepilone (Ixempra) interfere with cancer cell
division, and
doxorubicin (Adriamycin) inhibits DNA synthesis in
susceptible cells.
15. A client is placed on a medical regimen of doxorubicin
(Adriamycin), cyclophosphamide (Cytoxan), and
fluorouracil (5-FU)
for breast cancer. Which side effect seen in the client should the
nurse report to the
provider immediately?
a. Shortness of
breath
b. Nausea and vomiting
c. Hair loss
d. Mucositis
ANS: A
Doxorubicin (Adriamycin) can cause cardiac problems with
symptoms of extreme fatigue, shortness of breath,
chronic cough,
and edema. These need to be reported as soon as possible to the
provider. Nausea, vomiting,
hair loss, and mucositis are common
problems associated with chemotherapy regimens.
17. A woman diagnosed with breast cancer had these laboratory tests performed at an office visit:
Alkaline phosphatase 125 U/L
Total calcium 12
mg/dL
Hematocrit 39%
Hemoglobin 14 g/dL
Which test
results indicate to the nurse that some further diagnostics are
needed?
a. Elevated alkaline phosphatase and calcium suggests
bone involvement.
b. Only alkaline phosphatase is decreased,
suggesting liver metastasis.
c. Hematocrit and hemoglobin are
decreased, indicating anemia.
d. The elevated hematocrit and
hemoglobin indicate dehydration.
ANS: A
The alkaline phosphatase (normal value 30 to 120 U/L) and
total calcium (normal value 9 to 10.5 mg/dL)
levels are both
elevated, suggesting bone metastasis. Both the hematocrit and
hemoglobin are within normal
limits for females.
1. The nurse is taking a history of a 68-year-old woman. What
assessment findings would indicate a high risk
for the
development of breast cancer? (Select all that apply.)
a. Age
greater than 65 years
b. Increased breast density
c.
Osteoporosis
d. Multiparity
e. Genetic factors
ANS: A, B, E
The high risk factors for breast cancer are age
greater than 65 with the risk increasing until age 80; an
increase
in breast density because of more glandular and
connective tissue; and inherited mutations of BRCA1 and/or
BRCA2
genes. Osteoporosis and multiparity are not risk factors for breast
cancer. A high postmenopausal
bone density and nulliparity are
moderate and low increased risk factors, respectively.
2. The nurse is formulating a teaching plan according to
evidence-based breast cancer screening guidelines for
a
50-year-old woman with low risk factors. Which diagnostic methods
should be included in the plan? (Select
all that apply.)
a.
Annual mammogram
b. Magnetic resonance imaging (MRI)
c.
Breast ultrasound
d. Breast self-awareness
e. Clinical
breast examination
ANS: A, D, E
Guidelines recommend a screening annual mammogram
for women ages 40 years and older, breast self-
awareness, and a
clinical breast examination. An MRI is recommended if there are known
high risk factors. A
breast ultrasound is used if there are
problems discovered with the initial screening or dense breast tissue.
3. After a breast examination, the nurse is documenting assessment
findings that indicate possible breast
cancer. Which abnormal
findings need to be included as part of the clients electronic medical
record? (Select
all that apply.)
a. Peau dorange
b.
Dense breast tissue
c. Nipple retraction
d. Mobile mass at
two oclock
e. Nontender axillary nodes
ANS: A, C, D
In the documentation of a breast mass, skin changes
such as dimpling (peau dorange), nipple retraction, and
whether
the mass is fixed or movable are charted. The location of the mass
should be stated by the face of a
clock. Dense breast tissue and
nontender axillary nodes are not abnormal assessment findings that may
indicate
breast cancer.
4. A woman has been using acupuncture to treat the nausea and
vomiting caused by the side effects of
chemotherapy for breast
cancer. Which conditions would cause the nurse to recommend against
further use of
acupuncture? (Select all that apply.)
a.
Lymphedema
b. Bleeding tendencies
c. Low white blood cell
count
d. Elevated serum calcium
e. High platelet count
ANS: A, B, C
Acupuncture could be unsafe for the client if there
is poor drainage of the extremity with lymphedema or if
there was
a bleeding tendency and low white blood cell count. Coagulation would
be compromised with a
bleeding disorder, and the risk of
infection would be high with the use of needles. An elevated serum
calcium
and high platelet count would not have any
contraindication for acupuncture.
10. A client has recently been diagnosed with stage III endometrial
cancer and asks the nurse for an
explanation. What response by
the nurse is correct about the staging of the cancer?
a. The
cancer has spread to the mucosa of the bowel and bladder.
b. It
has reached the vagina or lymph nodes.
c. The cancer now involves
the cervix.
d. It is contained in the endometrium of the cervix.
ANS: B
Stage III of endometrial cancer reaches the vagina or
lymph nodes. Stage I is confined to the endometrium.
Stage II
involves the cervix, and stage IV spreads to the bowel or bladder
mucosa and/or beyond the pelvis.
11. The client is emotionally upset about the recent diagnosis of
stage IV endometrial cancer. Which action by
the nurse is
best?
a. Let the client alone for a long period of reflection
time.
b. Ask friends and relatives to limit their visits.
c.
Tell the client that an emotional response is unacceptable.
d.
Create an atmosphere of acceptance and discussion.
ANS: D
Discussion of a clients concerns about the presence of
cancer and the potential for recurrence will provide
emotional
support and allay fears. Coping behaviors are encouraged with the
support of friends and relatives.
An emotional response should be accepted.
12. A client has scheduled brachytherapy sessions and states that she
feels as though she is not safe around her
family. What is the
best response by the nurse?
a. You are only reactive when the
radioactive implant is in place.
b. To be totally safe, it is a
good idea to sleep in a separate room.
c. It is best to stay a
safe distance from friends or family between treatments.
d. You
should use a separate bathroom from the rest of the family.
.
ANS: A
In brachytherapy, the surgeon inserts an applicator into
the uterus. After placement is verified, the radioactive
isotope
is placed in the applicator for several minutes for a single
treatment. There are no restrictions for the
woman to stay away
from her family or the public between treatments
14. A 20-year-old client is interested in protection from the human
papilloma virus (HPV) since she may
become sexually active. Which
response from the nurse is the most accurate?
a. You are too old
to receive an HPV vaccine.
b. Either Gardasil or Cervarix can
provide protection.
c. You will need to have three injections
over a span of 1 year.
d. The most common side effect of the
vaccine is itching at the injection site.
ANS: B
Current HPV vaccines are Gardasil and Cervarix, which
should be given before the first sexual contact to
protect
against the highest risk HPV types associated with cervical cancer.
The client is not too old since it is
recommended that young
women up to 26 years should receive an HPV vaccine. The entire series
consists of
three injections over 6 months, not 1 year. Local
pain and redness surrounding the injection site are very
common,
but this does not include itching.
3. The nurse is taking the history of a 24-year-old client diagnosed
with cervical cancer. What possible risk
factors would the nurse
assess? (Select all that apply.)
a. Smoking
b. Multiple
sexual partners
c. Poor diet
d. Nulliparity
e. Younger
than 18 at first intercourse
ANS: A, B, C, E
Smoking, multiple sexual partners, poor diet,
and age less than 18 for first intercourse are all risk factors
for
cervical cancer. Nulliparity is a risk factor for endometrial cancer.
4. A client is scheduled to start external beam radiation therapy
(EBRT) for her endometrial cancer. Which
teaching by the nurse is
accurate? (Select all that apply.)
a. You will need to be
hospitalized during this therapy.
b. Your skin needs to be
inspected daily for any breakdown.
c. It is not wise to stay out
in the sun for long periods of time.
d. The perineal area may
become damaged with the radiation.
e. The technician applies new
site markings before each treatment.
ANS: B, C, D
EBRT is usually performed in ambulatory care and
does not require hospitalization. The client needs to know
to
evaluate the skin, especially in the perineal area, for any breakdown,
and avoid sunbathing. The technician
does not apply new site
markings, so the client needs to avoid washing off the markings that
indicate the
treatment site.
5. The nurse is teaching a client who is undergoing brachytherapy
about what to immediately report to her
health care provider.
Which signs and symptoms would be included in this teaching? (Select
all that apply.)
a. Constipation for 3 days
b. Temperature
of 99 F
c. Abdominal pain
d. Visible blood in the
urine
e. Heavy vaginal bleeding
ANS: C, D, E
Health teaching for a client having brachytherapy
should emphasize reporting abdominal pain, visible blood in
the
urine, and heavy vaginal bleeding. Severe diarrhea (not constipation),
urethral burning, extreme fatigue,
and a fever over 100 F should
also be reported.
6. A postmenopausal client is experiencing low back and pelvic pain,
fatigue, and bloody vaginal discharge.
What laboratory tests
would the nurse expect to see ordered for this client if endometrial
cancer is suspected?
(Select all that apply.)
a. Cancer
antigen-125 (CA-125)
b. White blood cell (WBC) count
c.
Hemoglobin and hematocrit (H&H)
d. International normalized
ratio (INR)
e. Prothrombin time (PT)
ANS: A, C
Serum tumor markers such as CA-125 assess for
metastasis, especially if elevated. H&H would evaluate
the
possibility of anemia, a common finding with postmenopausal
bleeding with endometrial cancer. WBC count
is not indicated
since there are no signs of infection. The INR and PT are coagulation
tests to measure the time
it takes for a fibrin clot to form.
They are used to evaluate the extrinsic pathway of coagulation in
clients
receiving oral warfarin.
2. A client is diagnosed with benign prostatic hyperplasia and seems
sad and irritable. After assessing the
clients behavior, which
statement by the nurse would be the most appropriate?
a.The urine
incontinence should not prevent you from socializing.
b.You seem
depressed and should seek more pleasant things to do.
c. It is
common for men at your age to have changes in mood.
d. Nocturia
could cause interruption of your sleep and cause changes in mood.
ANS: D
Frequent visits to the bathroom during the night could
cause sleep interruptions and affect the clients mood and
mental
status. Incontinence could cause the client to feel embarrassment and
cause him to limit his activities
outside the home. The social
isolation could lead to clinical depression and should be treated
professionally.
The nurse should not give advice before exploring
the clients response to his change in behavior. The statement about
age has no validity.
You seem depressed and should seek more
pleasant things to do.
It is common for men at your age to have
changes in mood.
Nocturia could cause interruption of your sleep
and cause changes in mood.
3. A 55-year-old African-American client is having a visit with his
health care provider. What test should the nurse discuss with the
client as an option to screen for prostate cancer, even though
screening is not routinely
recommended?
a. Complete blood count
b. Culture and sensitivity
c.
Prostate-specific antigen
d. Cystoscopy
ANS: C
The prostate-specific antigen test should be discussed as
an option for prostate cancer screening. A complete
blood count
and culture and sensitivity laboratory test will be ordered if
infection is suspected. A cystoscopy
would be performed to assess
the effect of a bladder neck obstruction.
4. The nurse is teaching a client with benign prostatic hyperplasia (BPH). What statement indicates a lack of understanding by the client?
a. There should be no problem with a glass of wine with dinner each night.
b. I am so glad that I weaned myself off of coffee about a year
ago.
c. I need to inform my allergist that I cannot take my
normal decongestant.
d. My normal routine of drinking a quart of
water during exercise needs to change.
ANS: A
This client did not associate wine with the avoidance of
alcohol, and requires additional teaching. The nurse must teach a
client with BPH to avoid alcohol, caffeine, and large quantities of
fluid in a short amount of time to prevent overdistention of the
bladder. Decongestants also need to be avoided to lower the chance for
urinary retention. I am so glad that I weaned myself off of coffee
about a year ago. I need to inform my allergist that I cannot take my
normal decongestant. My normal routine of drinking a quart of water
during exercise needs to change.
5. A client has returned from a transurethral resection of the
prostate with a continuous bladder irrigation. Which action by the
nurse is a priority if bright red urinary drainage and clots are noted
5 hours after the surgery?
a.Review the hemoglobin and hematocrit
as ordered.
b. Take vital signs and notify the surgeon
immediately.
c. Release the traction on the three-way
catheter.
d. Remind the client not to pull on the catheter.
ANS: B
Bright red urinary drainage with clots may indicate
arterial bleeding. Vital signs should be taken and the
surgeon
notified. The traction on the three-way catheter should not be
released since it places pressure at the
surgical site to avoid
bleeding. The nurses review of hemoglobin and hematocrit and reminding
the client not
to pull on the catheter are good choices, but not
the priority at this time.
6. A nurse and an unlicensed assistive personnel (UAP) are caring for
a client with an open radical
prostatectomy. Which comfort
measure could the nurse delegate to the UAP?
a. Administering an
antispasmodic for bladder spasms
b. Managing pain through
patient-controlled analgesia
c. Applying ice to a swollen scrotum and penis
d. Helping the
client transfer from the bed to the chair
ANS: D
The UAP could aid the client in transferring from the bed
to the chair and with ambulation. The nurse would be
responsible
for medication administration, assessment of swelling, and the
application of ice if needed.
7. A client is diagnosed with metastatic prostate cancer. The client
asks the nurse the purpose of his treatment
with the luteinizing
hormonereleasing hormone (LH-RH) agonist leuprolide (Lupron) and the
bisphosphonate
pamidronate (Aredia). Which statement by the nurse
is most appropriate?
a. The treatment reduces testosterone and
prevents bone fractures.
b. The medications prevent erectile
dysfunction and increase libido.
c. There is less gynecomastia
and osteoporosis with this drug regimen.
d. These medications
both inhibit tumor progression by blocking androgens.
ANS: A
Lupron, an LH-RH agonist, stimulates the pituitary gland
to release luteinizing hormone (LH) to the point that the gland is
depleted of LH and testosterone production is lessened. This may
decrease the prostate cancer since it is hormone dependent. Lupron can
cause osteoporosis, which results in the need for Aredia to prevent
bone loss. Erectile dysfunction, decreased libido, and gynecomastia
are side effects of the LH-RH medications. Antiandrogen drugs inhibit
tumor progression by blocking androgens at the site of the prostate.
8. The nurse is administering sulfamethoxazole-trimethoprim (Bactrim)
to a client diagnosed with bacterial
prostatitis. Which finding
causes the nurse to question this medication for this client?
a.
Urinary tract infection
b. Allergy to sulfa medications
c.
Hematuria
d. Elevated serum white blood cells
ANS: B
Before administering sulfamethoxazole-trimethoprim, the
nurse must assess if the client is allergic to sulfa drugs. Urinary
tract infection, hematuria, and elevated serum white blood cells are
common problems
associated with bacterial prostatitis that
require long-term antibiotic therapy.
9. A 55-year-old male client is admitted to the emergency department
with symptoms of a myocardial
infarction. Which question by the
nurse is the most appropriate before administering
nitroglycerin?
a. On a scale from 0 to 10, what is the rating of
your chest pain?
b. Are you allergic to any food or
medications?
c. Have you taken any drugs like Viagra
recently?
d. Are you light-headed or dizzy right now?
ANS: C
Phosphodiesterase-5 inhibitors such as sildenafil
(Viagra) relax smooth muscles to increase blood flow to the penis for
treatment of erectile dysfunction. In combination with nitroglycerin,
there can be extreme hypotension with reduction of blood flow to vital
organs. The other questions are appropriate but not the highest
priority before administering nitroglycerin.
10. A 34-year-old client comes to the clinic with concerns about an
enlarged left testicle and heaviness in his
lower abdomen. Which
diagnostic test would the nurse expect to be ordered to confirm
testicular cancer?
a. Alpha-fetoprotein (AFP)
b.
Prostate-specific antigen (PSA)
c. Prostate acid phosphatase
(PAP)
d. C-reactive protein (CRP)
ANS: A
AFP is a glycoprotein that is elevated in testicular cancer. PSA and
PAP testing is used in the screening of
prostate cancer. CRP is
diagnostic for inflammatory conditions.
11. A 25-year-old client has recently been diagnosed with testicular
cancer and is scheduled for radiation
therapy. Which intervention
by the nurse is best?
a. Ask the client about his support system
of friends and relatives.
b. Encourage the client to verbalize
his fears about sexual performance.
c. Explore with the client
the possibility of sperm collection.
d. Provide privacy to allow
time for reflection about the treatment.
ANS: C
Sperm collection is a viable option for a client
diagnosed with testicular cancer and should be completed before
radiation therapy, chemotherapy, or radical lymph node dissection. The
other options would promote psychosocial support but are not the
priority intervention.
12. A 70-year-old client returned from a transurethral resection of
the prostate 8 hours ago with a continuous bladder irrigation. The
nurse reviews his laboratory results as follows:
Sodium 128
mEq/L
Hemoglobin 14 g/dL
Hematocrit 42%
Red blood cell
count 4.5
What action by the nurse is the most appropriate?
a. Consider starting a blood transfusion.
b. Slow down the
bladder irrigation if the urine is pink.
c. Report the findings
to the surgeon immediately.
d. Take the vital signs every 15 minutes.
ANS: B
The serum sodium is decreased due to large-volume bladder
irrigation (normal is 136 to 145 mEq/L). By slowing the irrigation,
there will be less fluid overload and sodium dilution. The hemoglobin
and hematocrit values are a low normal, with a slight decrease in the
red blood cell count. Therefore, a blood transfusion or frequent vital
signs should not be necessary. Immediate report to the surgeon is not necessary.
1. The nurse is administering finasteride (Proscar) and doxazosin
(Cardura) to a 67-year-old client with benign prostatic hyperplasia.
What precautions are related to the side effects of these medications?
(Select all that apply.)
a. Assessing for blood pressure changes when lying, sitting, and
arising from the bed
b. Immediately reporting any change in the
alanine aminotransferase laboratory test
c. Teaching the client
about the possibility of increased libido with these
medications
d. Taking the clients pulse rate for a minute in
anticipation of bradycardia
e. Asking the client to report any
weakness, light-headedness, or dizziness
ANS: A, B, E
Both the 5-alpha-reductase inhibitor (5-ARI) and
the alpha1-selective blocking agents can cause orthostatic (postural)
hypotension and liver dysfunction. The 5-ARI agent (Proscar) can cause
a decreased libido rather than an increased sexual drive. The
alpha-blocking drug (Cardura) can cause tachycardia rather than bradycardia.
2. A client is interested in learning about the risk factors for
prostate cancer. Which factors does the nurse
include in the
teaching? (Select all that apply.)
a.Family history of prostate
cancer
b. Smoking
c. Obesity
d. Advanced age
e.
Eating too much red meat
f. Race
ANS: A, D, E, F
Advanced family history of prostate cancer, age,
a diet high in animal fat, and race are all risk factors for prostate
cancer. Smoking and obesity are not known risk factors.
3. A client came to the clinic with erectile dysfunction. What are
some possible causes of this condition that the nurse could discuss
with the client during history taking? (Select all that
apply.)
a. Recent prostatectomy
b. Long-term
hypertension
c. Diabetes mellitus
d. Hour-long exercise
sessions
e. Consumption of beer each night
ANS: A, B, C,
E
Organic erectile dysfunction can be caused by surgical
procedures, hypertension and its treatment, diabetes
mellitus,
and alcohol consumption. There is no evidence that exercise is related
to this problem.
ANS: A, B, C, E
Organic erectile dysfunction can be caused by
surgical procedures, hypertension and its treatment,
diabetes
mellitus, and alcohol consumption. There is no evidence
that exercise is related to this problem.
1. Post transurethral resection of the prostate, a client has a
three-way catheter with a continuous bladder irrigation. Over the last
12 hours, there has been 1400 mL of irrigation solution infused and
2000 mL measured
in output from the drainage bag. What is the
recording of the urinary output for the 12-hour period? (Record your
answer using a whole number.) ____ mL
ANS: 600 mL
2000 mL from the drainage bag (including both the
irrigation fluid and urine) minus the 1400 mL of irrigation fluid
equals 600 mL of urine: 2000 mL 1400 mL = 600 mL.