Font size
WorksheetsNSG 170 Final Prep
Total questions: 100
Worksheet time: 5hrs 8mins
The nurse is reviewing the arterial blood gas results for a patient with a respiratory disorder. What should the nurse recognize as being the most important chemical regulator of respiration?
The blood level of oxygen
The blood level of nitrogen
The blood level of carbon dioxide
The amount of hemoglobin in red blood cells
During the admission assessment of an individual admitted to the medical respiratory unit, the nurse notes the patient has a barrel-shaped chest. Which assessment should the nurse perform next?
Assess the patient’s rate and character of respirations.
Ask the patient about presence of a productive cough.
Palpate the patient’s thorax to determine presence of tenderness.
Obtain a blood sample for arterial blood gas (ABG) to detect respiratory acidosis.
A patient’s oxygen saturation value is 92% on room air. What does this value mean to the nurse?
The percentage of oxygen in the lungs
The partial pressure of the oxygen in the blood
The amount of oxygen saturating the lymphocytes
The percentage of hemoglobin that is saturated with oxygen
The nurse is caring for a patient experiencing dyspnea. What should the nurse instruction the patient to breathe more effectively?
“Use deep breathing, and exhale as forcefully as you are able.”
“Take four quick, panting breaths, and then blow out for 6 seconds.”
“Hold your breath for 3 seconds after each exhalation to empty all the alveoli.”
“Breathe using your abdominal muscles, and blow out slowly through pursed lips.”
A nurse is providing discharge instructions for a patient who is to use an adrenergic bronchodilator metered dose inhaler (MDI). What should be included in the teaching?
“Avoid using the MDI at night.”
“Take one puff every 5 minutes until your symptoms are relieved.”
“Using the MDI more often than prescribed can result in worsening symptoms.”
“Take two puffs whenever you feel wheezy but no more than six puffs per day.”
A summer camp worker reports to the camp nurse with complaints of shortness of breath and audible wheezing. Which inhaled medication should the nurse provide?
Albuterol (Proventil)
Cromolyn sodium (Intal)
Triamcinolone (Azmacort)
Nedocromil sodium (Tilade)
A patient with chronic obstructive pulmonary disease is prescribed methylprednisolone (Solu-Medrol). For what reason should the nurse realize that corticosteroids are used in the treatment of this health problem?
Dry secretions
Treat infection
Improve the oxygen-carrying capacity of hemoglobin
Reduce airway inflammation
The nurse is assisting in the planning of care for a patient with chronic obstructive pulmonary disease. What should be the goals of care for this patient? (Select all that apply.)
Smoking cessation
Improve activity tolerance
Prevent disease progression
Complete an advance directive
Prevent and treat exacerbations
The nurse is providing dietary teaching to an individual with iron-deficiency anemia. Which patient statement indicates that teaching has been effective?
“I know I need to eat more green vegetables and dairy products.”
“Berries and natural cereals are good for me because of my low iron levels.”
“I’m going to drink orange juice for breakfast and increase red meats in my diet.”
“Yellow vegetables and green tea will be important to help build up my blood levels.”
The nurse is caring for a patient with anemia. Which blood component is deficient in this patient?
Plasma
Platelets
Red blood cells (RBCs)
White blood cells (WBCs)
A child with respiratory distress can experience dehydration because:
The child is not drinking enough fluids.
The body requires an increased amount of fluids when sick.
The child is retaining water in the kidneys since the body is using all the oxygen in the lungs.
Mouth breathing occurs when in distress, so the child is losing hydration.
Signs that a child is exhibiting respiratory distress include: (Select all that apply.)
Nasal flaring.
Synchronized rise and fall of the abdomen and the chest.
A capillary refill of less than three seconds.
Grunting.
Intercostal retractions.
A 50-year-old woman states, “It is such a relief not to need birth control any more. I haven’t had a period in 3 months.” How should the nurse respond?
“Birth control is usually unnecessary after age 50, even if you are still having periods.”
“It is still possible for you to get pregnant. You should consider having a tubal ligation.”
“You should continue to use birth control for at least 6 months after cessation of your periods.”
“You may still be fertile for several months after your last period. You should consult with your physician to know when to stop using birth control.”
A female patient approaching menopause asks about the use of hormone replacement therapy. Which findings from a study on hormone replacement therapy should the nurse explain to the patient? (Select all that apply.)
A decrease in strokes
A decrease in breast cancer
An increase in heart attacks
A reduction in total fractures
An increase in thromboembolism
The nurse is caring for a man diagnosed with prostatitis. What symptom should the nurse expect when collecting data from the patient?
Dysuria
Polyuria
Hematuria
Glycosuria
A male patient is experiencing erectile dysfunction. For which medication classification should the nurse assess if the patient is prescribed?
NSAIDs
Antibiotics
Antidiabetics
Antihypertensives
An older male patient is upset to learn about the diagnosis of benign prostatic hyperplasia. What should the nurse explain to the patient about this health problem?
This health problem is a precursor to prostate cancer.
75% of men over the age of 70 have this health problem.
50% of men with this health problem need the prostate removed.
25% of men with this health problem will have erectile dysfunction.
During data collection the nurse notes the presence of a chancre on a male patient’s penis. For which sexually transmitted infection should the nurse focus additional data collection?
Herpes
Syphilis
Gonorrhea
Chlamydia
The nurse is performing an assessment of a female patient’s breasts. Which findings indicate the need for further assessment? Select all that apply.
One breast is shaped differently from the other.
The breasts do not display prominent veins.
The nipples are a light tan in color.
There is clear discharge from one nipple.
There is an area of dimpled skin on one breast.
During an assessment, a female patient asks why the nurse is “feeling her armpit.” Which responses are appropriate? Select all that apply.
“I’m counting your ribs.”
“Don’t you feel your own armpits?”
“Breast tissue extends into this area.”
“I’m assessing hair distribution in this area.”
“The armpits should be part of your breast self-exam.”
When assessing a 13-year-old boy, the nurse would keep in mind physical changes in the pubertal male, beginning with:
Development of axillary and facial hair
Enlargement of pectoral muscles
Enlargement of testicles
Voice changes
The Tanner stages are a rating for which of the following in females?
sequence of secondary sexual characteristics with stages describing breast and pubic hair growth
ability to be independent of caregivers and care for oneself while living alone
readiness for marriage or mating and readiness for childbearing activities, with a scoring of 1 to 100
sequence of emotional and psychological changes occurring in adolescence and ending in maturity
A 15-year-old patient is seeking information on birth control and sexually transmitted infections (STIs). What teaching should the nurse provide? Select all that apply.
Multiple sex partners increase the risk for STIs.
Condom use is 100% effective in preventing pregnancy and STIs.
Abstinence is the only sure way to prevent pregnancy.
Abstinence prevents transmission of STIs.
Young girls having unprotected sex are more likely to become pregnant than to contract an STI.
A teenaged female patient tells the nurse that she has been sexually active with her boyfriend for 2 months. She has no symptoms of a sexually transmitted infection (STI). Screening for which infection is the nurse’s priority?
Genital herpes
Human papillomavirus (HPV)
Condylomata acuminata
Chlamydia
A patient presents to the medical-surgical unit confused and with a blood pressure of 90/50. Which assessment findings would support the nurse’s concern that the patient has low cardiac output?
Skin tenting (poor turgor) and heart rate 102
Pallor and peripheral edema
Bounding peripheral pulses and pulse oximeter reading 90%
Prolonged capillary refill and diminished peripheral pulses
A patient with peripheral arterial disease has a nursing diagnosis of Ineffective Tissue Perfusion. Which nursing intervention is most appropriate for this nursing diagnosis?
Assist the patient in taking hot baths.
Do not elevate the patient’s legs.
Encourage the patient to limit activity.
Limit visitors.
The nurse notes that a patient’s lower legs are brown and the feet are blue when they are in the dependent position. For which health problem should the nurse collect additional data?
Anemia
Insufficient oxygenation
Decreased arterial blood flow
Venous blood flow problems
Cardiac output is dependent on: (Select all that apply.)
heart rate.
peripheral pulses.
venous return.
viscosity of the blood.
strength of contraction.
A patient is taking hydrochlorothiazide (HydroDIURIL) for hypertension. When providing dietary teaching what should the nurse encourage the patient to increase the intake of?
bananas
apple juice
sugar-free foods
low fat milk
An 89-year-old patient is taking an antihypertensive medication. What should the nurse include when providing home care teaching?
Get up out of bed slowly.
Take hot baths.
Report sexual dysfunction immediately.
Stop taking the drug if side effects occur.
What should be the nursing priority when caring for a patient with a hypertensive crisis?
Suctioning secretions
Monitoring for seizure activity
Monitoring fluid volume
Preventing hyperthermia
A new nurse is caring for a woman previously diagnosed with preeclampsia who was admitted to the high-risk OB unit after suffering a seizure in the perinatal clinic. The new nurse is preparing to administer a dose of magnesium sulfate (Sulfamag). Which action by the nurse warrants intervention by the unit manager?
Explains to the patient that her vital signs and EKG will be monitored frequently
Piggybacks the Sulfamag into a main line using an infusion pump
Places 10% calcium gluconate in a secure location in the patient’s room
Runs the Sulfamag as the main IV line through an infusion pump
A patient on the high-risk OB unit is receiving magnesium sulfate. The nurse notes that her magnesium level is 14 mEq/L. Which of the following actions by the nurse is most appropriate?
Bring the crash cart to the patient’s room.
Document the findings in the woman’s chart.
Order another blood level in 6 hours.
Prepare to administer calcium gluconate.
Of the following, an appropriate seasoning choice to use for a sodium-restricted diet would be
celery salt
lemon juice
soy sauce
BBQ sauce
A primigravida is being monitored in her prenatal clinic for preeclampsia. What finding should concern her nurse?
Blood pressure (BP) increase to 138/86 mm Hg
Weight gain of 0.5 kg during the past 2 weeks
A dipstick value of 3+ for protein in her urine
Pitting pedal edema at the end of the day
The patient that you are caring for has severe preeclampsia and is receiving a magnesium sulfate infusion. You become concerned after assessment when the woman exhibits:
A sleepy, sedated affect.
A respiratory rate of 10 breaths/min.
Deep tendon reflexes of 2.
Absent ankle clonus.
A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on “high.” The nurse instructs the mother that the fan should not be directed toward the newborn and the newborn should be wrapped in a blanket. The mother asks why. The nurse’s best response is:
“Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him.”
“Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him.”
“Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him.”
“Your baby will get cold stressed easily and needs to be bundled up at all times.”
What infant response to cool environmental conditions is either not effective or not available to them?
Constriction of peripheral blood vessels
Metabolism of brown fat
Increased respiratory rates
Unflexing from the normal position
Nurses can prevent evaporative heat loss in the newborn by:
Drying the baby after birth and wrapping the baby in a dry blanket.
Keeping the baby out of drafts and away from air conditioners.
Placing the baby away from the outside wall and the windows.
Warming the stethoscope and the nurse’s hands before touching the baby.
A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). The nurse determines that discharge teaching has been effective when the patient makes which statement?
“I will take salt tablets when I work outdoors in the summer.”
“I should take acetaminophen (Tylenol) if I start to feel too warm.”
“I should drink sports drinks when working outside in hot weather.”
“I will move to a cool environment if I notice that I am feeling confused.”
An unresponsive 79-year-old is admitted to the emergency department (ED) during a summer heat wave. The patient’s core temperature is 105.4° F (40.8° C), blood pressure (BP) 88/50, and pulse 112. The nurse initially will plan to
apply wet sheets and a fan to the patient.
provide O2 at 6 L/min with a nasal cannula.
start lactated Ringer’s solution at 1000 mL/hr.
give acetaminophen (Tylenol) rectal suppository.
A postsurgical patient who is recovering in the postanesthetic recovery unit states that she is freezing cold. Which of the following measures is likely to be initiated in the patient’s hypothalamus in an effort to reduce heat loss?
Opening of arteriovenous (AV) shunts
Reduced exhalation of warmed air
Contraction of pilomotor muscles
Decreased urine production
An elderly patient is dressed only in a hospital gown and complains of a draft in her room. Consequently, she has requested a warm blanket while she sits in her wheelchair. Which of the following mechanisms of heat loss is most likely the primary cause of her request?
Evaporation and conduction
Radiation and convection
Conduction and convection
Convection and evaporation
What is/are signs of hypothermia?
Systemic vasodilation
Lethargy and confusion
Nausea and cramps
Rapid but strong pulse
A homeless person is brought to the hospital for weakness, feeling faint, and having a headache. The patient’s skin is cool and clammy and vital signs are temperature 99.9°F, pulse 100 bpm, respirations 18/minute, blood pressure 108/60 mm Hg. What action should the nurse take?
Provide oral fluids.
Provide Ciprofloxin 400 mg intravenously (IV).
Prepare the patient for a chest x-ray.
Provide acetaminophen (Tylenol) 500 mg orally.
A patient is admitted for mild hypothermia. Which manifestations should the nurse expect when assessing this patient? (Select all that apply.)
Pinpoint pupils
Depleted glucose stores
Increased respiratory rate
Decreased respiratory rate
Decreased muscular activity
The nurse reminds the parents of a newborn that newborns must be protected from environments that are too cold or too hot because newborns have: (Select all that apply)
Very little subcutaneous fat
Low metabolic rates
Ineffective sweat glands
Small fluid reserves
Low red blood cells counts
Following delivery of the newborn, which nursing intervention should be carried out immediately?
Weigh the infant
Warm the infant
Bathe the infant
Inoculate the infant
The metabolic abnormalities that lead to type 2 diabetes include:
chronic overeating.
insulin resistance.
acute pancreatitis.
recurrent hypoglycemia.
A patient is experiencing rapid deep breathing, fruity odor, lethargy, and weight loss. Laboratory results include a blood glucose of 720 mg/dL. Which symptom should indicate to the nurse that the patient has type 1 diabetes mellitus?
thirst
hunger
lethargy
fruity odor
A patient with type 1 diabetes mellitus asks what caused the fruity odor that was present at diagnosis. How should the nurse respond?
“Excess sugar is excreted in the urine, which causes the fruity odor.”
“The proteins in the blood are metabolized to a substance that has a fruity odor.”
“The excess sugar in the blood is metabolized to fructose and excreted via the lungs.”
“In the absence of available sugar, the body breaks down fat into ketones, which have a fruity odor.”
The nurse is reinforcing teaching for a patient who is on four injections of regular insulin daily. About how many hours after each injection of insulin should the nurse teach the patient to be alert for symptoms of hypoglycemia?
1/2 hour
3 hours
8 hours
12 hours
A patient with diabetes has peripheral neuropathy. What should the nurse do to prevent related complications?
Wash, dry, and inspect feet daily.
Use a lubricating lotion on feet daily.
Avoid wearing shoes as much as possible.
Soak feet in soap and water for 20 minutes daily.
A patient with type 1 diabetes mellitus is prescribed insulin glargine (Lantus). What should the nurse instruct the patient about this medication? (Select all that apply.)
It can be inhaled.
It is not injectable.
It has no peak action time.
It has a duration of 24 hours.
It cannot be mixed with other insulin.
A patient with type 2 diabetes mellitus is prescribed metformin (Glucophage). What should the nurse assess and monitor in this patient? (Select all that apply.)
Weight gain
Fluid retention
Family history of glaucoma
Presence of renal or hepatic disease
Presence of congestive heart failure (CHF)
The nurse explains that pregnancy affects glucose metabolism because:
Placental hormones increase the resistance of cells to insulin
Insulin cells cannot meet the body’s demands as the woman’s weight increases
There is a decreased production of insulin during pregnancy
The speed of insulin breakdown is decreased during pregnancy
The nurse is teaching a pregnant woman with type 1 diabetes about her diet during pregnancy. Which client statement indicates that the nurse’s teaching was successful?
“I’ll basically follow the same diet that I was following before I became pregnant.”
“Because I need extra protein, I’ll have to increase my intake of milk and meat.”
“Pregnancy affects insulin production, so I’ll need to make adjustments in my diet.”
“I’ll adjust my diet and insulin based on the results of my urine tests for glucose.”
Because a pregnant client’s diabetes has been poorly controlled throughout her pregnancy, the nurse would be alert for which of the following in the neonate at birth?
Macrosomia
Hyperglycemia
Low birth weight
Hypobilirubinemia
A woman with gestational diabetes has had little or no experience reading and interpreting glucose levels. The client shows the nurse her readings for the past few days. Which reading signals the nurse that the client may require an adjustment of insulin or carbohydrates?
75 mg/dl before lunch. This is low; better eat now.
115 mg/dl 1 hour after lunch. This is a little high; maybe eat a little less next time.
115 mg/dl 2 hours after lunch. This is too high; it is time for insulin.
50 mg/dl just after waking up from a nap. This is too low; maybe eat a snack before going to sleep.
Which statement concerning the complication of maternal diabetes is the most accurate?
Diabetic ketoacidosis (DKA) can lead to fetal death at any time during pregnancy.
Hydramnios occurs approximately twice as often in diabetic pregnancies than in nondiabetic pregnancies.
Infections occur about as often and are considered about as serious in both diabetic and nondiabetic pregnancies.
Even mild-to-moderate hypoglycemic episodes can have significant effects on fetal well-being.
A student nurse is reviewing the use of intravenous (IV) fluids for a school paper. Which definition should the student use to explain the process of diffusion?
The expenditure of energy to transport a solute
The movement of solute and water caused by hydrostatic pressure differences
Movement of a solute from an area of higher concentration to an area of lesser concentration
Movement of water from an area of lesser concentration to an area of higher concentration
A patient with a history of renal failure is admitted to the hospital because of decreasing urine output and a potassium level of 5.9 mEq/L. Which food should the nurse teach the patient to avoid?
gelatin
potatoes
zucchini
white bread
The nurse is testing a patient for the presence of Trousseau’s sign. Which patient response should the nurse recognize as a positive result?
Weakness of the arm
Pain in the arm and hand
Spasticity of the arm and fingers
Redness of the arm below the cuff
The nurse is concerned that an older patient is at risk for dehydration. What reduced function did the nurse assess in this patient?
Filtration
Kidney function
Sensation of thirst
Cardiac contractility
The health care provider is planning to discontinue total parenteral nutrition for a patient who has been receiving it for 3 weeks after an episode of severe gastrointestinal (GI) bleeding. What patient care order should the nurse anticipate?
Place the patient on clear liquids for 1 week.
Start tube feedings tid via nasogastric tube.
Sodium-restricted diet with high-protein snacks bid.
Taper PN rate and introduce regular feedings slowly.
A patient is prescribed IV fluid to replace electrolytes and expand plasma volume. Which type of fluid will the nurse provide to the patient?
Isotonic solution
Dextrose solution
Hypotonic solution
Hypertonic solution
The nurse uses a diagram to demonstrate how in dehydration the water is drawn into the plasma from the cells by the process of:
distillation
diffusion
filtration
osmosis
The nurse assessing a patient with vomiting and diarrhea observes that the urine is scant and concentrated. The nurse explains that the compensatory reabsorption of water is controlled by:
osmoreceptors in the hypothalamus.
antidiuretic hormone in the posterior pituitary.
baroreceptors in the carotid sinus.
insulin from the pancreas.
The patient taking furosemide (Lasix) to correct excess edema shows a weight loss of 5.5 pounds in 24 hours. The nurse calculates this weight loss to be the excretion of approximately _____ liters of fluid.
1.0
1.5
2.0
2.5
While the nurse is washing the face of a patient in renal failure, the patient demonstrates a spasm of the lips and face. The nurse examines the recent electrolyte levels to assess the level of:
potassium
calcium
sodium
magnesium
The nurse is caring for a patient who has been on total parenteral nutrition (TPN) for 48 hours. The nurse demonstrates the most effective nursing care by:
checking the patient’s blood glucose level according to facility protocol.
speeding up the solution if the prescribed intake falls behind.
informing the patient that TPN can only be administered via a central line for 1 week.
monitoring the peripheral IV site of TPN infusion for signs of infiltration at least every 8 hours.
The nurse is assessing the hydration status of the patient. The nurse demonstrates knowledge of proper assessment techniques by: (Select all that apply.)
monitoring the patient’s daily weight.
assessing the patient’s skin turgor on the back of the hand.
checking the patient’s blood glucose level 4 times a day.
assessing for skin tenting on the patient’s forehead.
asking the patient if he is experiencing thirst.
A woman’s obstetric history indicates that she is pregnant for the fourth time, and all her children from previous pregnancies are living. One was born at 39 weeks of gestation, twins were born at 34 weeks of gestation, and another child was born at 35 weeks of gestation. What is her gravidity and parity using the GTPAL system?
3-1-1-1-3
4-1-2-0-4
3-0-3-0-3
4-2-1-0-3
A woman at 10 weeks of gestation who is seen in the prenatal clinic with presumptive signs and symptoms of pregnancy likely has:
Amenorrhea
Positive pregnancy test
Chadwick sign
Hegar sign
The musculoskeletal system adapts to the changes that occur during pregnancy. A woman can expect to experience what change?
Her center of gravity will shift backward.
She will have increased lordosis.
She will have increased abdominal muscle tone.
She will notice decreased mobility of her pelvic joints.
A nurse caring for a pregnant client must understand that the hormone essential for maintaining pregnancy is:
Estrogen
Human chorionic gonadotropin (hCG)
Oxytocin
Progesterone
A nurse providing care to a pregnant woman should know that all are normal gastrointestinal changes in pregnancy except:
Ptyalism
Pyrosis
Pica
Decreased peristalsis
A pregnant woman tells her nurse that she is worried about the blotchy, brownish coloring over her cheeks, nose, and forehead. The nurse can reassure her that this is a normal condition related to hormonal change, commonly called the mask of pregnancy or, scientifically:
Chloasma
Linea nigra
Striae gravidarum
Palmar erythema
The diagnosis of pregnancy is based on which positive signs of pregnancy? Choose all that apply.
Identification of fetal heartbeat
Palpation of fetal outline
Visualization of the fetus
Verification of fetal movement
Positive human chorionic gonadotropin (hCG) test
A woman arrives at the clinic for a pregnancy test. Her last menstrual period (LMP) was February 14, 2011. Her expected date of birth (EDB) is:
September 17, 2011
November 7, 2011
November 21, 2011
December 17, 2011
The nurse is explaining the difference between meiosis and mitosis. Which statements would be best? Select all that apply.
Meiosis is the division of a cell into two exact copies of the original cell.
Mitosis is splitting one cell into two, each with half the chromosomes of the original cell.
Meiosis is a type of cell division by which gametes, or the sperm and ova, reproduce.
Mitosis occurs in only a few cells of the body.
Meiotic division leads to cells that halve the original genetic material.
The nurse is preparing a class on reproduction. What is the cell division process that results in two identical cells, each with the same number of chromosomes as the original cell called?
Meiosis
Mitosis
Oogenesis
Gametogenesis
The nurse is listening to the fetal heart tones of a client at 37 weeks’ gestation while the client is in a supine position. The client states, “I’m getting lightheaded and dizzy.” What is the nurse’s best action?
Assist the client to sit up.
Remind the client that she needs to lie still to hear the baby.
Help the client turn onto her left side.
Check the client’s blood pressure.
The nurse working in an outpatient obstetric clinic assesses four primigravida clients. Which client findings would the nurse tell the physician about?
17 weeks’ gestation and client denies feeling fetal movement
24 weeks’ gestation and fundal height is at the umbilicus
4-6 weeks’ gestation and softening of the cervix
34 weeks’ gestation and complains of hemorrhoidal pain
A patient is scheduled for a needle biopsy of the breast. Which statement indicates that teaching has been effective?
“A small needle will be used to inject chemotherapy into my tumor.”
“The doctor will use a needle to go into the tumor for a sample of cells.”
“A needle will be implanted into the tumor so medication can be injected.”
“The doctor is going to make a small incision in my breast to get some tumor cells.”
A patient is scheduled for radiation treatments before having surgery to remove a tumor. What should the nurse cite as the reason for the radiation treatments?
Reduces the need for chemotherapy
Reduces the size of the tumor before surgery
Reduces the need for radiation after the surgery
Reduces the spread of cancer cells during the surgery
A patient is diagnosed with a stage I tumor in situ (TIS). Which explanation of TIS by the nurse is the best?
“The tumor has spread and is generalized throughout the body.”
“The tumor has not invaded any tissues beyond the original site.”
“The tumor has spread to the lymph nodes in the immediate area.”
“The tumor is situated between two tissues, so there is risk for metastasis to both tissues.”
A patient receiving radiation therapy for a tumor in the salivary gland is complaining of a very dry mouth. How should the nurse document this finding?
“Halitosis noted.”
“Patient reports xerostomia.”
“Grade II stomatitis present.”
“Patient experiencing dysphagia with liquids.”
When inspecting the IV site of a patient receiving a vesicant chemotherapy agent, the nurse notes a small area of swelling. What should the nurse do first?
Check the site every hour.
Document the finding in the chart.
Discontinue the infusion.
No action is needed; this is an expected finding.
The nurse is caring for a patient with neutropenia. Which item creates the greatest risk for this patient?
A fresh apple brought in by a friend
A can of soda from a vending machine
A get-well card from a family member
A paperback book purchased at the hospital gift shop
A patient on chemotherapy after surgery develops thrombocytopenia. Which manifestation should the nurse report immediately to the physician?
Headache
Tarry stools
Pain at the surgical site
Blood pressure 136/88 mm Hg
The nurse is assessing a 58-year-old patient. For what yearly screening test for colorectal cancer should the nurse assess the patient?
Colonoscopy
Barium enema
Stool test for blood
Flexible sigmoidoscopy
The nurse is explaining the characteristics of a malignant tumor to a patient who is newly diagnosed with cancer. What should the nurse include in this explanation? (Select all that apply.)
The growth rate is rapid.
Tissue damage is minimal.
The cells resemble the tissue of origin.
The cells may invade surrounding tissues.
The cells can travel to distant organs and initiate new tumors.
A patient is experiencing mucositis as a result of radiation therapy. Which interventions should the nurse include in the plan of care? (Select all that apply.)
Provide oral care once daily.
Discourage use of alcohol and tobacco.
Encourage citrus juice for vitamin C supplementation.
Advise the patient to avoid very cold foods and drinks.
Heat all liquids before drinking to promote oral blood flow.
A definitive diagnosis for leukemia is based on results of:
Fatigue and pallor.
A urinalysis.
A bone marrow aspirate.
A history and a physical.
The most frequent presenting signs of leukemia are related to bone marrow infiltration. The main symptoms are:
Anemia, infection, and bleeding.
Thrombocytopenia, headache, and abdominal pain.
Respiratory distress and pain.
Confusion and decreased peripheral vascular resistance.
After the nurse has finished teaching a patient who is scheduled to receive external beam radiation for abdominal cancer about appropriate diet, which dietary selection by the patient indicates that the teaching has been effective?
Fresh fruit salad
Roasted chicken
Whole wheat toast
Cream of potato soup
A patient with leukemia is considering whether to have hematopoietic stem cell transplantation. Which information will be included in patient teaching?
Transplant of the donated cells is painful because of the nerves in the tissue lining the bone.
Donor bone marrow cells are transplanted through an incision into the sternum or hip bone.
The transplant procedure takes place in a sterile operating room to minimize the risk for infection.
Hospitalization will be required for several weeks after the hematopoietic stem cell transplant (HSCT).
When caring for a patient who is pancytopenic, which action by nursing assistive personnel (NAP) indicates a need for the RN to intervene?
The NAP assists the patient to use dental floss after eating.
The NAP adds baking soda to the patient’s saline oral rinses.
The NAP puts fluoride toothpaste on the patient’s toothbrush.
The NAP has the patient rinse after meals with a saline solution.
When teaching a 28-year-old patient about breast self-examination (BSE), the nurse will instruct the patient that
BSE will reduce the risk of dying from breast cancer.
BSE should be done daily while taking a bath or shower.
annual mammograms should be scheduled in addition to BSE.
performing BSE right after the menstrual period will improve comfort.
