Oncology
The nurse is providing instructions to the client receiving external radiation therapy. Which statement, if made by the client, indicates the need for further instruction?
1."I will dry affected areas with patting motions.”
2."I will wear soft clothing over the affected site."
3."I will use a washcloth to wash the affected area."
4."I need to make sure I carry my purse on the unaffected side."
Answer: 3
External radiation therapy requires markings to be placed on the skin so that therapy can be aimed at the affected areas. The hand rather than a washcloth should be used to wash the area to avoid irritation. The nurse should instruct the client undergoing external radiation therapy to dry affected areas with a patting (rather than rubbing) motion so as not to disrupt the markings on the skin. Soft clothing should be worn so that the affected area is not irritated. The client should be sure to carry her purse on the unaffected side.
The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent?
1. Palpation of a thrill over the fistula
2. Presence of a radial pulse in the left wrist
3. Visualization of enlarged blood vessels at the fistula site
4. Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand
Answer: 1
Rationale: A nurse should listen for a thrill or bruit over AV fistula site. All other options don't REALLY show if the AV fistula is patent, just that there's perfusion to the hand.
The nurse admits a client who is in sickle cell
crisis to the hospital. Which does the nurse prepare
as the priority in the management of the
client?
1. Pain management
2. Fluid administration
3. Oxygen administration
4. Red blood cell transfusion
Answer: 3
Rationale: The priority nursing intervention for a client in sickle cell crisis
is to administer supplemental oxygen because the client is hypoxemic, and
as a result, the red blood cells change to the sickle shape. In addition,
oxygen is the priority because airway and breathing are more important
than circulatory needs. The nurse also plans for fluid therapy to promote
hydration and reverse the agglutination of sickled cells, opioid analgesics
for relief from severe pain, and, blood transfusions to increase the blood's
oxygen-carrying capacity.
Priority Nursing Tip: In sickle cell anemia, situations that precipitate sickling
include fever, dehydration, and emotional and physical stress.
Test-Taking Strategy: Focus on the client's diagnosis. Recalling that clumping of sickled cells occurs when the sickle cell client is hypoxemic and that airway and breathing are the client's priority will direct you to option 3. Review the treatment for sickle cell crisis if you had difficulty with this
A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply.
Increase in pH
Comatose state
Deep, rapid breathing
Decreased urine output
Elevated blood glucose level
Answer: 2, 3, 5
Because of the profound deficiency of insulin associated with DKA, glucose cannot be used for energy and the body breaks down fat as a secondary source of energy. Ketones, which are acid by-products of fat metabolism, build up, and the client experiences a metabolic ketoacidosis. High serum glucose contributes to an osmotic diuresis and the client becomes severely dehydrated. If untreated, the client will become comatose due to severe dehydration, acidosis, and electrolyte imbalance. Kussmaul’s respirations, the deep rapid breathing associated with DKA, is a compensatory mechanism by the body. The body attempts to correct the acidotic state by blowing off carbon dioxide, which is an acid. In the absence of insulin, the client will experience severe hyperglycemia. Option 1 is incorrect, because in acidosis the pH would be low. Option 4 is incorrect because a high serum glucose will result in an osmotic diuresis and the client will experience polyuria.
The nurse notes documentation that a child with meningitis is exhibiting a positive Kernig's sign. Which observation is characteristic of this sign?
1. The child complains of muscle and joint pain.
2. Petechial and purpuric rashes are noted on the child's trunk.
3. Neck flexion causes adduction and flexion movements of the lower extremities.
4. The child is not able to extend the leg when the thigh is flexed anteriorly at the hip.
Answer: 4
Rationale: Meningitis is an infectious process of the central nervous system caused by bacteria and viruses. The inability to extend the leg when the thigh is flexed anteriorly at the hip is a positive Kernig's sign, noted in meningitis. Muscle and joint pain is characteristic of meningococcal infection and H. influenzae infection. A petechial or purpuric rash is characteristic of meningococcal infection. A positive Brudzinski's sign is noted when neck flexion causes adduction and flexion movements of the lower extremities in children and adolescents. This is also a characteristic of meningitis.
The nurse is caring for a client with leukemia who is receiving intravenous chemotherapy. The nurse reviews the laboratory results and notes that the white blood cell count is 2000 cells/mm3, the platelet count is 150,000 cells/mm3, the clotting time is 10 minutes, and the ammonia level is 20 mcg/dL. Which nursing action would be appropriate?
1. Place the client on bleeding precautions.
2. Place the client on neutropenic precautions.
3. Remove the rectal thermometer from the client's room.
4. Instruct the dietary department to eliminate all proteins from the diet.
Answer: 2
The normal white blood cell count is 4500 to 11,000 cells/mm3. When the white blood cell count drops, neutropenic precautions need to be implemented. This includes protective isolation techniques to protect the client from infection. Bleeding precautions need to be initiated when the platelet count drops below 90,000 to 100,000 cells/mm3. The normal platelet count is 150,000 to 450,000 cells/mm3. The normal clotting time is 8 to 15 minutes, and the normal ammonia level is 10 to 80 mcg/dL. Removing the rectal thermometer from the client's room would be done if bleeding precautions were initiated. There is no useful reason to eliminate all
The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. Which actions should the nurse take? Select all that apply.
1. Check the level of the drainage bag.
2. Reposition the client to his or her side.
3. Contact the health care provider (HCP).
4. Place the client in good body alignment.
5. Check the peritoneal dialysis system for kinks.
6. Increase the flow rate of the peritoneal dialysis solution.
Answer: 1,2,4,5
Try to fix the flow yourself before calling the HCP or messing with the flow rate. Imbalance may be r/t a kink or improper positioning so fix those first.
The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy . The nurse notes that the platelet count is 20,000/ul. Based on the laboratory result, which intervention will the nurse document in the plan of care?
A. Monitor closely for signs of infection
B. Monitor the temperature every 4 hours
C. Initiate protective isolation precautions
D. Use soft small toothbrush for mouth care
Answer D
If a child is severely thrombocytopenic and has a platelet count less than 20,000/ul, bleeding precautions need to be initiated because of increased risk of bleeding or hemorrhage. Options A, B, and C are related to the prevention of infection rather than bleeding.
The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) and has a serum sodium of 118 mEq/L (118 mmol/L). Which primary health care provider prescriptions should the nurse anticipate receiving? Select all that apply.
Initiate an infusion of 3% NaCl
Administer intravenous furosemide
Restrict fluids to 800 mL over 24 hours
Elevate the head of the bed to high-Fowler’s
Administer a vasopressin antagonist as prescribed
Answer: 1, 3, 5
Clients with SIADH experience excess secretion of ADH, which leads to excess intravascular volume, a declining serum osmolarity, and dilutional hyponatremia. Management is directed at correcting the hyponatremia and preventing cerebral edema. Hypertonic saline is prescribed when the hyponatremia is severe, less than 120 mEq/L (120 mmol/L). And IV infusion of 3% saline is hypertonic. Hypertonic saline must be infused slowly as prescribed, and an infusion pump must be used. Fluid restriction is a useful strategy aimed at correcting delusional hyponatremia. Vasopressin is an ADH; vasopressin antagonists are used to treat SIADH. Furosemide may be used to treat extravascular volume and dilutional hyponatremia in SIADH, but it is only safe to use if the serum sodium is at least 125 mEq/L (125 mmol/L). When furosemide is used, potassium supplementation should also occu and serum potassium levels should be monitored. To promote venous return, the head of the bed should not be raised more than 10 degrees for the client with SIADH. Maximizing venous return helps avoid stimulating stretch receptors in the heart that signal to the pituitary that more ADH is needed.
The nurse correlates which clinical manifestation to a definitive diagnosis of multiple sclerosis?
Onset of double vision
2. Loss of bowel and bladder control
3. Numbness and tingling of one limb
4. Magnetic resonance imaging (MRI) changes in two separate locations
Answer: 4
Double vision is a manifestation of multiple sclerosis; however, it does not provide a definitive diagnosis of the disease
Loss of bowel and bladder control is a manifestation of a herniated disk.
Numbness and tingling of one limb is a manifestation of multiple sclerosis; however, it does not provide a definitive diagnosis of the disease.
For a definitive diagnosis of multiple sclerosis, the patient must have MRI changes in at least two separate locations.
A client has stage II ovarian cancer. The nurse plans care based on which characteristic of this tumor at this stage?
a. Tumor growth involves both ovaries, the peritoneum and regional lymph nodes
b. Tumor growth involves one or both ovaries, with extension into the pelvic area
c. Tumor growth is in situ and limited to the ovaries
d. Tumor growth involves distant metastasis with cancer now growing in other organs
Answer: B
Rationale: In stage II ovarian cancer, tumor growth involves one or both ovaries with pelvic extension. In stage I tumor growth is limited to the ovaries. IN stage III, lymph nodes become positive. In stage IV, there is distant metastasis
The nurse is caring for a patient who describes changes in his voiding patterns. The patient states, I feel the urge to empty my bladder several times an hour and when the urge hits me I have to get to the restroom quickly. But when I empty my bladder, there doesnt seem to be a great deal of urine flow. What would the nurse expect this patients physical assessment to reveal?
A) Hematuria
B) Urine retention
C) Dehydration
D) Renal failure
Answer B
Increased urinary urgency and frequency coupled with decreasing urine volumes strongly suggest urine retention. Hematuria may be an accompanying symptom, but is likely related to a urinary tract infection secondary to the retention of urine. Dehydration and renal failure both result in a decrease in urine output, but the patient with these conditions does not have normal urine production and decreased or minimal flow of urine to the bladder. The symptoms of urgency and frequency do not accompany renal failure and dehydration due to decreased urine production.
Which statement is correct about the rate of cell growth in relation to chemotherapy?
Faster growing cells are less susceptible to chemotherapy.
Nondividing cells are more susceptible to chemotherapy.
Faster growing cells are more susceptible to chemotherapy.
Slower growing cells are more susceptible to chemotherapy.
Answer C
The faster the cell grows, the more susceptible it is to chemotherapy and radiation therapy. Slow-growing and nondividing cells are less susceptible to chemotherapy. Repeated cycles of chemotherapy are used to destroy nondividing cells as the begin active cell division.
A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially?
Warm the client
Maintain a patent airway
Administer thyroid hormone
Administer fluid replacement
Answer: 2
Myxedema coma is a rare but serious disorder that results from persistently low thyroid production. Coma can be precipitated by acute illness, rapid withdrawal of thyroid medication, anesthesia and surgery, hypothermia, and the use of sedatives and opioid analgesics. In myxedema coma, the initial nursing action is to maintain a patent airway. Oxygen should be administered, followed by fluid replacement, keeping the client warm, monitoring vital signs, and administering thyroid hormones by the IV route.
A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis?
1. Clear CSF, decreased pressure, and elevated protein level
2. Clear CSF, elevated protein, and decreased glucose levels
3. Cloudy CSF, elevated protein, and decreased glucose levels
4. Cloudy CSF, decreased protein, and decreased glucose levels
Answer: 3
Rationale: Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. Meningitis is diagnosed by testing cerebrospinal fluid obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure; turbid or cloudy cerebrospinal fluid; and elevated leukocyte, elevated protein, and decreased glucose levels.
The nurse is analyzing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory value would the nurse specifically note as a result of the massive cell destruction that occurred from the chemotherapy?
a. Anemia
b. Decreased platelets
c. Increased uric acid level
d. Decreased leukocyte count
Answer: C
Hyperuricemia is especially common following treatment for leukemias and lymphomas because chemotherapy results in massive cell kill. Although options 1, 2, and 4 also may be noted, an increased uric acid level is related specifically to cell destruction.
The nurse is caring for a patient diagnosed with end stage renal disease (ESRD). The patient is experiencing metabolic acidosis. Which statement best describes the scientific rationale for metabolic acidosis in this patient?
Select one:
There is an increased excretion of phosphates leading to an increase in arterial blood pH.
A shortened red blood cell lifespan which leads to metabolic acidosis.
The kidney cannot excrete ammonia and cannot reabsorb sodium bicarbonate.
An increase in nausea and vomiting causes loss of hydrochloric acid.
Answer C
CKD causes DECREASED excretion of phosphates and an INCREASE in arterial blood pH is alkalosis.A shorter RBC lifespan does not affect acidosis. Also, CKD does not decrease RBC lifespan, but does decrease RBC production due to decreased erythropoietin. An increase in nausea and vomiting would cause a loss of acid, however, this would not cause metabolic acidosis. Vomiting or nasogastric (NG) suction generates metabolic alkalosis by the loss of gastric secretions, which are rich in hydrochloric acid
The nurse has provided instructions to a client with sickle cell disease regarding measures that will prevent a sickle cell crisis. Which client statement indicates an understanding of these measures?
1. "I need to avoid any exercise."
2. "I need to avoid increasing my fluid intake."
3. "I need to avoid going outdoors in warm weather."
4. "I need to avoid situations that may lead to an infection."
Answer 4
The client should avoid infections, which can increase metabolic demands and cause dehydration, precipitating a sickle cell crisis. Fluids are important to prevent dehydration, which could lead to sickle cell crisis. Warm weather and mild exercise do not need to be avoided, but the client should take measures to avoid dehydration during these conditions.
A client with a diagnosis of addisonian crisis is being admitted to the intensive care unit. Which findings will the interprofessional healthcare team focus on? Select all that apply.
Hypotension
Leukocytosis
Hyperkalemia
Hypercalcemia
Hypernatremia
Answer: 1, 3
In addison’s disease, also known as adrenal insufficiency, destruction of the adrenal gland leads to decreased production of adrenocortical hormones, including the glucocorticoid cortisol and the mineralocorticoid aldosterone. Addisonian crisis, also known as acute adrenal insufficiency, occurs when there is extreme physical or emotion stress and lack of sufficient adrenocortical hormones to manage the stressor. Addisonian crisis is a life-threatening emergency. One of the roles of endogenous cortisol is to enhance vascular tone and vascular response to the catecholamines epinephrine and norepinephrine. Hypotension occurs when the vascular tone is decreased and blood vessels cannot respond to epinephrine and norepinephrine. The role of aldosterone in the body is to support the blood pressure by holding salt and water and excreting potassium. When there is insufficient aldosterone, salt and water are lost and potassium builds up; this leads to hypotension from decreased vascular volume, hyponatremia, and hyperkalemia. The remaining options are not associated with addisonian crisis.
Which of the following clinical signs is NOT typically observed in a patient with Parkinson disease?
1. Flexed or stooped posture
2. Mask-like facial expression
3. Bradykinesia
4. Spasticity
Answer: 4
1. Flexed or stooped posture is commonly observed in patients who have Parkinson disease.
2. A mask-like facial expression is a typical symptom of Parkinson disease.
3. Bradykinesia is a classic sign of Parkinson disease.
4. Spasticity is not a typical symptom of Parkinson disease. Muscle tone does increase with Parkinson disease, but tone is more rigid in nature, not spastic.
The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy?
1) Restrict all visitors
2) Restrict fluid intake
3) Teach the client and family about the need for hand hygiene
4) Insert an indwelling urinary catheter to prevent skin breakdown.
Answer: 3
Meticulous hand hygiene education is implemented for the client, family, visitors and staff in neutropenic clients. Not all visitors are restricted, but client is protected from persons with known infections. Fluids should be encouraged. Invasive measures s/a urinary catheters should be avoided to prevent infections.
A patient’s most recent laboratory findings indicate a glomerular filtration rate (GFR) of 58 mL/min. The nurse should recognize what implication of this diagnostic finding?
A) The patient is likely to have a decreased level of blood urea nitrogen (BUN).
B) The patient is at risk for hypokalemia.
C) The patient is likely to have irregular voiding patterns.
D) The patient is likely to have increased serum creatinine levels.
Answer D
The adult GFR can vary from a normal of approximately 125 mL/min (1.67 to 2.0 mL/sec) to a high of 200 mL/min. A low GFR is associated with increased levels of BUN, creatinine, and potassium.
The nurse is performing an assessment on a client with a diagnosis of anemia that developed as a result of blood loss after a traumatic injury. The nurse should expect to find which sign or symptom in the client as a result of the anemia?
1. Bradycardia
2. Shortness of breath with activity
3. Increased respiratory rate
4. Muscle cramps
Answer 2
The client with anemia is likely to experience shortness of breath and complain of fatigue because of the decreased ability of the blood to carry oxygen to the tissues to meet metabolic demands. The client is likely to have tachycardia, not bradycardia, as a result of efforts by the body to compensate for the effects of anemia. Muscle cramps are an unrelated finding. Increased respiratory rate is not an associated finding.
A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply.
Fever
Nausea
Lethargy
Tremors
Confusion
Bradycardia
Answer: 1, 2, 4, 5
Thyroid storm is an acute and life-threatening complication that occurs in a client with uncontrollable hyperthyroidism. Signs and symptoms of thyroid storm include elevated temperature (fever), nausea, and tremors. In addition, as the condition progresses, the client become confused. The client is restless and anxious and experiences tachycardia.
The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching?
"I can sit down to put on my pants and shoes.”
"I try to exercise every day and rest when I'm tired."
"My son removed all loose rugs from my bedroom."
"I don't need to use my walker to get to the bathroom."
Answer: 4
The client with Parkinson's disease should be instructed regarding safety measures in the home. The client should use his or her walker as support to get to the bathroom because of bradykinesia. The client should sit down to put on pants and shoes to prevent falling. The client should exercise every day in the morning when energy levels are highest. The client should have all loose rugs in the home removed to prevent falling.