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57 Cards in this Set
- Front
- Back
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Which of the following surgical procedure from a patient’s health history predisposes him at an increased risk of developing infections?
a. splenectomy b. vasectomy c. appendectomy d. tonsillectomy |
A. Splenectomy
The spleen destroys old RBCs, stores platelets, and filters antigens. A patient who had a spleen removed has reduced immune functions. Thus, after splenectomy, the patient is less able to rid of disease-causing organisms and at higher risk for infection or sepsis. (ch. 41, p 879) |
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A nurse is caring for a patient with a bleeding disorder. Upon reviewing the patient’s medical history, the nurse noted that the patient is diagnosed with a deficient blood clotting factor VIII. The condition associated with the patient’s clotting factor deficiency would be:
a. aplastic anemia b. hemophilia A c. hemophilia B d. sickle-cell anemia |
B. Hemophilia A
Factor VIII combines with another protein to help platelets adhere to capillary walls in areas of tissue injury. A lack of factor VIII is basis for classic hemophilia (hemophilia A). (ch. 41, p 881) |
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A nurse is caring for a patient who became anemic after having significant blood loss. Which of the following lab values indicate that the patient’s condition is improving?
a. Increased WBC count b. Positive Coomb’s test c. Increased reticulocyte count d. Prolonged PT-INR |
C. Increased reticulocyte count
An elevated reticulocyte count is desirable in a patient after hemorrhage because this indicates that the bone marrow is responding appropriately to the decreased RBC mass by producing more RBCs in the bone marrow. (ch. 41, p 886) |
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Which of the following interventions is not included in the plan of care for the patient undergoing a bone marrow biopsy of the iliac crest?
a. Place patient in prone position prior to beginning of the procedure b. Administer lidocaine around the site c. Avoid applying pressure on the site after the procedure d. Place an ice pack over the site |
C. Avoid applying pressure on the site after the procedure
External pressure should be applied to the site after the procedure until hemostasis has occurred. If the iliac crest is the site, the patient is placed in the prone or side-lying position (ch. 41, p 889-890) |
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A nurse is performing discharge teaching for a patient who just had a bone marrow aspiration and biopsy. Which of the following patient statements indicate a need for further teaching?
a. I have to stop playing basketball for at least 2 days b. I need to cover the site with a dressing c. I can cover the site with an ice pack d. I can take an ibuprofen if I feel any discomfort |
D. I can take an ibuprofen if I feel any discomfort
NSAIDs such as ibuprofen reduce platelet action and thus increase the patient’s risk for bleeding. A mild analgesic that is aspirin-free may be given for discomfort. Ice packs can be placed over the site to prevent bruising. (ch. 41, p 883-884, 890) |
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Which of the following signs and symptoms is not manifested by patients diagnosed with sickle cell anemia?
a. Acute pain b. Iron deficiency c. Jaundice d. Fatigue |
B. Iron deficiency
Despite the anemia, patients w/ sickle cell disease usually aren’t iron deficient. Pain is the most common symptom of the condition. Jaundice may also be present with RBC destruction and release of bilirubin. (ch. 42, p 894-895) |
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Which of the following interventions should not be included in the plan of care for the patient in sickle cell crisis?
a. Encourage patient to keep extremities extended b. Administer IM analgesic as prescribed c. Remove any constrictive clothing d. Check circulation of extremities every hour |
B. Administer IM analgesic as prescribed
IM injections should be avoided because absorption is impaired by poor perfusion. Extremities should be kept extended to promote venous return. (ch. 42, p 896-897) |
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A patient is admitted with a temperature of 101.6 °F and is experiencing a sickle cell crisis. As part of the plan of care for the patient, the nurse would anticipate an order for which of the following lab tests?
a. Bone marrow biopsy b. Radioisotope scan c. Blood culture d. Blood type and crossmatch |
C. Blood culture
The patient w/ sickle cell anemia who develops a fever should have diagnostic testing for sepsis including CBC with differentials, blood culture, urine culture and a chest x-ray. (ch. 42, p 897) |
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All of the following are manifested in patients with folic acid deficiency anemia except:
a. Weight loss b. Pallor c. Paresthesia d. Jaundice |
C. Paresthesia
Manifestations for folic acid deficiency anemia are similar to those of vitamin B12 deficiency, but nervous system functions remain normal because folic acid deficiency doesn’t affect nerve function. (ch. 42, p 900) |
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A nurse is reviewing the medical history of a patient with anemia. Which of the following type of medications that if regularly used by the patient, would increase the risk of developing folic acid deficiency anemia? [select all that apply]
a. Anticonvulsant b. Anticoagulant c. Oral contraceptive d. ACE inhibitor e. Cephalosporin f. NSAIDs |
A. Anticonvulsant
C. Oral contraceptive Anticonvulsants and oral contraceptives can slow or prevent the absorption and conversion of folic acid to its active form, leading to folic acid deficiency and anemia. (ch. 42, p 900) |
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A patient presents to the emergency room with generalized weakness, pallor, and petechiae. Latest blood values indicate a decreased WBC, platelet, and RBC count. The signs and symptoms presented by the patient are related to which condition?
a. Polycythemia vera b. Aplastic anemia c. Hodgkin’s lymphoma d. Sickle cell anemia |
B. Aplastic anemia
Aplastic anemia is a deficiency of circulating RBCs because of failure of the bone marrow to produce these cells. Pancytopenia (deficiency of RBC, WBC, and platelet count) is common in patients with aplastic anemia. (ch. 42, p 900) |
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Which of the following cardiovascular manifestations are present in a patient diagnosed with leukemia?
a. Tachycardia and hypertension b. Bradycardia and hypotension c. Tachycardia and hypotension d. Bradycardia and hypertension |
C. Tachycardia and hypotension
Cardiovascular changes are usually related to the adjustment the heart needs to make when tissue perfusion with oxygen is reduced because of anemia. The heart rate is increased and blood pressure is decreased. (ch. 42, p 903) |
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A nurse is performing discharge teaching for a patient with leukemia who is ordered to follow a “minimal bacteria diet” and is on regular antiviral drug therapy. Which of the following patient statements indicates that teaching is successful?
a. I have to avoid keeping a flower vase in my room b. I need to add fresh raw fruits and cooked vegetables in my diet c. Ringing in the ears is an expected side effect of drug therapy d. I have to wash my hands 3 times a day to prevent infection |
A. I have to avoid keeping a flower vase in my room
Standing water in vases, denture cups, or humidifiers aren’t allowed because they are breeding grounds for organisms. Some patients are ordered to follow a “minimal bacteria diet”. Any uncooked foods such as raw fruits and vegetables should be avoided. (ch. 42, p 906) |
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A patient with leukemia is about to undergo autologous hematopoietic stem cell transplantation (HSCT). The patient asks the nurse what an autologous transplant is. How should the nurse respond?
a. A matched relative or sibling will donate the stem cells for transplant b. Stem cells from a matched unrelated donor will be used for transplant c. Your own stem cells will be used for transplant d. Stem cells genetically created in the lab will be used for transplant |
C. Your own stem cells will be used for transplant
In autologous transplants, patients receive their own stem cells, which were collected before initiation of high-dose therapy. (ch. 42, p 907) |
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A nurse received the latest lab results for a patient who had an allogeneic stem cell transplant 2 weeks ago. The patient’s lab results indicate an increased WBC, RBC, and platelet count. What should be the nurse’s most appropriate action?
a. Contact physician b. Assess patient for signs of bleeding c. Obtain blood culture samples d. Document finding |
D. Document finding
Engraftment of the transplanted cells in the patient’s bone marrow is the key to the whole transplantation process. It takes 12 to 28 days for engraftment of stem cells to take place. WBC, RBC, and platelet count begins to rise when engraftment occurs. (ch. 42, p 909) |
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Which of the following statements best describes Non-Hodgkin’s lymphoma?
a. Presence of a specific marker, Reed-Sternberg cell, is evident in patients with Non-Hodgkin’s lymphoma b. The most common finding for the condition is pain upon palpation of lymph nodes c. It may be associated with an autoimmune disease d. It is more common in female, and older adult patients |
C. It may be associated with an autoimmune disease
Non-Hodgkin’s lymphoma includes all lymphoid cancers that don’t have the Reed-Sternberg cell. Several theories suggest that the condition is associated with autoimmune disease such as celiac disease, rheumatoid arthritis, and lupus. (ch. 42, p 914) |
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Assessment findings for a patient diagnosed with Hodgkin’s lymphoma include:
a. Large, palpable lymph nodes in the groin area b. Night sweats c. Weight gain d. Cool, clammy skin |
B. Night sweats
The most common assessment finding is a large palpable lymph node often in the neck and cervical area. The patient may also have fever, night sweats, and unexplained weight loss. (ch. 42, p 913) |
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A nurse is preparing a patient for blood transfusion. If dilution of blood product is needed, the nurse should prepare to administer which type of IV solution?
a. Normal saline b. 5% dextrose c. Lactated Ringer’s solution d. IV insulin |
A. Normal saline
Normal saline is administered with blood products. Lactated Ringer’s and dextrose aren’t used because they cause clotting or hemolysis of blood cells. (ch. 42, p 918) |
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A nurse received an order for packed RBC transfusion for her patient with a hemoglobin level of 7 g/dL. The blood product delivered has a blood type of A-negative; the patient’s blood type is AB-positive. What should be the nurse’s most appropriate action?
a. Administer Rh-immune globulin before starting blood transfusion b. Start blood transfusion as scheduled c. Hold the transfusion and contact physician d. Administer Rh-immune globulin after blood transfusion |
B. Start blood transfusion as scheduled
People who have Rh-positive blood can receive an RBC transfusion from an Rh-negative donor, but an Rh-negative person shouldn’t receive Rh-positive blood. (ch. 42, p 920) |
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Which of the following statements is not true regarding platelet transfusions?
a. Platelets are infused over 15-30 minutes b. A smaller filter and shorter tubing is used for transfusion c. Fever and chills aren’t true indicators of platelet transfusion reaction d. ABO compatibility is required for transfusion of platelets |
D. ABO compatibility is required for transfusion of platelets
Platelet transfusions are usually pooled from as many as 10 donors and don’t have to be of the same blood type as the patient has. (ch. 42, p 920) |
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A patient receiving blood transfusion presents to the nurse w/ complains of difficulty breathing and feeling restless. Further assessment by the nurse indicates hypertension, tachycardia, and a visible distended neck vein. Blood infusion is immediately stopped because the patient is experiencing signs and symptoms of:
a. Hemolytic transfusion reaction b. Bacterial reaction c. Circulatory overload d. Allergic reaction |
C. Circulatory overload
Overload can occur if blood products are infused too quickly. Manifestations include hypertension, rapid bounding pulse, distended neck veins, dyspnea, and restlessness. (ch. 42, p 921) |
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Which of the following characteristics describe benign tumor cells? [select all that apply]
a. Continuous cell growth occurs b. Features a large nucleus c. Cells have an unlimited lifespan d. Cells are encapsulated e. Migration and expansion of cells to other tissues f. May have broken and rearranged chromosomes |
A. Continuous cell growth occurs
D. Cells are encapsulated Benign tumor cells are normal cells growing in the wrong place or at the wrong time. Orderly growth patterns occur even though growth isn’t needed. Many benign cells are encapsulated to help hold the tissue together. (ch. 23, p 402) |
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A nursing student is assigned to do a clinical post-conference teaching about cancer development. Which of the following statements should the nursing student include in her teaching?
a. Most tumors arise from cells incapable of cell division b. Benign tumors grow by expansion c. Primary prevention of cancer involves screening for early detection d. Numerous cells have to undergo transformation for cancer to develop |
B. Benign tumors grow by expansion
Benign tumor cells grow by hyperplastic expansion, whereas malignant cells grow my invasion. Primary prevention of cancer involves avoiding exposure to known causes of cancer. (ch. 23, p 402-403) |
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When assessing a patient for predisposing factors of cancer development, the nurse should note that the most important risk factor would be:
a. Chronic drug or alcohol use b. Family history of cancer c. Age d. Genetic abnormalities |
C. Age
Advancing age is the single most important risk factor for cancer. As a person ages, immune protection decreases and exposure to carcinogens accumulate. (ch. 23, p 409) |
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A nurse is assigned to perform an assessment for a patient that has a history of chronic prostate problems. To assess for manifestations related to prostate cancer, what should the nurse ask the patient?
a. Any unexplained fevers, or night sweats b. Pain in the arms or chest c. Pain in the back or legs d. Presence of bruising, fatigue, or bleeding tendency |
C. Pain in the back or legs
Assessment for prostate cancer includes asking the patient about history of UTIs, presence of back pain or leg pain, and change in size of urine stream. (ch. 23, p 409) |
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Which type of cancer has the highest mortality rate in the female population?
a. Breast cancer b. Ovarian cancer c. Lung cancer d. Cervical cancer |
C. Lung cancer
Lung cancer has the highest mortality rate among all other types of cancers in both genders. About 30% of cancers diagnosed in North America are related to tobacco use. (ch. 23, p 406) |
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A nurse is caring for a patient undergoing teletherapy radiation. Which of the following should the nurse instruct the patient regarding the procedure?
a. Bodily waste products are radioactive and shouldn’t be directly touched b. Your body will emit radiation while receiving therapy c. Don’t remove the markings or outlines on your skin d. Radioactive isotopes will be given PO or through IV |
C. Don’t remove the markings or outlines on your skin
In teletherapy, the radiation source is external to the patient thus the patient isn’t radioactive and isn’t a hazard to others. Ink outlines or markings are used to indicate exactly where the radiation beam is focused. The patient should be thought not to remove or erase them. (ch. 24, p 419) |
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A nurse is caring for a patient diagnosed with breast cancer receiving teletherapy radiation. When assessing for side effects of therapy, what question should the nurse ask the patient?
a. do you have any trouble sleeping? b. do you feel dizzy when you get up in the morning? c. how much food have you eaten on your last meal? d. are you experiencing any pain, numbness, or tingling on your fingers? |
C. How much food have you eaten on your last meal?
Altered taste sensation and fatigue are two systemic side effects often noted by patients receiving external radiation regardless of the radiation site. (ch. 24, p 420) |
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A patient called the nurses’ station and said that his radioactive implant “fell off”. Which of the following is the most appropriate action for the nurse?
a. Call a biohazard code b. Carefully retrieve the radioactive source c. Place patient in strict isolation d. Ask patient to place it the lead container kept in the room |
B. Carefully retrieve the radioactive source
The radioactive source shouldn’t be touched with bare hands. A long-handled forceps should be used to retrieve it if it gets dislodged. It should be placed in a lead container that is kept in the patient’s room. (ch. 24, p 420) |
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A drug that is labeled as emetogenic is known to cause which of the following side effects?
a. Tissue or skin damage b. Increased bleeding tendencies c. Decreased appetite d. Nausea and vomiting |
D. Nausea and vomiting
Numerous chemotherapeutic drugs can cause potential tissue damage and are emetogenic (induce nausea and vomiting). An antiemetic may be given as part of therapy. (ch. 24, p 421) |
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The nursing student is asked by her clinical preceptor to give an example of interventions on how to prevent extravasation during drug therapy. What should be the nursing student’s response?
a. Assess the patient’s level of consciousness during therapy b. Closely monitor vital signs during the first 15 minutes of therapy c. Close monitoring of IV site during therapy d. Assess patient for onset of sudden headache or dyspnea during therapy |
C. Close monitoring of IV site during therapy
A major complication of chemotherapy IV infusion is extravasation, or movement of IV needle which leads to the chemotherapy drug leaking into the surrounding tissues. Results of extravasation can include pain, infection, and tissue loss. (ch. 24, p 423) |
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Which nursing diagnosis is most appropriate for a patient with neutropenia?
a. Risk for infection b. Risk for hemorrhage c. Fatigue d. Impaired gas exchange |
A. Risk for infection
Infection risk results from neutropenia, placing the patient at extreme risk for sepsis. Most chemotherapy drugs suppress bone marrow function and decrease the patient’s protective responses to invading organisms. (ch. 24, p 425) |
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Which of the following interventions would receive highest priority for a patient diagnosed with lung cancer who has a platelet count of 40,000/mm3? [select all that apply]
a. Apply ice to areas of trauma b. Auscultate lung sounds every 8 hours c. Obtain specimen for culture d. Assist patient with deep-breathing and coughing exercises e. Instruct patient to use a razor rather than an electric shaver f. Use a lift sheet when repositioning in bed |
A. Apply ice to areas of trauma
F. Use a lift sheet when repositioning in bed Patients with a low platelet count are at high risk for bleeding. Priority interventions are directed at preventing excessive blood loss. An electric shaver should be used instead of a razor to reduce the risk of bleeding. (ch. 24, p 426-427) |
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A patient diagnosed with lung cancer has a platelet count of 50,000/mm3. Oprelvekin (Neumega) is given to increase the platelet count. What potential side effect should the nurse note for the patient receiving the drug?
a. Fluid retention b. Nausea and vomiting c. Hypertension d. Bradycardia |
A. Fluid retention
Oprelvekin (Neumega) causes fluid retention and increases the risk for CHF and pulmonary edema. Other side effects include hypotension, and tachycardia. Patients taking this drug should assess their weights daily and report dyspnea immediately to the primary healthcare provider. (ch. 24, p 427) |
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A nurse administered ondansetron (Zofran) for a patient to prevent nausea and vomiting associated with chemotherapy. Which of the following statements would be an appropriate teaching instruction for the patient regarding the drug?
a. Take drug with antacid to aid in absorption of drug b. Change positions slowly c. Drug should be taken on an empty stomach d. Increase fluid intake if feeling nauseous |
B. Change positions slowly
Drug may induce bradycardia, hypotension, and vertigo. Patients should be instructed to change positions slowly to prevent falls. (ch. 24, p 429) |
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A nurse administered Dexamethasone (Decadron) for a patient to prevent nausea and vomiting associated with chemotherapy. Which of the following statements would be an appropriate teaching instruction for the patient regarding the drug?
a. Avoid driving or operating heavy machinery b. INR levels need to be checked before and after therapy c. Change positions slowly d. Reduce salt intake |
D. Reduce salt intake
Drug causes fluid retention and hypertension. (ch. 24, p 429) |
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A patient is experiencing severe fatigue as a side effect of chemotherapy. The nurse caring for the patient would anticipate administering which of the following for the patient?
a. High-flow oxygen through non-rebreather mask b. 5% dextrose c. Epoetin alfa (Procrit) IV d. Total parenteral nutrition |
C. Epoetin alfa (Procrit) IV
Anemia also results from bone marrow suppression caused by some chemotherapeutic drugs. Anemia causes patients to feel fatigued. Epoetin alfa (procrit) can prevent or improve anemia associated w/ chemotherapy and can reduce the need for transfusion therapy. (ch. 24, p 426) |
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A patient who had a below-knee-amputation 12 hours ago reports “shooting, and burning” pain and feeling “pins and needles” on the area around the amputated limb. The patient is experiencing which type of pain?
a. Idiopathic b. Somatic c. Visceral d. Neuropathic |
D. Neuropathic
Neuropathic pain is characterized by poorly localized shooting, stabbing, and burning pain and feeling of “pins and needles”. Somatic pain arises from skin and musculoskeletal organs, and visceral pain arises from organs and linings of body cavities. (ch. 5, p 38) |
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When performing an assessment on a post-op patient who complains of having pain, the most reliable indicator of acute pain would be:
a. Decreased BP b. Patient’s verbal descriptions of pain c. Decreased HR d. Delayed wound healing |
B. Patient’s verbal descriptions of pain
Although physiologic changes occur in response to acute noxious stimuli, these changes aren’t usually reliable indicators of pain. People with acute pain may have changes in vital signs such as tachycardia, and BP changes. (ch. 5, p 41) |
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One of the patients in the med-surg unit called for the nurse and reports having increasing pain. When asked about the pain, the patient states that he’s been “hurting all over”. To accurately assess the location of the pain, what should the nurse do first?
a. Ask patient to rate the pain level using the pain scale available b. Perform a complete head-to-toe assessment c. Encourage patient to focus on parts of the body that aren’t painful d. Palpate the area reported to have the most pain |
C. Encourage patient to focus on parts of the body that aren’t painful
Patients who can’t identify painful areas or states that they just “hurt all over” are encouraged to focus on parts of the body that aren’t painful. By focusing attention on selected areas of the body, the patient is assisted in localizing painful areas. (ch. 5, p 41) |
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A patient with pancreatic cancer is regularly taking aspirin for pain relief. During a follow-up assessment, the nurse caring for the patient should ask which of the following questions to determine presence of side effects of the drug?
a. Do you have difficulty urinating b. are you experiencing any groin pain c. have you had any nausea and vomiting while taking the drug d. do you feel tired during the day |
C. Have you had any nausea and vomiting while taking the drug
Aspirin and NSAIDs can cause GI disturbances and can prevent platelet aggregation, which results in GI bleeding. The patient should be assessed for any GI distress such as vomiting and for bleeding or bruising. (ch. 5, p 45) |
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A patient post-chemotherapy complains of pain and asks for Tylenol. The patient’s most recent lab work shows a platelet count of 50,000/mm3. What should the nurse do next?
a. Request for a STAT PT-INR level b. Prepare patient for blood transfusion c. Administer a low-dose NSAID instead of Tylenol d. Administer Tylenol as prescribed |
D. Administer Tylenol as prescribed
Acetaminophen (Tylenol) has no effect on platelet aggregation as most of the other NSAIDs do. This drug is preferred for people who are whom bleeding is likely. (ch. 5, p 46) |
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The patient receiving epidural opioids complains of feeling itchy and nauseous. The nurse caring for the patient will prepare to administer which medication to help relieve pruritus associated with epidural opioids?
a. Diphenhydramine (Benadryl) b. Acetaminophen (Tylenol) c. EMLA topical cream d. Naloxone (Narcan) |
D. Naloxone (Narcan)
Pruritus associated with epidural opioids is first treated with a small amount of Naloxone (Narcan). Diphenhydramine (Benadryl) may not be effective because epidural-induced pruritus doesn’t appear to be caused by histamine release. (ch. 5, p 53) |
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A nurse is caring for a patient starting initial therapy of epidural opioids for pain relief. The nurse should monitor the patient for which additional side effect of the therapy?
a. Tachypnea b. Urinary retention c. Diaphoresis d. Diarrhea |
B. Urinary retention
Urinary retention is another common problem associated with epidural analgesia which usually occurs during the first or second day of analgesic administration. (ch. 5, p 53) |
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A patient with chronic pain tells the nurse that she wants to try massage and therapeutic touch to help relieve pain. The nurse should include which of the following statements when teaching the patient about these types of complementary alternative medicine (CAM)?
a. Pain relief continues for a longer time after stimulation has stopped b. Benefits of each technique are similar and very predictable c. Multiple trials aren’t necessary to establish desired effects d. Stimulation may aggravate pre-existing pain |
D. Stimulation may aggravate pre-existing pain
Although cutaneous stimulation strategies such as massage and therapeutic touch are effective in managing acute or chronic pain, the patient should be taught that stimulation itself may aggravate pre-existing pain or may produce pain. (ch. 5, p 55) |
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Which of the following statements is not true regarding hospice care?
a. Care focuses on slowing and postponing the progression of death b. Hospice care is appropriate for terminally ill patients with a prognosis of 6 months or less to live c. Care can be provided in the hospital or at home d. A desired outcome of hospice care is facilitation of a peaceful death |
A. Care focuses on slowing and postponing the progression of death
Hospice care neither hastens nor postpones death but provides relief of symptoms experienced by the dying patient. (ch. 9, p 113) |
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A nursing student is assigned to work with a hospice nurse for the day. The hospice nurse asks the student to assess the terminally-ill patient for any signs of approaching death. Which of the following signs or symptoms isn’t an indication of imminent death?
a. Palpable blood pressure b. Cold, cyanotic extremities c. Irregular pulse d. Slow and deep respirations |
D. Slow and deep respirations
As death nears, patients often have signs and symptoms of decline in function which includes BP decreasing often is only palpable, cold, cyanotic, and mottled skin, irregular pulses, and periods of apnea with breaths becoming shallow and rapid. (ch. 9, p 115) |
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The family of a patient with end-stage liver disease tells the hospice nurse that the patient hasn’t been eating for the past few days, is very dehydrated and has lost a significant amount of weight. The family asks about IV fluid replacement for the patient. Which of the following is the most appropriate nursing action?
a. Request an order for IV fluid replacement from the patient’s primary care provider b. Request an order for total parenteral nutrition for the patient c. Place patient in a pure-liquid diet d. Inform the family that giving fluids can increase discomfort in the patient |
D. Inform the family that giving fluids can increase discomfort in the patient
Once the patient is unable to swallow, oral intake should stop. The family should be informed that giving fluids can actually increase discomfort in a person with multisystem slowdown. Discomfort from fluid replacement could lead to respiratory distress, nausea, vomiting and ascites. (ch. 9, p 116) |
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A patient with end-stage liver disease receiving routine doses of opioids for pain management had a urine output of 320 ml/day for the past 3 days. The primary care physician ordered for the discontinuation of routine opioid doses. The nurse caring for the patient should know that the medication is discontinued to decrease the risk of developing which side effect?
a. Bradycardia b. Delirium c. Urinary retention d. Increased drug tolerance |
B. Delirium
Discontinuing routine opioid doses in patients who become oliguric or anuric decreases the risk for delirium that may occur as a result of an increase in serum metabolite levels when renal excretion is reduced. (ch. 9, p 116-117) |
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A nurse educator is assigned to do a breast cancer seminar in a local community center. Which of the following statements about breast cancer is not true and should not be included in the teaching?
a. Breast cancer is the most commonly diagnosed cancer in women b. Less than 1% of all cases of breast cancer occur in men 30-50 years old c. Invasive breast cancers are most common than noninvasive types d. Gynecomastia may be present in men with breast cancer |
B. Less than 1% of all cases of breast cancer occur in men 30-50 years old
Excluding skin cancers, breast cancer is the most commonly diagnosed cancer in women and less than 1% of cases occur in men around the age of 60 years. About 20% of breast cancers are noninvasive; the remaining 80% are invasive. (ch. 73, p 1663-1664) |
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A patient is in the local community clinic for a routine health exam. The patient reports to the nurse that she felt a lump on her left breast while she was in the shower. The patient also mentioned that her mother had breast cancer and underwent mastectomy on both breasts. Which of the following, if noted in the patient’s medical history presents an increased risk for developing breast cancer? [select all that apply]
a. The patient had her first born child when she was 16 years old b. History of long-term alcohol use c. Jewish heritage d. Low estrogen levels e. Use of barrier contraceptive for birth control f. Low body weight |
B. History of long-term alcohol use
C. Jewish heritage Having a first-degree relative (mother, sister) increases the risk for developing breast cancer. Nulliparity (no pregnancies) and first birth after 30 years of age appear to also increase the risk. Women of Ashkenazi Jewish heritage have higher incidences of BRCA1 and BRCA2 gene mutation. (ch. 73, p 1664-1665) |
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A nurse is teaching a group of adolescent high-school girls about breast self-examination (BSE). Which of the following statements by the students indicate that further teaching is necessary?
a. I have to pick a day each month to do breast self-examination b. Breast self-examination doesn’t prevent breast cancer c. Breast self-examination can be done while lying down d. The fingertips shouldn’t be used to palpate the breast |
A. I have to pick a day each month to do breast self-examination
Premenopausal women should be taught to examine their breasts 1 week after the menstrual period. At this time, hormonal influence on breast tissue is decreased. Because BSE doesn’t prevent breast cancer, the purpose of screening is early detection. (ch. 73, p 1666) |
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A nurse is performing discharge teaching for a patient who underwent modified radical mastectomy and has a temporary JP drain. Which of the following patient statements indicate that further teaching is needed?
a. I have to avoid taking my IM medications on the affected side b. I have to return to the doctor in 2 weeks to remove the JP drain c. I need to call the physician if drainage is less than 25 ml in a 24-hour period d. I can resume a regular diet the day after surgery |
C. I need to call the physician if drainage is less than 25 ml in a 24-hour period
Drainage amount should be less than 25ml in 24 hours. Drainage tubes are usually removed about 1 – 3 weeks after discharge. Ambulation and regular diet are resumed the day after surgery. (ch. 73, p 1674) |
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The patient diagnosed with breast cancer asks her nurse why radiation therapy is prescribed for her. The nurse should answer the patient based on the fact that the purpose of radiation therapy is:
a. Reduce the risk of reoccurrence of cancer b. Reduce the size of the tumor c. Decrease the production of cancer cells in the body d. Inhibit production of hormones needed by the cancer cells |
A. Reduce the risk of reoccurrence of cancer
Radiation therapy is administered after breast-conserving surgery to kill breast cancer cells that may remain near the site of the original tumor. The purpose of radiation therapy is to reduce the risk for local reoccurrence of breast cancer. (ch. 73, p 1676) |
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A nurse is administering tamoxifen (Nolvadex), a selective estrogen receptor modulator (SERM), to a 50-year-old patient as part of her breast cancer therapy. The nurse should monitor the patient for which potential side effect while taking the drug?
a. Deep vein thrombosis b. Hypotension c. Loss of bone density d. Increased urinary frequency |
A. Deep vein thrombosis
Common side effects of SERMs include hot flashes and weight gain. Rare but serious side effects include endometrial cancer and thromboembolytic disease. A main side effect not seen in tamoxifen is loss of bone density. (ch. 73, p 1678) |
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A nurse is performing discharge teaching for a patient with breast cancer who underwent modified radical mastectomy of the right breast. Which patient statement warrants a need for additional teaching?
a. I can take sponge baths or tub baths when I get home b. I need to call the doctor if I have a blood pressure reading of 120/70 on my right arm c. I can do hand exercises such as circular wrist motions and flexing my fingers d. Numbness near the surgical area is normal after surgery |
B. I need to call the doctor if I have a blood pressure reading of 120/70 on my right arm
The patient should avoid taking blood pressure readings, having injections, and blood drawn on the right arm on the side of the mastectomy. Sponge baths or tub baths may be taken but the area of incision and drain should be kept dry. (ch. 73, p 1679-1680) |
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A nurse is caring for a 25-year-old female patient recently diagnosed with breast cancer who is about to start chemotherapy. Which of the following should be the nurse’s priority when teaching the patient about the procedure?
a. Assess the involvement of family members and significant other in caring for the patient b. Reassure patient that hair loss is temporary c. Advise patient to use an effective birth control during therapy d. Teach patient about taking calcium supplements to prevent loss of bone density during therapy |
C. Advise patient to use and effective birth control during therapy
For young women, issues related to childbearing may be a concern. Chemotherapy is considered a serious teratogenic agent. Sexually active patients should be advised to use an effective birth control during therapy. (ch. 73, p 1681) |
