Kaplan – Med Surg I – Flashcards

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question
Prior to insertion of a cervical radioactive implant, enemas are prescribed for the patient. The nurse understands enemas are prescribed for which of the following reasons? 1. Make more space for the implant. 2. Decrease the chance of the implant becoming dislodged. 3. Prevent constipation due to altered activity level during treatment. 4. Enhance tissue susceptibility to the effects of radiation.
answer
Decrease the chance of the implant becoming dislodged.
question
The client reports dyspnea the third day after a major burn episode. The nurse notes the client has rhonchi in both lower lung fields, urine output is 125 mL/hr, and the CVP is 20 cm of water pressure. The nurse identifies which statement is the MOST appropriate interpretation of these data? 1. The client is developing shock. 2. The clients in the remobilization phase. 3. The client is returning to normal. 4. The client is developing hypostatic pneumonia.
answer
The clients in the remobilization phase.
question
The nurse administers D5W 100 mL/hr. The administration set administers 10 gtt/mL. The nurse should adjust the flow rate to deliver how many gtt/min?
answer
17 gtt/min
question
The nurse helps the client diagnosed with cancer make a plan for regaining weight that was lost during antineoplastic therapy. Which food should the nurse suggest to provide the highest protein and calorie intake? 1. Raisins. 2. Liver and onions. 3. Peanut butter with on preservatives. 4. Milkshakes made with whole milk, fruit, and ice cream.
answer
Milkshakes made with whole milk, fruit, and ice cream.
question
The nurse identifies nasogastric drainage, vomiting, diarrhea, and the use of diuretics likely cause which electrolyte imbalance? 1. Hypernatremia 2. Hyperkalemia 3. Hyponatremia 4. Hypokalemia
answer
Hypokalemia
question
Which over-the-counter medication decreases hyperphosphatemia in clients diagnosed with chronic kidney disease? 1. Maalox 2. Pepto-bismol 3. Kaopectate 4. Amphogel
answer
Amphogel
question
The client asks the nurse, "What does it mean if someone is a universal blood donor?" Which is the BEST explanation the nurse can give the client? 1. A universal blood donor has type O blood, which is compatible with a blood types. This means the person can give blood to anyone. 2. A universal blood donor has special factors in the blood that convert the recipient's blood type. This means the person can give blood to anyone. 3. A universal blood donor has type AB blood, which means the person can receive a transfusion from anyone. 4. A universal blood donor is one who is Rh positive which means the person can give blood to anyone.
answer
A universal blood donor has type O blood, which is compatible with a blood types. This means the person can give blood to anyone.
question
Which action should the nurse do when administering packed red blood cells to the client through a peripheral intravenous line? 1. Prime the tubing with a D5W solution 2. Obtain the client's vitals 3. Infuse the blood slowly over a period of five to six hours 4. Initially infuse at a rapid rate & check pulse frequently
answer
Obtain the client's vitals
question
The nurse assesses the skin of the client who has skin lesions. Which assessment finding should the nurse associate with basal cell carcinoma? 1. A small, crusty nodule on the face 2. A red, scaly lesion on the back of the hand 3. An irregular, bluish-black lesion on the back 4. A red, scaly raised plaque on the knee with pruritus
answer
A small, crusty nodule on the face
question
The nurse teaches a class on first aid at a community center. Which instruction is the MOST appropriate initial community care for a person experiencing an electrical burn? 1. Tell the burned person to stop, drop and roll 2. Ensure the burned person has an unobstructed airway 3. Turn off the electrical current 4. Remove the burned person's clothing
answer
Turn off the electrical current
question
The nurse teaches stoma care to the client with a total laryngectomy. Which client statement indicates th=o the nurse an understanding of the instructions? 1. "I am so glad I do not have to wear anything over the stoma." 2. "I will cover the stoma with a gauze pad while I shower." 3. "I will keep my medial emergency card in the car." 4. "I will not put anything around the exterior of the stoma."
answer
"I will cover the stoma with a gauze pad while I shower."
question
The nurse notices flattened T waves on the electrocardiogram (ECG) of the client diagnosed with acute kidney injury. Based on this finding, the nurse should check the laboratory values for which electrolyte imbalance? 1. Hypocalcemia 2. Hyponatremia 3. Hypomagnesemia 4. Hypokalemia
answer
Hypokalemia
question
The nurse cares for the client diagnosed with cancer of the cervix. The client undergoes brachytherapy. To minimize the danger of radiation exposure, the nurse should include which intervention in the plan of care? 1. Isolate client and allow no visitors 2. Ensure that visitors stand at least 3ft from radiation source. 3. Assign a different nurse each day 4. Assign only male nurses
answer
Assign a different nurse each day
question
A female patient diagnosed with acute myelogenous leukemia (AML) begins menstruating. Which of the following actions should the nurse take FIRST? 1. Instruct the patient to report any increased dizziness and weakness. 2. Contact the physician 3. Weigh the patient's pads and tampons before and after use. 4. Ask the patient if she had heavy periods in the past.
answer
Weigh the patient's pads and tampons before and after use.
question
The client newly diagnosed with cancer tells the nurse, "I know I don't have a tumor. There must be some mistake." What is the significance of this client's denial? 1. The denial prevents the client from receiving the required treatment 2. The denial causes the client's anxiety to increase 3. The denial is maladaptive for the client 4. The denial may be helpful as a temporary protection
answer
The denial may be helpful as a temporary protection
question
The nurse cares for the client diagnosed with partial thickness and full thickness burns over 40% of the body. Which essential nursing action should the nurse perform before changing the dressing? 1. Administer hyperimmune tetanus 2. Administer analgesics thirty minutes before procedure 3. Stop tube feedings for a least four hours before the dressing change 4. Weigh the client
answer
Administer analgesics thirty minutes before procedure
question
The client has burns over approximately 40% total body surface area (TBSA). Which clinical findings suggest that the client is in the shock phase? 1. Extreme dryness of the skin, elevated temperature over 104 degrees F (40 degrees C), cardiac dysrhythmias. 2. Generalized body edema, tachycardia, dehydration 3. Decreased capillary permeability, decreased intracellular fluid, increased intravascular fluid volumes 4. The shock phase would not start unless total body surface area (TBSA) burned is greater than 50%
answer
Generalized body edema, tachycardia, dehydration
question
The nurse cares for a patient diagnosed with immunosuppression due to chemotherapy. The nurse determines care is appropriate if which of the following is observed? 1. The nurse obtains the patient's vitals every 8h 2. The patient is placed in a room with a patient admitted with ulcerative colitis 3. The nursing assistant washes hands prior to changing the patient's bed linens 4. The staff brings the blood pressure equipment to obtain the patients blood pressure
answer
The nursing assistant washes hands prior to changing the patient's bed linens
question
The nurse administers peripheral intravenous fluids to a child. For which purpose does he nurse utilize a volume control set? 1. To keep air out of the IV line 2. To limit the chance of an infiltration 3. To filter bacteria from the IV fluid 4. To decrease the risk for fluid overload
answer
To decrease the risk for fluid overload
question
The client reports sleepiness, nausea, and vomiting. The nurse notes the client is confused and respirations are deep and labored with a respiratory rate of 32 breaths per minute. The arterial blood gas values are PaCO2 30 mmHg, pH 7.30, and HCO3 20 mEq/L. Which action should the nurse take? 1. Start an infusion of D5W as per standing orders and contact the HCP 2. Place a paper bag over the client's nose and mouth to re-breath expired air 3. Give morphine IV to relieve the client's pain 4. Place the client in Fowler's position and encourage measures to support hyperventilation
answer
Place the client in Fowler's position and encourage measures to support hyperventilation
question
When measuring the central venous pressure, it is MOST important for the nurse to take action? 1. Find out about the previous reading 2. Place the manometer at level of the right atrium 3. Position the patient in an upright position 4. Instruct the patient hold his breath during the reading
answer
Place the manometer at level of the right atrium
question
The nurse makes a home visit to a client receiving chemotherapy for the treatment of cancer. The nurse instructs the client about ways to avoid injury due to bone marrow suppression. The nurse should intervene if which of the following is observed? 1. The client takes Alka-Seltzer for indigestion 2. The client uses and electric razor to shave 3. The client blows his nose gently 4. After bumping his leg, the client applies ice for an hour
answer
The client takes Alka-Seltzer for indigestion
question
Which assessment is necessary for the nurse to make prior to administering an IV medication? 1. Determine the client's oral intake 2. Check for blood return from the catheter 3. Observe for redness or swelling at the IV site 4. Assess for the presence of a heparin lock
answer
Observe for redness or swelling at the IV site
question
Which results does the nurse expect after the client received a transfusion of whole blood? 1. Increased H&H levels in 12-24h 2. Increased platelet level in approximately 24h 3. The increase in plasmas will cause an increase in circulating blood volume, but hematocrit will not change 4. Reduced edema since water will move from the extravascularto to the intravascular space
answer
Increased H&H levels in 12-24h
question
48h after the client's burn injury, the nurse notes large amounts of edema in all burned areas. The nurse monitors the client for signs and symptoms of hypovolemic shock. Which is a factor that contributes to the development of hypovolemic shock in the burn client? 1. Large urine output 2. Decreased insensible fluid loss 3. Decreased hematocrit 4. Increase capillary permeability
answer
Increase capillary permeability
question
The nurse understand which of the following is the most significant risk factor for developing cancer? 1. Advancing age 2. Smoking tobacco 3. Drinking alcohol 4. Family history of cancer
answer
Advancing age
question
A client diagnosed with AIDS has recurrent bouts of diarrhea, nausea, and vomiting. Which is the most important goal for the client? 1. Maintenance of fluid and electrolyte balance 2. Decreased sense of social isolation 3. Improved activity tolerance 4. Expression of grief
answer
Maintenance of fluid and electrolyte balance
question
The nurse observes a student nurse begin an IV on an elderly patient. The nurse should intervene if which is observed? 1. The student nurse uses a 24-gauge catheter to start the IV 2. The student marks the time on the IV bag with a permanent marker 3. The student inserts the catheter at a 10 degree angle 4. The student sets the flow rate at 100mL/h
answer
The student marks the time on the IV bag with a permanent marker
question
Which part(s) of the client's body should the nurse examine to assess or anasarca? 1. Lower extremities 2. Total body surfaces 3. Peripheral areas 4. Periorbital areas
answer
Total body surfaces Anacarca = massive generalized edema
question
The school aged child with burns on the legs continually picks off the new scabs. The exposed wonld will not heal because of this behavior. The child explains, "The picking helps with the itches." Which is the most appropriate nursing intervention to foster the child's behavioral change? 1. Tell the child wounds may become infected by picking off the protective scabs 2. Medicate the client with PRN sedatives to promote sleep and reduce discomfort 3. Offer to take the client off the unit to visit the child's dog if there is no touching of the wounds 4. Restrain the client's hands when the client is unaccompanied
answer
Offer to take the client off the unit to visit the child's dog if there is no touching of the wounds
question
The client diagnosed with Hodgkin's lymphoma has the first external radiation treatment. Which statement by the client demonstrates and understanding of the teaching plan? 1. "I will stay inside after the treatments and avoid sunlight." 2. "I should apply a cream, such as baby oil, before each treatment." 3. "I will wear loose fitting, cotton clothing that will not irritate the treatment area." 4. "I should use cold applications to the area if needed."
answer
"I will wear loose fitting, cotton clothing that will not irritate the treatment area."
question
A patient is scheduled for a total laryngectomy. He tells the nurse, "I am worried about my operation. I just can't help it." Which of the following responses by the nurse is best? 1. "Have you discussed your worries with your doctor?" 2. "I hear your concerns about having the operation." 3. "You have a really fine doctor so there seems to be little need to worry." 4. "Everyone worries about surgery, especially when it is a first time experience."
answer
"I hear your concerns about having the operation."
question
The nurse cares for a patient diagnosed with cancer receiving chemotherapy. The patient shares with the nurse how upset she is that she is losing her hair. Which of the following statement by the nurse is best? 1. "I'm sure that your daughter will help you find a wig that you like," 2. "I would not want to lose my hair!" 3. "Your hair will grow back about one month after chemo is complete." 4. "There are many attractive hats and scarves that will look very good on you."
answer
"Your hair will grow back about one month after chemo is complete."
question
The home care nurse visits a client undergoing external radiation for treatment of lung cancer. It is most important for the nurse to include which of the following intervention in the clients plan of care? 1. Use a washcloth to gently cleanse the irradiated area 2. Apply cram to the irradiated area daily 3. Apply sunscreen to the irradiated area if exposed to the sun 4. Use a patting motion to dry the irradiated area.
answer
Use a patting motion to dry the irradiated area.
question
The nurse cares for the client diagnosed with dehydration. The client has a past medical history of a stroke. The nurse needs to evaluate the therapeutic effect of fluid replacement. Which action is a priority? 1. Assess for circumoral cyanosis 2. Assess BP 3. Assess urinalysis daily 4. Assess for increased mental alertness
answer
Assess for increased mental alertness
question
The client will receive a unit of whole blood within the next hour. Which intravenous solution should the nurse obtain for infusion with the blood? 1. D5W 2. D5W1/2NS 3. 0.9% NaCl 4. 0.45% NaCl
answer
0.45% NaCl
question
The client has a unit of blood infusing. Which effect does the nurse expect when transfusion is complete? 1. This client's BP will increase 2. The client's HH levels will improve 3. There is no need to worry about a transfusion reaction 4. This client should be assessed for emotional depression
answer
The client's HH levels will improve
question
The nurse cared for the client diagnosed with acute myelogenous leukemia. Which laboratory result would the nurse expect? 1. Hematocrit (Hct) 55% 2. Hemoglobin (Hgb) 16g/dL 3. Platelets 500,000/mm3 4. White blood cells (WBC) 11,000/mm3 with myeloblasts
answer
White blood cells (WBC) 11,000/mm3 with myeloblasts
question
A newborn is transferred to the neonatal intensive care unit with a heart rate of 200 beats/min. At delivery the child's wight was 3675 grams. The health care provider orders an initial dose of digoxin 0.03mg/kg in 3 doses over 24h. The syringe is labeled digoxin 100 mcg/mL. How many mL will the nurse deliver in one dose?
answer
0.36mL 3675/1000 = 3.675kg x 0.03 = 0.11025mg/day 0.01125/3 = 0.03675mg/dose 0.0375mg/100 = 36.75mcg
question
The nurse cares fore the client days after a mastectomy. The client is encouraged by the health care provider to participate in an exercise program. which activity should the nurse suggest to facility mobility of the affected side? 1. combing her hair 2. weeding her rose garden 3. walking 4. swimming
answer
combing her hair
question
A young woman receiving chemotherapy for a brain tumor suddenly becomes angry and irritable with the staff. When the nurse tries to administer the patient's medications, the patient throws a tray across the room and curses. Which of the following action by the nurse is most appropriate? 1. Ask another nurse to administer the medication 2. Leave the room, promising to return when the patient gains control 3. Remain with the patient and call for help 4. Restrain the patient and call for help
answer
Remain with the patient and call for help
question
Which the client has highest risk for sudden changes in homeostasis? 1. Client with vital signs taken every 4 hours 12 hours after a hermiorrhaphy 2. Client on IV antibiotics every other hour with infected leg ulcer 3. Client with vital signs taken every hour admitted after a motor vehicle accident earlier today 4. Client who is ambulating two days after a transurethral resection for benign hypertrophy of the prostate
answer
Client with vital signs taken every hour admitted after a motor vehicle accident earlier today
question
The nurse identifies which central venous pressure (CVP) reading indicates fluid overload? 1. 0 mm Hg 2. 3 mm Hg 3. 8 mm Hg 4. 15 mm Hg
answer
15 mm Hg normal range is 2-8 mm Hg
question
The nurse cares for a client with an IV infusion running at 60mL/hr. The nurse notes that the IV is not running at the correct rate. The nurse assesses the IV set up and discovers no abnormalities or infiltration. Which is the most appropriate action for the nurse to take? 1. Reposition the client's arm 2. Restart the IV in a new site 3. Apply a warm compress to the client's arm 4. Call the health care provider
answer
Reposition the client's arm
question
The client diagnosed with cancer asks the nurse, "Why must I take so many drugs?" Which response by the nurse is best? 1. "Cancer is so individual, and because no one drug works the same way with every person, more than one drug is usually used." 2. "Cancer cells grow differently than normal cells, so more than one drug is used to ensure an effect," 3. "Like bacteria, cancer cells can resist chemotherapy drugs. By using drugs with different actions, more cells are destroyed before resistance develops." 4. "It's like the 'magic bullet.' If one doesn't work, the other will."
answer
"Like bacteria, cancer cells can resist chemotherapy drugs. By using drugs with different actions, more cells are destroyed before resistance develops."
question
The nurse makes staff assignments for the oncology unit. The nurse's main concern is that there is a client on the unit who has an internal radiation source implanted for the treatment of prostate cancer. Which should the nurse plan to protect the staff from radiation exposure? 1. One staff member wears a lead apron when caring for this client 2. Three staff members share a dosimeter when caring for the client during the shift 3. One staff member assigned for close contact with this client and another staff member assigned to answer the call light for this client 4. Limiting any staff member's contact with client to not exceed 30 mins per 8h shift
answer
Limiting any staff member's contact with client to not exceed 30 mins per 8h shift
question
The 3 yr old child is brought to the ER with a history of vomiting and diarrhea for the past three days. Which finding is the nurse most likely to see? 1. Shortness of breath 2. Slow heart rate 3. Sunken eyes 4. Tremors
answer
Sunken eyes
question
An elderly client is admitted to the hospital to undergo abdominal surgery. Admitting orders include activity as desired, standard bowel prep, and an IV infusion of D5W at 75 mL/h starting at 1800 the evening before surgery. The nurse understands that the primary purpose of administering IV fluids to a pt prior to surgery includes which of the following? 1. Establish a route for administering medications rapidly 2. Avoid the need for inserting it on the morning of surgery 3. Decrease the client's desire to take fluids PO 4. Ensure the client remains adequately hydrated
answer
Ensure the client remains adequately hydrated
question
The client diagnosed with severe anemia received a unit of A positive blood. The client's blood type is A negative. The nurses must inform the client of problems that can be anticipated. Which statement is most appropriate for the nurse to say to the client? 1. "Be sure to tell us if you continue to feel tired because your anemia might be worse." 2. "Your BP may increase dramatically, so be alert for headaches or nosebleeds." 3. "Observe your urine when you get home, and be sure to report any signs of blood," 4. "A second expose to Rh positive blood will cause a severe reaction. Therefore, you must inform any future caregivers of this incident."
answer
"A second expose to Rh positive blood will cause a severe reaction. Therefore, you must inform any future caregivers of this incident."
question
The cares for the client diagnosed with hypotonic dehydration. Which laboratory study should the nurse monitor in the client? 1. Platelet count 2. Immunoglobin E level (IME) 3. Albumin level 4. Sodium level
answer
Sodium level
question
The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder? 1. increased calcium level 2. increased WBCs 3. decreased BUN level 4. decreased number of plasma cells in the bone marrow
answer
increased calcium level
question
The nurse is developing a plan of care for the client with multiple myeloma and includes which priority intervention in the plan? 1. encourage fluids 2. providing frequent oral care 3. coughing and deep breathing 4. monitoring the RBC count
answer
encourage fluids
question
The nurse is caring for a client with an internal radiation implant. When caring for the client, the nurse should observe which principle? 1. limit the time with the client to 1 hour per shift 2. do not allow pregnant women into the clients room 3. remove the dosimeter film badge when entering the client's room 4. individuals younger than 16y/o may be allowed to go in the room as long as they are 6 feet away from the client
answer
do not allow pregnant women into the clients room
question
The nurse is caring for a client experiencing neutropenia as a result of chemotherapy and develops a plan of care for the client. The nurse plans to: 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
teach the client and family about the need for hand hygiene
question
The home health care nurse is caring for a client with cancer and the client is complaining of acute pain. The most appropriate nursing assessment of the client's pain would include which of the following? 1. the client's pain rating 2. nonverbal cues from the client 3. the nurse's impression of the client's pain 4. pain relief after appropriate nursing intervention
answer
the client's pain rating
question
The nurse recognizes which of the following signs indicate cancer of the larynx? 1. increased drooling 2. blood-streaked sputum 3. difficulty swallowing 4. jaundice
answer
difficulty swallowing
question
The nurse cares for a pt w/stomatitis due to the chemotherapy. Which of the following actions is most important for the nurse to include in the pt's plan of care? 1. examine the pt's mouth for blisters, sores, or drainage 2. encourage the pt to use a commercially prepared mouthwash twice daily 3. instruct the pt to use a soft-bristled toothbrush 4. offer mouth care morning and night
answer
examine the pt's mouth for blisters, sores, or drainage
question
The nurse is caring for a client who is postoperative following a pelvic exoneration and the physician changes the client's diet from NPO status to clear liquids. the nurse makes which priority assessment before administering the diet? 1. bowel sounds 2. ability to ambulate 3. incision appearance 4. urine specific gravity
answer
bowel sounds
question
The nurse performs postoperative care for a pt after a Whipple procedure for tx of pancreatic cancer. the nurse is MOST concerned if which of the following is observed? 1. there is a clear, colorless, bile-tinged drainage from the NG tube 2. the NG tube is connected to a low continuous suction 3. the pt is lying in a semi-fowlers position 4. the nurse instills air to open the drainage lumen of the NG tube
answer
there is a clear, colorless, bile-tinged drainage from the NG tube
question
Ondansetron HCI (Zofran) 6mg PO q 6hr is ordered for a pt. The nurse knows that the most appropriate time to administer this medication is: 1. 1hr after chemotherapy 2. 30 min prior to start of chemotherapy 3. 2hr after chemotherapy 4. after the pt complains of nausea
answer
30 min prior to start of chemotherapy
question
The nurse instructs a group of pts about dietary habits to reduce the risk of cancer. which of the following statements, if made by a pt to the nurse, indicates further teaching is necessary? 1. "eating polyunsaturated fats will decrease my chances of developing cancer" 2. "I should increase my intake of foods high in fiber" 3. "I should eat apricots, carrots, leafy vegetables, and citrus fruits" 4. "i should eat turkey on my sandwich rather than bologna
answer
"eating polyunsaturated fats will decrease my chances of developing cancer"
question
The nurse performs a home care visit for a client receiving chemotherapy for tx of cancer. The client's white blood cell count is 3,500mm^3. Which of the following observations; if made by the nurse, requires an intervention? 1. the client cleans the toothbrush daily by washing it in the dishwater 2. the client eats peeled fruits and cooked vegetables 3. the client takes and records the oral temp each day 4. the client pulls weeds in the garden every day
answer
the client pulls weeds in the garden every day
question
The nurse recognizes which of the following is an early symptom of gastric cancer? 1. occult blood in stool 2. vomiting 3. iron deficiency anemia 4. abdominal discomfort relieved w/ antacids
answer
abdominal discomfort relieved w/ antacids
question
The nurse knows which of the following is the MOST life-threatening side effect of chemotherapy? 1. alopecia 2. bone marrow suppression 3. vomiting 4. mucositis
answer
bone marrow suppression
question
On the evening before a scheduled lung biopsy, a pt says to the nurse, "Do you think i have cancer?" Which of the following responses by the nurse is MOST appropriate? 1. it is not for me to say; you'll know after tomorrow 2. you know that you have been taking a chance smoking cigarettes all these years 3. several tests will have to be done to confirm that diagnosis 4. you sound worried about what they might find tomorrow
answer
you sound worried about what they might find tomorrow
question
Which of the following nursing interventions is MOST effective in promoting adequate nutrition for patients undergoing radiation and chemotherapy? 1. include pts when making meal and snack selection 2. ensure meals are served hot 3. offer salty snacks every 2 hours 4. serve additional portions of food at mealtime
answer
include pts when making meal and snack selection
question
The nurse instructs staff members about care of pt diagnosed with cancer of the cervix. the pt has internal radiation in place. the nurse should intervene if a staff member makes which of the following statements? 1. i should allow the pt to bathe herself 2. i should not stand at the foot of the bed 3. i should place all linens in a special, lead-lined hamper 4. i should wear a dosimeter while i am in the pt's room
answer
i should place all linens in a special, lead-lined hamper
question
A client experiences numbness and decreased sensation in both lower extremities during the course of treatment with vinblastine (Velban). The nurse instructs the pt to take which of the following actions? 1. soak both legs in hot water four times/day 2. increase walking to three times a week for 30 min 3. ambulate carefully with broad-based gait 4. elevate legs while sitting
answer
ambulate carefully with broad-based gait
question
The nurse performs discharge teaching for a pt after a right mastectomy. the nurse determines that teaching is effective if the pt makes which of the following statements? 1. "I should eat a full liquid diet for 3-4 days." 2. "I can take a shower as soon as i get home." 3. "I should empty the drain reservoir twice a day." 4. "I should eat with my left hand until the stitches are removed."
answer
"I should empty the drain reservoir twice a day"
question
The home care nurse monitors a client diagnosed with cancer of the lung. the client complains about awakening with a severe headache several mornings during the past week. the client also admits to becoming suddenly nauseated, has vomiting, and notices drooling. which of the following actions by the nurse is BEST? 1. administer the prescribed antiemetic 2. reassure the client that this is expected 3. assess the status of the client's lungs 4. contact the physician
answer
contact the physician
question
The nurse assesses a pt w/ a diagnosis of colorectal cancer. the nurse understands that eating which of the following foods may contribute to the pt developing colon cancer? 1. broccoli and cabbage 2. fried red meat 3. water 4. oranges and grapefruit
answer
fried red meat
question
The nurse leads adult women in a wellness class. the nurse instructs the class about risk factors for developing breast cancer. the nurse should intervene if one of the women makes which of the following statements? 1. women over the age of 40 have a greater chance of developing breast cancer 2. women with a history of benign breast disease have a greater risk of developing breast cancer 3. women who have a mother or sister with breast cancer are at a higher risk of developing breast cancer 4. women who have never had children have a higher risk of developing breast cancer
answer
women with a history of benign breast disease have a greater risk of developing breast cancer
question
The nurse performs health screening on a group of people. the nurse identifies which of the following individuals is at GREATEST risk for developing skin cancer? 1. a 15 yr old male with dark skin works as a lifeguard at the local pool 2. a 30 yr old female w/ light skin works as a cashier at the local store 3. 47 yr old female w/ dark skin swims daily at a health club 4. 62 yr old male w light skin worked as a roofer for 40 years
answer
62 yr old male w light skin worked as a roofer for 40 years
question
The home nurse cares for a client diagnosed with acute myelogenous leukemia(AML). the clients temp is 101F. which of the following actions should the nurse take FIRST? 1. notify the physician 2. offer the client oral fluids 3. administer an antipyretic 4. encourage the client to cough and deep breathe
answer
notify the physician
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