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Nursing Concepts 4


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1. Which assessment findings are manifestations of acute leukemia? (Abnormal Cellular Growth)
â–¡ Fatigue, anemia, and enlarged liver and spleen
â–¡ Rationale: These are common manifestations of acute leukemia. Anemia causes the fatigue, and proliferation of abnormal cells leads to enlargement of the liver and spleen
2. Which expected outcome is most appropriate for the nurse to include in the home care plan for a patient with a new colostomy? The patient will..
(Abnormal Cellular Growth)
â–¡ Demonstrate colostomy care
â–¡ Rationale: A return demonstration is the best way to ensure that the patient knows self-care techniques
3. A patient with malignant melanoma asks the nurse the purpose of taking interleukin-2. Which explanation should the nurse provide? (Abnormal Cellular Growth)
â–¡ It strengthens the immune response
□ Rationale: Therapy with biologic response markers (BRMs) like interleukin-2 is based on restoration of the body’s natural defenses (immune response).
4. Which information in a patient’s health history indicates that the patient is at risk for cervical cancer? (Abnormal Cellular Growth)
â–¡ Multiple sexual partners
5. Which food should the nurse encourage to decrease a patient’s risk of developing colorectal cancer? (Abnormal Cellular Growth)
â–¡ Steamed vegetables
â–¡ Rationale: Fruits and vegetables (especially cruciferous vegetables) are recommended to decrease the risk of colorectal cancer. Steaming preserves nutritive qualities and does not introduce carcinogens.
6. Which intervention is most appropriate to increase intake in a patient with cancer who is experiencing anorexia? The nurse instructs the patient to
â–¡ Rinse mouth prior to meals
â–¡ Rationale: Rinsing the mouth reduces unpleasant taste sensations and stimulates appetite.
7. The nurse administering vincristine (Oncovin) to a patient with head and neck cancer should monitor the patient for which possible effects?
â–¡ Hair loss, numbness, and decreased reflexes
â–¡ Neuropathy and alopecia are expected side effects of vincristine chemotherapy
8. A toddler with neuroblastoma has completed a course of chemotherapy and is being cared for at home. Which sign should the community health nurse instruct the parents to report immediately?
â–¡ The central venous catheter entry site appears reddened.
â–¡ Rationale: May indicate the beginning of an infection
9. Which pathophysiology underlies the vomiting associated with pyloric stenosis?
â–¡ Hypertrophy of the stomach muscles
â–¡ Rationale: Pyloric stenosis is the result of overgrowth (hypertrophy and/or hyperplasia) or thickening of the muscle at the outlet of the stomach.
10. At 2AM, a 60-year-old patient who is receiving intracavitary radiation therapy for uterine cancer calls the nurse and says the implant has fallen out of place and is in the bed. Which is the appropriate initial nursing intervention?
â–¡ Use long handled forceps to pick up the implant and place it in a lead-lined container.
â–¡ Rationale: Principles of time, distance, and shielding
11. In planning care for a patient who is chronic intractable pain related to metastatic cancer, the nurse should include which strategy?
□ Before moving the patient, ask the patient’s advice about how to initiate and perform the moves
â–¡ Rationale: The patient knows better than the nurse what will be painful and how much pain is tolerable, and will benefit from a sense of control in making decisions about being moved.
12. When death occurs from metastatic osteogenic sarcoma, which site is most often affected?
â–¡ Lungs
â–¡ Rationale: Osteogenic sarcoma (osteosarcoma) generally begins in the distal femur, the proximal tibia, or the humerus. Regardless of the point of origin, the most common site of metastasis is the lung. Metastasis typically takes about two years and is usually fatal
13. In planning a presentation for a support group of clients with cancer, the nurse should include which information about metastasis?
â–¡ Cancer cells can enter blood vessels and go to other parts of the body.
â–¡ Rationale: Cancer cells traveling in the bloodstream is one of the primary mechanisms of metastasis.
14. Which is the most appropriate action for the nurse to take when a patient is experiencing nausea related to chemotherapy?
â–¡ Administer prescribed antiemetics prior to chemotherapy
15. A patient who is receiving IV chemotherapy for treatment of cancer complains of burning at the infusion site. Which action should the nurse carry out initially?
â–¡ Stop the infusion
16. A child with leukemia is being discharged from the hospital and will continue to take prednisone at home. Which statement by the child’s parent indicates a need for additional teaching about the effects of this medication?
□ “I’ll watch her caloric intake, since she has gained so much weight”
â–¡ Rationale: The parent should understand that the weight gain is a temporary side effect of the medications, not the result of overeating.
17. The nurse is assessing a patient with thrombocytopenia secondary to chemotherapy. Which clinical manifestation indicates the need for immediate action?
â–¡ Excessive bleeding
â–¡ Rationale: Excessive bleeding is an emergency in the patient with thrombocytopenia
18. A patient has a colostomy following surgical treatment for colon cancer. The nurse should discourage the patient from eating which food to decrease odors from the ostomy pouch?
â–¡ Cucumbers
â–¡ Rationale: Cucumbers cause the formation of gas and associated odors in the pouch.
19. Which finding in a patient with small cell lung cancer should lead the nurse to suspect that the patient has developed the syndrome of inappropriate antidiuretic hormone (SIADH) ?
â–¡ Decreased serum sodium (this is the clearest indicator)
20. On a patient’s fifth day following chemotherapy, the nurse observes a decrease in neutrophils. Which nursing diagnosis should receive priority?
â–¡ Risk for infection
□ Rationale: Neutrophils (white blood cells) are an important defense against infection, and addressing a decrease should be the nurse’s first priority
21. Which is the primary goal for postoperative management of a patient who had a left lower lobectomy for treatment of cancer?
â–¡ Promote optimal ventilation
â–¡ Rationale: Because the lobectomy has removed a section of the lung, respiratory complications are the most likely to occur. Nursing measures to promote optimal ventilation, including positioning, breathing exercises, and removal of excess secretions may be used to achieve this goal.
22. Which instruction should the nurse include in the teaching plan of a patient who develops diarrhea as a side effect of an antineoplastic drug?
â–¡ Increase the intake of high potassium foods such as bananas
â–¡ Rationale: Low bulk foods like bananas are indicated for treatment of diarrhea. There is a risk for hypokalemia in patients with diarrhea.
23. A patient with actinic keratosis asks if she is at risk for developing skin cancer. The nurse’s reply should be based on which knowledge?
â–¡ 10-20% of these lesions transform into skin cancer.
â–¡ Rationale: Some actinic keratosis lesions do eventually transform into squamous cell carcinoma.
24. A nursing goal for a patient being treated with steroid hormones for cancer is to decrease the intake of which of the following?
â–¡ Sodium
â–¡ Rationale: Fluid retention is often a problem for patients receiving steroid hormones for chemotherapy. Restricting sodium intake helps prevent this problem.
25. Which nursing action should be employed to help prevent dislodgement of the applicator containing radioactive elements used to treat cervical cancer?
â–¡ Provide a low-residue diet
â–¡ Rationale: A low-residue diet limits bowel movements and decreases the risk of dislodgement.
26. Which lab data is of most concern for the patient undergoing radiation therapy?
□ Platelets 100,000/mm³
â–¡ Rationale: This value is too low, placing the patient at risk for bleeding and infection
27. A school-age child with lymphoma is receiving chemotherapy. Which activity by the child’s parent indicates adequate learning regarding the child’s condition?
□ Denying a visit by the child’s classmate who has a cold
28. Which instruction should the nurse give to an adult patient with severe stomatitis from chemotherapy?
â–¡ Rinse mouth with baking soda in water
29. A child with Wilm’s tumor is receiving dactinomycin (Cosmegen) and vincristine (Oncovin). The nurse should teach the child’s parents how to manage which adverse reactions to the drugs?
â–¡ Constipation and leucopenia
30. Which is an appropriate intervention for a patient with lung cancer who develops superior vena cava syndrome?
â–¡ Monitor neurological status
□ Rationale: The patient’s neurological status can be compromised by increased intracranial pressure and lack of oxygen as a result of superior vena cava syndrome.
31. In planning care for a young adult patient with glioma, the nurse should instruct the family that the patient is prone to developing which problem?
â–¡ Seizures
â–¡ Rationale: Glioma, a common type of brain tumor, is very likely to cause seizures.
32. Which information does the nurse need to know in developing a teaching plan for a patient with a sigmoid colostomy?
â–¡ Irrigation may not be necessary to establish regularity.
33. Which clinical manifestation should the nurse expect to find as the most common symptom in a patient with cancer of the bladder?
â–¡ Hematuria without dysuria
â–¡ Rationale: Hematuria (blood in the urine) without dysuria (painful urination) is the most common symptom of bladder cancer.
34. Which intervention is appropriate to include in a care plan for a patient with multiple myeloma?
â–¡ Prepare for hemodialysis
â–¡ Rationale: Plasmapheresis (a form of hemodialysis) is used when a patient with multiple myeloma shows signs of increased serum viscosity.
35. When planning care for a patient immediately following a modified radical mastectomy, the nurse should give priority to which nursing diagnosis?
â–¡ Ineffective breathing pattern related to fear and pain
36. Which findings should lead the nurse to suspect bleeding in a patient with cancer who had a lobectomy 24 hours ago?
â–¡ Shortness of breath and restlessness
37. Which discharge instruction should the nurse plan to give to prevent complications associated with lymphedema in a patient who has had a modified radical mastectomy?
â–¡ Apply lotion to the hand of the affected side instead of cutting cuticles.
â–¡ Rationale: Trauma such as skin breaks is the primary cause of lymphedema, so trimming the cuticles should be avoided.
38. The nurse is developing a care plan for a family with a nursing diagnosis of anticipatory grieving related to a diagnosis of advanced ovarian cancer in the mother. The nurse should consider which intervention to be of primary importance?
â–¡ Establish a trusting relationship
39. The nurse’s plan of care for a patient who is receiving internal radiation therapy should include which action?
□ Limit the patient’s exposure to visitors.
â–¡ Rationale: Visitors should be protected from long exposure to the radiation source, and the patient should have limited contact because of the risk of infection while the radiation treatment is being given.
40. Which statement made by the patient who is receiving external radiation therapy indicates the need for more teaching?
□ I’ll limit swimming in my pool to twice a week.
â–¡ Rationale: Swimming may pose unnecessary risks because of skin irritation and exposure to sources of infection
41. Which clinical findings in an infant with Down syndrome contribute to feeding difficulties? (Anomalies, Genetic Disorders and Developmental Problems)
â–¡ Depressed nasal bone and protruding tongue
42. Which statement, by the parents of an infant who is being discharged following surgery for a ventricular peritoneal shunt, reflects understanding of their child’s condition?
â–¡ Behavior changes may be a sign of shunt dysfunction
43. A toddler is receiving digoxin and furosemide. Which foods should the nurse instruct the parents to provide?
â–¡ Oranges and bananas
44. Which drug is contraindicated for a child with hemophilia because it inhibits platelet function?
â–¡ Indomethacin (Indocin)
â–¡ Rationale: Indocin inhibits platelet function and effects renal function
45. Which nursing action should be included in the plan of care for an infant following the insertion of a ventriculoperitoneal shunt?
â–¡ Observe for abdominal distention
â–¡ Rationale: Secondary to catheter placement, colony stimulating factor may cause peritonitis or a postoperative illeus.
46. A mother is informed that her newborn has Down syndrome. The mother repeatedly asks, “Why did this happen?” Which is the nurse’s most appropriate intervention?
â–¡ Allow the mother to express her feelings about post-discharge counseling.
47. Which nursing diagnosis should receive priority for the newborn with a cleft lip and palate?
â–¡ Altered nutrition: less than body requirements related to physical defect.
48. Which data in an infant’s health history is most consistent with diagnosis of Tay-sachs disease?
â–¡ The family is of Ashkenazi Jewish origin.
49. A school-age child with muscular dystrophy is admitted to the hospital with pneumonia. During the initial interview, the mother says that she performs all the child’s treatments because the child is only comfortable with her giving the care. Which
□ I’ll observe your technique and then you can participate in your child’s care as much as possible.”
50. Attainment of which patient outcome best affects the prognosis of a child with cystic fibrosis?
â–¡ Minimal pulmonary complications
51. Which question is most important for the nurse to ask a patient before administering thrombolytic medication? (Cardiovascular Problems)
□ “Have you recently injured yourself?”
â–¡ Rationale: Because of the risk of bleeding during thrombolytic therapy, a recent injury should be investigated further before starting the therapy, to ensure that protective clots are not dissolved.
52. A patient suddenly develops chest pain and dyspnea. Which intervention is the highest nursing priority?
â–¡ Apply oxygen via nasal cannula.
â–¡ Rationale: To minimize myocardial damage
53. A patient who has been admitted to the coronary care unit with myocardial infarction is very anxious. What is the rationale for initiating measures to reduce the patient’s anxiety?
□ Anxiety increases the body’s oxygen demand.
â–¡ Rationale: Hormones related to anxiety stimulate the sympathetic nervous system, causing a stress response that increases cardiac workload. Measures to reduce anxiety will decrease oxygen demand, which should relieve pain as well.
54. Which information should the nurse include when providing instruction about propranolol (Inderal) to a patient with hypertension? Inderal⬦
â–¡ May produce insomnia
â–¡ Rationale: Inderal, a beta blocker, can produce insomnia in conjunction with mental depression
55. Which statement made by a patient on long-term anticoagulant therapy indicates that the nurse needs to revise the teaching plan?
□ “I use laxatives as needed, to keep stools soft.”
56. An anginal episode is often precipitated by which physiological factor?
â–¡ Insufficient coronary blood flow
â–¡ Rationale: Coronary insufficiency results in a decreased oxygen supply to meet increased myocardial demand for oxygen in response to a physical condition or emotional stress.
57. In which position should the nurse place a patient with pericarditis to relieve pain?
â–¡ Fowlers
58. A preschool child is admitted to the hospital in sickle cell crisis. In assessing this child, which information is of primary importance?
â–¡ The child refuses to drink fluids
â–¡ Rationale: Oral hydration is of highest importance during painful sickle cell crisis.
59. Which medication is administered to increase a patient’s cardiac output?
â–¡ Digoxin (Lanoxin) (strengthens myocardial contraction, thus increasing cardiac output.
60. The nurse has completed teaching regarding precipitating factors of angina. Which statement by the patient indicates that outcomes for teaching have been met?
□ “I will avoid outdoor activities when the temperatures are extreme.”
â–¡ Rationale: Exposure to cold, in particular, leads to increased oxygen demand, as does exercise. The patient should be encouraged to exercise but to avoid adding the stress of extremes in temperature.
61. A patient receiving furosemide (Lasix) 40 mg daily. Which observation is most indicative that an electrolyte imbalance is developing?
â–¡ Muscle weakness
â–¡ Rationale: Muscle weakness is a symptom of hypokalemia, which occurs in patients taking diuretics like Lasix that deplete potassium.
62. Which statement by a patient indicates understanding of proper care and monitoring of a pacemaker?
□ “When my pacemaker needs checking, I can have it checked over the telephone.”
63. How does the nurse monitor the effectiveness of a plasma transfusion?
â–¡ Review coagulation times
â–¡ Rationale: To monitor the effectiveness of a transfusion, a platelet count is usually ordered one hour afterwards, and the data on coagulation times reviewed.
64. A patient with heart failure is given potassium, digitalis, and furosemide (Lasix). Which finding is essential for the nurse to report to the physician?
â–¡ Weight gain of two pounds over a couple of days
â–¡ Rationale: May indicate a worsening condition
65. A patient has been admitted with congestive heart failure. Which assessment data indicates right sided ventricular failure?
â–¡ Dependent edema
â–¡ Rationale: Dependent edema is a key indicator of right-sided heart failure (failure of the right ventricle).
66. The nurse teaches a patient about the effect of cigarette smoking on the development of coronary artery disease. What is the rationale for this instruction?
â–¡ Cigarette smoking promotes platelet aggregation, resulting in blood clot formation in the heart.
67. When planning care for a 10-month –old infant with iron deficiency anemia, the nurse should be chiefly concerned with increasing the infant’s intake of which food?
â–¡ Cereals (iron fortified cereals and formula)
68. Which nursing intervention should be included in the plan of care for a patient with cardiac failure?
□ Support the lower arms and pillows when the head of the bed is elevated 30º
â–¡ Rationale: This intervention decreases the workload of the heart.
69. Which coagulation disorder is characterized by formation of tiny clots in the microcirculation?
â–¡ Disseminated intravascular coagulation (DIC)
â–¡ Rationale: In disseminated intravascular coagulation (DIC), normal hemostatic mechanisms are altered and many tiny clots form in the microcirculation.
70. Which assessment for the patient who has undergone cardiac surgery requires priority intervention?
â–¡ Serum potassium level 3.0 mEq/L
â–¡ Rationale: This potassium level is below the normal range of 3.5 to 5.0 mEq/L. Hypokalemia can cause dysrythmias and even cardiac arrest.
71. The physician prescribes an antihypertensive medication for a male patient recently diagnosed with hypertension. Which information should the nurse include in the patient’s teaching plan to ensure that the patient takes the medication as prescribed
â–¡ Discuss the side effects of the medication and potential for an alteration in sexual function.
72. Which data supports a nursing diagnosis of decreased cardiac output related to loss of mechanical pumping ability secondary to myocardial infarction?
â–¡ Cyanotic nail beds, decreased urinary output, and cool skin
â–¡ Rationale: These data indicate cardiogenic shock as an effect of the inadequate output of the heart following a myocardial infarction.
73. A patient becomes suddenly pale and diaphoretic, then quickly becomes nonresponsive and pulseless. The cardiac monitor displays a series of wide and bizarre QRS complexes at regular intervals. Which condition is the patient likely experiencing?
â–¡ Ventricular tachycardia
74. In caring for a group of patients on a cardiac rehabilitation unit, which task should not be delegated by the registered nurse?
â–¡ Instructing the patient to avoid exercises after eating
â–¡ Rationale: This task is considered patient education, and should not be delegated.
75. Which is a therapeutic effect of nitroglycerin (Nitrostat)?
â–¡ Smooth muscle relaxation
76. A patient with acute pulmonary edema is receiving furosemide (Lasix) PO and digoxin (Lanoxin) PO. It is most essential that the nurse assess this patient for which potential complication? (Respiratory Problems)
â–¡ Hypokalemia
â–¡ Rationale: Lasix depletes potassium, and has the potential to cause hypokalemia. The addition of digoxin makes assessment of potassium balance especially important because of the risk of digoxin toxicity.
77. Which assessment finding is most indicative of cardiac tamponade in the patient after cardiac surgery?
â–¡ Increased chest tube drainage
â–¡ Rationale: An increase in chest tube drainage is a key finding in cardiac tamponade, as it indicates the build-up of fluid in the pericardium.
78. After completing chest physiotherapy for a patient with chronic obstructive pulmonary disease (COPD), the nurse auscultates diminished breath sounds in all lung fields. Which nursing action is appropriate?
â–¡ Document the finding
79. The nurse teaches pursed-lip exercises to patients with emphysema. What is the purpose of pursed-lip breathing?
â–¡ To prolong exhalation and increase airway pressure during expiration
□ Rationale: Pursed-lip breathing slows (prolongs) exhalation and builds the patient’s ability to control rate and depth of respiration.
80. What is necessary for continuous positive airway pressure (CPAP) to be most effective for an infant with respiratory distress? The infant must be⬦
â–¡ Able to breath spontaneously without assistance
81. Which nursing intervention can help a patient on a ventilator cope with anxiety?
â–¡ Relaxation therapy
82. Following an auto accident, a patient is brought to the emergency department with right-sided paradoxical movement of the chest wall and complaints of difficulty breathing. Which is the most likely cause of these symptoms?
â–¡ Flat chest
â–¡ Rationale: Paradoxical chest movement with breathing difficulty results from movement of a detached rib segment (flail segment)
83. A three-year-old child who has Hodgkin’s disease is administered a Mantoux TB skin test. After 72 hours, a red raised area approximately 11 mm in diameter develops at the test site. What is the nurse’s best interpretation of this result?
â–¡ There is sensitivity to the tuberculosis bacillus
84. Which observation indicates an improvement in the condition of a 16-year-old patient who is experiencing an acute asthma attack?
â–¡ Respiration rate of 18 breaths per minute
85. Which acid-base disturbance is indicated by a PaCO2 of 52mm/Hg and pH of 7.30?
â–¡ Respiratory acidosis
â–¡ Rationale: The combination of pH<7.4 and PaCO2>40 indicates respiratory acidosis.
86. Which nursing intervention is the priority when administering thrombolytic therapy to a patient with a pulmonary embolism?
â–¡ Discontinue infusion if uncontrolled bleeding occurs.
87. Which patient should have priority in receiving pneumococcal vaccination during a vaccine shortage?
â–¡ A 23-year-old patient with cystic fibrosis
88. Which assessment is most important when caring for a patient who is scheduled for a tonsillectomy?
â–¡ Airway patency
89. Which situation indicates that a chest tube drainage system is working properly?
â–¡ There is fluid in the suction chamber
90. The physician orders gentamicin sulfate (Garamycin) 60mg IV every 8 hours to treat an upper respiratory infection in an older adult patient. The nurse should assess the patient for toxic effects to which body system?
â–¡ Renal
â–¡ Rationale: Gentamicin sulfate, an aminoglycoside, has a number of serious side effects. The toxic effect on the renal system is of special concern if the patient is an older adult.
91. Which is an appropriate discharge instruction for the nurse to give a patient who has undergone a laryngectomy? The nurse demonstrates⬦
â–¡ Alternative communication methods
92. Asthma is associated with airway obstruction caused by which physiological factors?
â–¡ Swelling of the bronchial lining and filling of the bronchi with mucus.
93. The home health nurse monitors a child using a peak expiratory flow meter. Which action by the patient indicates that the patient needs additional teaching? The patient⬦
â–¡ Sits up straight for the test
â–¡ Rationale: Correct use of a peak expiratory flow meter requires the patient to stand up
94. Which nursing action would be omitted from the plan of care for a patient with chronic obstructive pulmonary disease (COPD)?
â–¡ Monitor cardiovascular status by assessing cardiac enzymes.
95. A patient has been admitted to the hospital for removal of malignancy in the larynx. A permanent tracheostomy will be inserted and the nurse will provide suctioning when secretions are present. Which action is appropriate when suctioning a tracheosto
â–¡ Applies suction for no longer than 10 seconds while withdrawing the catheter
96. Which assessment data should lead the nurse to suspect that a patient is developing pneumonia?
â–¡ Fever, tachypnea, cough, and crackles
97. Which data is most suggestive that the patient is beginning to experience hypoxia?
â–¡ Mental confusion
98. A patient who has chest tubes attached to a Pleur-evac water-seal drainage system is being transported to X-ray. Which is the most appropriate action for the nurse to take during transit?
â–¡ Maintain the patency of the chest tubes and keep the Pleur-evac below the chest level.
99. In which position should the nurse place a patient with orthopnea to reduce fatigue and dyspnea?
□ High-Fowler’s with the arms supported on pillows
100. Which finding in a chest tube drainage system connected to suction requires nursing action?
â–¡ Continuous bubbling in the water-seal chamber

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