24
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24
Test Bank
MULTIPLE CHOICE
1. What statement indicates that the client understands teaching about neutropenia?
a. I need to use a soft toothbrush.
b. I have to wear a mask at all times.
c. My grandchildren may get an infection from me.
d. I will call my doctor if I have an increase in temperature.
ANS: D
Bone marrow suppression leads to neutropenia and increases the clients risk for infection.
Decreased numbers of neutrophils and other white blood cells can minimize the clinical
manifestations of infection. For this reason, the client may not develop a high temperature,
even with severe infection, and any elevation of temperature should be reported immediately
to the health care provider. The client does not need to wear a mask or use a soft toothbrush
(although if the client has low platelets, he or she should use a soft toothbrush to avoid
causing trauma). The client is not contagious.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Evaluation)
2. A client is undergoing radiation therapy and asks the nurse about skin care for the exposed
a.
b.
c.
d.
ANS: B
A recent placebo-controlled study showed that none of three products used to manage
radiation-related skin reactions was superior to the others. Researchers concluded that clients
should use products that are easy to obtain and use and are within the clients budget. Simply
stating that no one product works well does not give the client enough information to make an
informed choice. Prescription medications for skin reactions can be expensive, but again this
response does not help the client make a decision.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 414
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
3. A client who has just had a mastectomy is crying. When the nurse asks about her crying, the
client responds, I know I shouldnt cry because this surgery may well save my life. What is
the nurses best response?
a. It is all right to cry. Mourning this loss will help make you stronger.
b. I know this is hard, but your chances of survival are better now.
c. I can arrange for someone who had a mastectomy to come visit if you like.
Often, cancer surgery involves the loss of a body part or a decrease in function. Mourning or
grieving for a body image alteration is a healthy part of adapting or adjusting to a new image.
Visiting with someone who has experienced the same situation as the client is very helpful in
showing the client that many aspects of life can be the same afterward. If the opportunity to
arrange this type of visit is available, this would be the nurses best response. The other
options do not provide any assistance to the client in coping with her new body image and
grieving for her loss.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 411
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communications)
MSC: Integrated Process: Caring
4. In evaluating dietary teaching for a client with chemotherapy-induced neutropenia, the nurse
The client who is neutropenic should be taught to eat a low-bacteria diet. This includes
avoiding raw fruits or vegetables and undercooked meat, eggs, or fish.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Evaluation)
5. What teaching is essential for a client who has received an injection of iodine-131?
a. Do not share a toilet with anyone else or let anyone clean your toilet.
b. You need to save all your urine for the next week.
c. No special precautions are needed because this type of radiation is weak.
d. Avoid all contact with other people until the radiation device is removed.
ANS: A
The radiation source is an unsealed isotope that is eliminated from the body in waste products,
especially urine and feces. This material is radioactive for about 48 hours after instillation of
the isotope. Having the client not share a toilet with other people or allowing anyone to clean
the clients toilet for a specific period of time ensures that the isotope has been completely
eliminated, and that the clients wastes are no longer radioactive.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control
Handling Hazardous and Infectious Materials)
MSC: Integrated Process: Nursing Process (Implementation)
6. A client has bone cancer. What intervention does the nurse implement as a priority for this
client?
a. Using a lift sheet when repositioning the client
b. Positioning the clients heels to keep them from touching the mattress
Bone metastasis of cancer can cause such bone destruction that grasping or pulling a client
can result in a pathologic fracture. Using a lift sheet spreads the clients weight more evenly,
preventing excessive force on any one body area. Preventing pressure on the heels will help
prevent pressure ulcers; this is a good intervention for all clients but does not take priority
over preventing fractures. Adding calcium and phosphorus to meals will not prevent fractures.
Applying pressure after IM injections is not related to this clients condition.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control
Accident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
7. A client is undergoing radiation therapy and says, I will be so glad when this is over and I
dont have to worry about my skin. What response by the nurse is most appropriate?
Unfortunately, your skin will be permanently damaged from the radiation.
You need to protect your skin from the sun for at least a year afterward.
You can get a prescription for special lotions that reduce the effects of radiation.
Youre having skin problems? That is unusual; let me take a look at your skin.
a.
b.
c.
d.
ANS: B
Skin that has been in the path of external radiation is more susceptible to sun damage and
must be protected from the sun for at least a year after completion of radiation therapy. Skin
changes due to radiation are common but may not be permanent, depending on the amount of
radiation absorbed. No one skin care product has been shown to significantly help radiationrelated skin problems.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 413
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications of Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Teaching/Learning
8. A client scheduled to undergo radiation therapy for breast cancer asks why 6 weeks of daily
treatment.
b. Giving larger doses of radiation for a shorter period of time does not produce
Because of varying responses of all cancer cells within a given tumor, small doses of radiation
are given on a daily basis for a set period of time. This method allows multiple opportunities
to destroy cancer cells while minimizing damage to normal tissues.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 411
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
9. A clients radiation implant has become dislodged overnight, and the nurse finds it in the
a.
b.
c.
d.
ANS: B
The implant does emit radiation and should be placed into the secure, lead-lined container in
the clients room. The nurse does not directly touch this implant but uses long-handled tongs
for this purpose. The nurse does not need to assess the clients skin, nor should he or she
attempt to replace the source. Moving the client is not necessary, although in keeping with
facility policy, the radiation safety officer may need to be notified.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control
Handling Hazardous and Infectious Materials)
MSC: Integrated Process: Nursing Process (Implementation)
10. A client is receiving a chemotherapeutic agent intravenously through a peripheral line. What is
the nurses first action when the client reports burning at the site?
a. Check for a blood return.
b. Slow the rate of infusion.
c. Discontinue the infusion.
d. Apply a cold compress.
ANS: C
Both irritants and vesicants can cause tissue damage. If the nurse suspects extravasation, he or
she should immediately stop the infusion. Even if the IV has a good blood return, some of the
chemotherapeutic agent can still be leaking into the tissues. Slowing the rate of infusion is not
sufficient to prevent further leakage and damage. Applying a cold compress may or may not
be the correct action, depending on the specific agent. However, the compress would be
applied only after the infusion has been discontinued.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Nursing Process (Implementation)
11. A client receiving intravenous chemotherapy asks the nurse the reason for wearing a mask,
gloves, and gown while administering drugs to the client. What is the nurses best response?
These coverings protect you from getting an infection from me.
I am preventing the spread of infection from you to me or any other client here.
The policy is for any nurse giving these drugs to wear a gown, gloves, and mask.
The clothing protects me from accidentally absorbing these drugs.
a.
b.
c.
d.
ANS: D
Most chemotherapy drugs are absorbed through the skin and mucous membranes. As a result,
health care workers who prepare or give these drugs, especially nurses and pharmacists, are at
risk for absorbing them. Even at low doses, chronic exposure to chemotherapy drugs can
affect health. The Oncology Nursing Society and the Occupational Safety and Health
Administration (OSHA) have specific guidelines for using caution and wearing protective
clothing whenever preparing, giving, or disposing of chemotherapy drugs.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control
Handling Hazardous and Infectious Materials)
MSC: Integrated Process: Teaching/Learning
12. A clients spouse reports that the last time the client received lorazepam (Ativan) before
receiving chemotherapy, the client was extremely drowsy and didnt remember the trip home.
Which is the nurses best action?
a. Hold the dose of lorazepam for this round of chemotherapy.
b. Explain that this is a normal response to the drug.
c. Perform a Mini-Mental State Examination.
d. Document the response in the clients chart.
ANS: B
This client has thrombocytopenia, which is a common side effect of chemotherapy. This
increases the clients risk for prolonged bleeding in response to even minor injury, especially
from highly vascular areas such as the gums. The client should be taught to use a soft
toothbrush. A low-bacteria diet and daily temperature monitoring would be used in a client
who is neutropenic. Alcohol-based mouthwashes will dry mucous membranes.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
14. A client with chemotherapy-induced bone marrow suppression has received filgrastim
(Neupogen). Which laboratory finding indicates that this therapy is effective for the client?
Hematocrit is 28%.
Hematocrit is 38%.
Segmented neutrophil count is 2500/mm3.
Segmented neutrophil count is 3500/mm3.
a.
b.
c.
d.
ANS: D
Filgrastim is a single-lineage growth factor that stimulates the maturation and release of only
segmented neutrophils. This drug is not given unless the neutrophil count is dangerously low.
The near-normal range of neutrophils indicates effective therapy.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Expected Actions/Outcomes) MSC:
Integrated Process: Nursing Process (Evaluation)
15. What is the priority problem for a client experiencing chemotherapy-induced anemia?
a. Risk for injury related to fatigue
b. Fatigue related to decreased oxygenation
c. Body image problems related to skin color changes
d. Inadequate nutrition related to anorexia
ANS: A
Safety is always a client priority. The client who is anemic will be fatigued and may need
assistance with activity to prevent injury. The other problems may apply; however, they do not
take priority over safety.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control
Accident/Injury Prevention) MSC:
Integrated Process: Nursing Process (Analysis)
16. A client is hospitalized for chemotherapy. The registered nurse intervenes when observing
The biggest dangers to clients on chemotherapy are neutropenia and the risk of serious
infection or sepsis. Most infections arise from overgrowth of the clients own normal flora, so
personal hygiene is critical. The client must perform hygiene measures on a schedule, even if
he or she is very tired. Instead of allowing the client to rest, the nursing assistant should help
the client perform oral hygiene and other measures. The other actions would be acceptable.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
17. The student nurse overhears several staff members referring to a client who is receiving
chemotherapy as having chemo brain. The student asks the instructor what that means.
Which response by the instructor is best?
a. That is an awful thing to say and the staff should not call a client by that name.
b. It refers to the clients brain as being irreversibly damaged by the chemotherapy.
c. The client has reduced cognitive function that may last for several years.
d. The client has delirium related to the toxic effects of the chemotherapy.
ANS: C
Chemo brain refers to the changes in concentration, memory, and learning that sometimes
accompany chemotherapy. It usually is not present at 3 years after chemotherapy has been
completed, so clients should be reassured that this is a temporary condition. Although the staff
should be more sensitive, simply criticizing them does not help the student understand the
situation.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 424
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Adverse Effects/Contraindications/Interactions/Side Effects)
MSC: Integrated Process: Teaching/Learning
18. A client with prostate cancer is taking estrogen daily to control tumor growth. He reports that
his left calf is swollen and painful. Which is the nurses best action?
a. Instruct the client to keep the leg elevated.
b. Measure and compare calf circumferences.
c. Apply ice to the calf after massaging it.
d. Document this expected response.
ANS: B
administer if needed?
a. Lorazepam (Ativan)
b. Meperidine (Demerol)
c. Furosemide (Lasix)
d. Epoetin alfa (Epogen)
ANS: B
Clients receiving IL-2 therapy usually experience chills, fever, and rigors during the infusion,
especially the first time that they receive the drug. These reactions are a normal response to
the administration of biological response modifiers such as IL-2. Clients are treated
symptomatically for the discomfort. Demerol is used to treat the chills and rigor. The other
medications would not treat a side effect of IL-2 therapy.
serious consequences for clients on the unit. Which action by the nursing manager is most
beneficial in this situation?
a. Review asepsis policies at a mandatory in-service for staff.
b. Spot-check all staff for good handwashing practices.
c. Develop standard protocols to identify and treat clients with infection.
d. Institute protective precautions for all clients receiving chemotherapy.
ANS: C
Treatment delays have a serious negative impact on neutropenic clients with infection.
Nursing units should have standardized protocols to obtain cultures and diagnostic tests, and
to start antibiotics as soon as a client is suspected of having an infection. In-services and spotchecking for good handwashing practice are good ideas as part of a comprehensive infection
control practice but are not as important as standard protocols that ensure rapid diagnosis and
treatment. Not all clients on chemotherapy will need protective precautions.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Planning)
21. A client has small cell lung cancer. Which laboratory result requires immediate intervention
by the nurse?
Serum potassium of 5.1 mEq/L
Serum sodium of 118 mEq/L
Hematocrit of 45%
Blood urea nitrogen (BUN) of 10 mg/dL
a.
b.
c.
d.
ANS: B
a.
b.
c.
d.
ANS: A
Mithramycin is used to treat hypercalcemia, which is seen most often in oncology clients who
have bone metastases. Hypercalcemia reduces excitable membrane activity, causing decreased
intestinal motility. Return of intestinal motility is an indication that serum calcium levels are
decreasing. Mithramycin has no direct effect on serum sodium levels or urine output. The
pulse rate most likely would be rapid and irregular with hypercalcemia and would normalize
as calcium levels return to normal.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Expected Actions/Outcomes) MSC:
Integrated Process: Nursing Process (Evaluation)
23. A nurse is reviewing the white blood cell count with differential for a client receiving
chemotherapy for cancer. Which finding alerts the nurse to the possibility of sepsis?
a. Total white blood cell count is 9000/mm3.
b. Lymphocytes outnumber basophils.
c. Bands outnumber segs.
d. Monocyte count is 1800/mm3.
ANS: C
Normally, mature segmented neutrophils (segs) are the major population of circulating
leukocytes, constituting 55% to 70% of the total white blood cell count. Less than 3% to 5%
of circulating white blood cells should be the less mature band neutrophils. A left shift occurs
when the bone marrow releases more immature neutrophils than mature neutrophils. This
condition indicates severe infection with possible sepsis and must be explored further.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory
Values)
MSC: Integrated Process: Nursing Process (Assessment)
24. A client is receiving high-dose chemotherapy for multiple myeloma. Which intervention is
most important for the nurse to implement to prevent complications during chemotherapy?
a. Ensure that the clients fluid intake is 3000 to 5000 mL/day.
b. Monitor telemetry every hour during therapy.
c. Apply pressure to all injection sites for 5 minutes.
d. Assist the client in all ambulatory activities.
ANS: A
This client is at high risk for tumor lysis syndrome. Tumor lysis syndrome is the precipitation
of intracellular products released when tumor cells are destroyed rapidly. These products,
particularly purines, can increase uric acid crystal precipitation in the kidney tubules and may
cause acute tubular necrosis. In addition, serum potassium levels can become high.
Maintaining adequate hydration and urine output is essential in preventing complications.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
25. The nurse teaches a client with superior vena cava syndrome that improvement is
a.
b.
c.
d.
ANS: A
With superior vena cava syndrome, blood flow through the vena cava is compromised as a
result of tumor growth. Blood backs up into the periphery, and the client experiences upper
body swelling, including the hands and feet. Compression of the superior vena cava has no
effect on breath sounds. This would occur when blood is impeded from leaving the lungs, and
with disorders that affect the left side of the heart. Back pain is not associated with this
disorder.
DIF: Cognitive Level: Comprehension/Understanding
REF: p. 432
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)
MSC: Integrated Process: Nursing Process (Evaluation)
26. A client has late-stage colon cancer with metastasis to the spine and bones. Which nursing
intervention does the nurse add to the care plan to address a priority problem?
Provide six small meals and snacks daily.
Offer the client prune juice twice a day.
Ensure that the client gets adequate rest.
Give the client pain medications around the clock.
a.
b.
c.
d.
ANS: D
Although all interventions might be appropriate, a client with late-stage cancer and bone
metastases is at risk for severe pain. Giving the client pain medication around the clock is the
best way to manage this type of pain.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies
Pharmacological Pain Management)
MSC: Integrated Process: Nursing Process (Analysis)
27. After receiving change-of-shift report, which client does the nurse assess first?
a. Client with leukemia who needs an antiemetic before chemotherapy
b. Client with breast cancer scheduled for external beam radiation
c. Client with xerostomia associated with laryngeal cancer
d. Client with neutropenia who has just been admitted with a possible infection
ANS: D
The most complex, potentially unstable client is the one with neutropenia with suspected
infection. Because the onset of infection is insidious in clients with neutropenia, this client is
at risk for sepsis. All other clients are stable.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care
Establishing Priorities)
MSC:
Integrated Process: Nursing Process (Analysis)
28. The nurse questions which activity for the client with thrombocytopenia?
a. Application of warm compresses to bruises
b. Cleaning teeth with a soft-bristled brush
Ice should be applied to areas of bruising or trauma to decrease bleeding. Warm compresses
would lead to vasodilation and potentially to more bleeding. It is important to implement
measures to decrease the risk of bleeding. A soft-bristled toothbrush decreases trauma to
gums, which could cause bleeding. Straining at the stool could increase risk for rectal
bleeding, so stool softeners may be prescribed. Acetaminophen does not affect platelet
function and bleeding as do aspirin products.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness
Management)
MSC: Integrated Process: Nursing Process (Implementation)
29. The nurse prioritizes which intervention in a client with xerostomia secondary to radiation
Head and neck radiation may damage the salivary glands, may cause dry mouth (xerostomia),
and may increase the clients lifelong risk for tooth decay. Instruct clients to avoid using
lotions or ointments in these areas unless the radiologist prescribes them. Xerostomia is not
associated with hair loss, which might require a hat. Monitoring vital signs is important for
any client receiving radiation therapy but is not a priority for the client with xerostomia.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Diagnostic Test/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Implementation)
30. Which statement indicates that the client needs more teaching about mucositis?
a. I will rinse my mouth with water after every meal.
b. I will use a soft-bristled toothbrush to prevent trauma.
c. I should use an alcohol-based mouth rinse to kill bacteria.
d. I cannot use floss because it may irritate my gums.
ANS: C
Mouthwashes that contain alcohol are drying and can exacerbate mucosal irritation, leading to
painful mouth sores. Rinsing the mouth with water or normal saline is indicated. Interventions
aimed at decreasing risk for trauma or irritation are matters of priority because of
inflammation associated with mucositis.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for
Complications from Diagnostic Test/Treatments/Procedures)
MSC: Integrated Process: Teaching/Learning
MULTIPLE RESPONSE
1. In planning a teaching session for a client undergoing photodynamic therapy for lung cancer,
a.
b.
c.
d.
e.
f.
ANS: B, E, F
Phototherapy causes general sensitivity to light for up to 12 weeks. During this time, the client
is at high risk for light sensitivity and eye pain. After the procedure, the client is taught to
decrease exposure to sunlight (to the point of being homebound).
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control
Accident/Injury Prevention) MSC:
Integrated Process: Teaching/Learning
2. The nurse is planning care for a client with hypercalcemia secondary to bone metastasis.
Which interventions are included in the plan? (Select all that apply.)
Increase oral fluids.
Place an oral airway at the bedside.
Monitor for Chvosteks sign.
Implement seizure precautions.
Assess for hyperactive reflexes.
Observe for muscle weakness.
a.
b.
c.
d.
e.
f.
ANS: A, F
a.
b.
c.
d.
e.
ANS: A, E
Pregnant nurses should never care for clients with sealed implants of radioactive material, so
if the nurse suspects she is pregnant, she should inform her supervisor and request a different
assignment. Nurses should wear lead aprons while providing care, ensuring that the apron
always faces the client. Each nurse should have his or her own dosimeter film badge. The
clients door should be kept closed whenever possible and dirty linens kept in the clients
room until the radiation source is removed.
DIF: Cognitive Level: Application/Applying or higher
REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control
Handling Hazardous and Infectious Materials)
MSC: Integrated Process: Nursing Process (Implementation)