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BSN 266 HESI
| Question | Answer |
|---|---|
| WK 2 Which finding in the patient’s medical record indicates that the patient with human immunodeficiency virus (HIV) infection has developed acquired immunodeficiency syndrome (AIDS)? | Correct Onset of wasting syndrome The onset of wasting syndrome indicates that the patient now has AIDS. Fever of 101° F and chills CD4 T-cell count of 1000 cells/µL Persistent generalized lymphadenopathy |
| WK 2 The nurse is caring for an HIV+ patient whose laboratory reports indicate a normal CD4 T-cell count and no physical symptoms. What should the nurse infer from this finding? | Correct The patient is in the incubation stage of HIV infection. The patient is in the early stage of HIV infection. The patient is in the crisis stage of HIV infection. The patient is in the latent stage of HIV infection. |
| WK 2 Which manifestation would the nurse expect to find when assessing the gastrointestinal tract of an HIV+ patient in the crisis stage? | Correct Diarrhea The nurse would expect the patient in the crisis stage of HIV infection to have diarrhea. Constipation Abdominal distention Hypoactive bowel sounds |
| WK 2 The nurse is caring for a patient who is HIV+ and has been admitted to the hospital for treatment of community-acquired pneumonia. Which intervention will prevent complications related to the patient’s HIV infection? | Correct Administer antiretroviral drugs on time Meds should be given on time to decrease viral load.improve immune function. Assign the patient to a private room Instruct the patient to cough up secretions Provide three full meals a day plus snacks |
| WK 2 The nurse is reviewing the laboratory test results for a patient who is HIV+. The results show no viral load. Which information should the nurse include in patient education? | Correct “Use barrier contraception during sexual contact.” “You can discontinue your antiretroviral drugs.” “You are no longer considered to be HIV positive.” “It is safe to breastfeed if you become pregnant.” |
| WK 2 A patient with a new diagnosis of human immunodeficiency virus (HIV) infection begins receiving antiretroviral therapy. Which finding indicates the patient is having complications related to the treatment regimen? | Correct Weight loss Nausea, vomiting, and diarrhea are major side effects of antiretroviral therapy. These side effects can lead to wasting syndrome. Shortness of breath Peripheral neuropathy Headaches. |
| WK 2 The school nurse is preparing to discuss HIV and AIDS with a group of teenagers. Which aspects of disease prevention would be best suited for this age group? | Y) Modes of transmission Y) Not assuming that HIV affects only certain groups Y) Avoiding exposure to sexually transmitted diseases N) The importance of prophylactic antiretroviral therapy N) Maintaining healthy relationships |
| WK 2 A patient with HIV comes to the health care provider’s office for a check-up, and the nurse notices the patient has lost 10 pounds since the last visit. Which factors should the nurse assess next? | Y)Oral cavity CD4 T-cell count Nutritional status Gastrointestinal (GI) function N)Medication compliance |
| WK 2 Which intervention would be most appropriate for the nurse to include in the plan of care for a patient having side effects from the antiretroviral drugs? | Correct Administer antiemetics The main side effects of antiretroviral therapy are nausea and vomiting. Provide warm goat’s milk Tell the patient to stay away from sick people Instruct the patient to obtain an annual flu shot |
| WK 2 Which patient finding should the nurse report to the provider? | Correct Monocytes 5.1 × 109/L This is abnormal. It is significantly increased and indicates inflammation. Neutrophils 4000/mm3 Lymphocytes 3800/µL Basophils 100/µL All normal findings ^ |
| WK 2 The nurse will anticipate administering a prescribed antibiotic to a patient with which infection? | Correct Staphylococcus aureus Staphylococcus aureus is a bacterial disease treated with antibiotic therapy. It causes meningitis and urinary tract infections. Herpes simplex, type 1 (viral) Candida albicans (viral) Toxoplasmosis gondii |
| WK 2 Which actions will the nurse avoid to prevent INDIRECT transmission of pathogens when caring for a patient with an infection? | N) Bathing patients personally Y) Handling medical equipment Y) Changing patient linens N) Obtaining vital signs Y) Removing food trays Y) Disposing of tissues |
| WK 2 Which clinical manifestations of sepsis differentiate it from a systemic infection? | Y) Oliguria Y) Hypotension Y) Confusion Y) Hypothermia N) Anorexia Y) Low platelets |
| WK 2 The nurse will take which action when caring for the patient admitted with influenza? | Correct Place in a single room on droplet precautions |
| WK 2 Which action will the nurse take when implementing standard precautions? | Correct Donning gloves prior to administering a patient intramuscular injection |
| WK 2 Which collaborative intervention does the nurse determine to implement for the patient with an infection, pain, and fever? | Acetaminophen Acetaminophen is an analgesic that reduces fever and provides pain relief. It is a collaborative intervention that addresses the patient’s pain and fever. |
| WK 2 Which intervention does the nurse determine addresses the collaborative goal of “eradication of the pathogenic agent”? | Correct Oseltamivir prescribed for influenza An antiviral, prescribed for the correct type of pathogen. Oseltamivir (Tamiflu) is used to decrease the length and severity of influenza. |
| WK 2 Which action does the nurse determine to take based on findings of a localized, purulent, infected leg lesion? | Correct Prepare the patient for incision and drainage. When a patient has a purulent, infected localized lesion, the nurse will prepare the patient for incision and drainage of the wound to prevent spread of the infection and/or systemic infection. |
| WK 2 What conclusion can be drawn by the nurse when a patient shows no improvement in assessment baseline after two weeks of treatment for an infection | Correct Collaborative interventions were ineffective. The team needs to discuss this finding/revise plan of care. Incorrect anti-infective administered. The patient didn’t follow instructions. Increased patient education required. |
| WK 2 Which statement by a patient can the nurse determine indicates the need for further teaching about a prescribed anti-infective medication? | “I can miss a dose as long as I take it the next time the dose is due.” |
| WK 2 The nurse determines to take which action based on the patient’s assessment finding of cloudy, foul-smelling urine? | Encourage increased fluid intake. This is an action that can be independently implemented by the nurse to address the patient findings of cloudy, foul-smelling urine. Increased fluids decrease urinary stasis and flush bacteria out of the urinary tract. |
| WK 3 Which diagnostic test differentiates the level of autoimmune disease activity from the presence of disease? | Correct Serum complement Marker for disease activity. Decreased levels indicate disease activity. As disease activity subsides, the serum complement level increases. This test differentiates disease activity from presence of disease. C-RP ANA RF |
| WK 3 The nurse determines the patient’s prescribed Basilximab (monoclonal antibody) is acting to prevent T cell activation based on which finding? | Correct Decreased lymphocyte count Decreased lymphocytes is a laboratory finding that indicates monoclonal antibodies are binding interleukin Il-2 to prevent T cell activation, which also reduces the number of leukocytes as a side effect. |
| WK 3 Which action will the nurse take after noting the newly elevated blood urea nitrogen (BUN) and serum creatinine on the laboratory report of a patient who has an autoimmune disorder, fever, and chills? | Correct Consult with HCP Consulted about new findings. Indicate possible renal damage that must be addressed (fever and chills) indicating glomerulonephritis. Collect a morning urine sample. Encourage increased fluid intake. Notify nursing unit man |
| WK 3 Which step does the nurse determine is first when caring for a patient with an autoimmune disorder? | Determining patient needs The first step in caring for a patient with an autoimmune condition after introducing self, is to carefully assess the patient to determine patient physical and mental status so his or her needs can be prioritized |
| WK 3 What does the nurse determine is the most important reason for teaching patients on immune suppressive therapy to weigh weekly? | Monitor for weight change Weight gain can occur from glucocorticoid therapy, and weight loss can occur from other immune suppressive drugs. Patients should be taught to monitor for changes in weight, both weight loss and/or weight gain. |
| WK 3 The nurse determines that which action takes priority for a newly admitted patient with an autoimmune disorder who is acutely ill with fever and pain? | Facilitating periods of uninterrupted rest Facilitating periods of uninterrupted rest and performing physical care allows the acutely ill patient with a fever and pain sufficient time to rest until the acute illness is controlled. |
| WK 3 How will the nurse interpret the results of the enzyme-linked immunosorbent assay (ELISA) ordered for a patient with a type I hypersensitivity disorder? | Pollen is the offending allergen. The ELISA is a serological assay that tests for and detects specific antibodies to antigens causing allergies and other hypersensitivity reactions, for example, pollen. |
| WK 3 Which goal reflects collaborative treatment for patients with a type III antigen-antibody complex hypersensitivity disorder, such as systemic lupus erythematosus? | Immune suppression to halt disease progression . In many instances, disease progression can be halted by suppressing the immune response and inhibiting the formation of immune complexes that become deposited in tissues and organs. |
| WK 3 Which finding associated with use of corticosteroids as collaborative treatment for type I hypersensitivity (allergy) will the nurse report to the patient’s health care provider? | Thrombocytopenia Thrombocytopenia, which is low platelet count, needs to be reported to the health care provider. Corticosteroids suppress platelet production and can lead to bleeding. |
| WK 3 The nurse determines which action will take priority upon recognizing a patient experiencing a febrile, non-hemolytic transfusion reaction? | Discontinue the infusion. This is definitely the priority nursing action when a patient has a febrile, non-hemolytic transfusion reaction. The reaction will not stop until the non-compatible blood stops infusing into the patient. |
| WK 3 The nurse is caring for a patient who underwent kidney transplantation 8 hours ago. Which finding would indicate that the patient is developing hyperacute rejection? | Correct Decreased to no urine output Hyperacute rejection occurs within first 24 hours after transplantation. The first sign is that the transplanted organ stops working. Pale and yellow urine Increased white blood cell count Maculopapular palmar |
| WK 3 Which patient would the nurse expect to be at highest risk for developing graft-versus-host disease (GVHD)? | Correct Patient who had a recent bone marrow transplant A patient who has undergone bone marrow or stem cell transplantation is at the highest risk of developing GVHD. |
| WK 3 A patient who underwent organ transplantation 2 months ago is admitted to the hospital with acute rejection. Which order would the nurse anticipate from the health care provider? | Increased doses of monoclonal antibodies The treatment for acute rejection is administration of increased doses of monoclonal antibodies. |
| WK 3 A female transplant recipient asks the nurse to explain why she is receiving a cytotoxic drug even though she does not have cancer. What is the nurse’s best response? | Correct “The use of chemotherapy medications can play an important role in preventing organ rejection.” Cyclophosphamide is a cytotoxic drug used to treat cancer, but it is also used to suppress the immune system. “Immunosuppressant medications can p |
| WK 3 Which assessment component will the nurse check when administering a dose of lymphocyte immune globulin to a patient with acute rejection? | Heart rate The nurse will assess the patient’s heart rate because tachycardia is a side effect of lymphocyte immune globulin. |
| WK 3 The nurse is reviewing the laboratory results for a patient who underwent kidney transplantation. Which finding warrants immediate health care provider notification? | Intake of 2000 mL and output of 800 mL in 24 Hrs A sign of rejection is that the transplanted organ stops working. A rapid decline in urinary output in a patient who received a kidney transplant indicates organ failure. |
| WK 3 The nurse is caring for a patient who received an organ transplant 3 days ago. Which nursing assessments and interventions will decrease the risk for infection? | Y) Administer prophylactic antibiotics Prophylactic antibiotic administration helps prevent infection. Y)Auscultate the patient’s lung sounds etermine fluid overload and pneumonia. Measure/ record I&O Give immunosuppressant meds Refrain from allo |
| WK 3 The nurse is caring for a patient who had a liver transplant 3 months ago. Which nursing intervention can prevent acute rejection in this patient? | Correct Administering the immunosuppressant medications as prescribed Immunosuppressant medications must be administered on time and as scheduled to prevent rejection. |
| WK 5 A patient with sepsis has been hospitalized for one week and is losing weight unintentionally. The nurse understands this is related to which cause? | Correct Marked inflammatory response and increased metabolic demands Pt that is hospitalized is at risk for developing undernourishment d/t increased metabolic needs Vitamin imbalance N/V Chronic starvation without inflammation |
| WK 5 A patient with prolonged malnutrition has a new diagnosis of nonalcoholic fatty liver disease. Which causes nonalcoholic fatty liver disease? | Rapidly depleted body proteins cause protein deprivation & fatty infiltrates in liver. Protein is used for energy & rapidly depleted in malnutrition; as a result, the liver loses the mass during deprivation. The liver is infiltrated with fat secondary to |
| WK 5 A patient with malnutrition presents with fatigue and low energy. Which laboratory value supports these clinical manifestations? | Hemoglobin 9.4 g/dL This hemoglobin level may indicate the patient is anemic. Anemia can cause fatigue and low energy, and patients with malnourishment are often anemic. (K+) 3.8 (AST) 28 RBC) 5.1 million All normal |
| WK 5 The nurse is caring for a patient with a history of undernutrition and stroke. The nurse observes the patient coughing while taking sips of water. Which is the nurse’s priority action? | Ensure pt remains NPO & contact HCP Pt demonstrating signs of aspiration. Pt should remain NPO until seen by HCP Tell the patient to slow drinking. Add a thickening substance to the patient’s liquids. Remove liquids from the patient’s tray and switc |
| WK 5 The nurse is assisting a patient with undernutrition to develop short-term nutrition goals. Which is the most appropriate goal? | Add 1 nutrition supplement w/ each meal. Adding a nutritional supplement will increase calorie intake to increase weight gain. Increase muscle mass to prevent wasting. Increase calorie intake to return to baseline weight. Focus on increased food int |
| WK 5 A patient with malnutrition is preparing to be discharged home. The patient states, “I’ll be sure to record my weight every week on Mondays.” Which is the nurse’s best response? | “Weights should be recorded every day at the same time.” Daily weights can give an ongoing record of body weight gain or loss. |
| WK 5 The nurse notes that a patient’s waist measurement is 100 cm and hip measurement is 80 cm. Calculate the patient’s waist-to-hip ratio (WHR) and determine the relevant risk for health complications. | Correct 1.25, w/ an increased risk of developing health complications 1.25 indicates truncal fat greater risk for -- 0.8, with a decreased risk of developing health complications 0.8, with an increased risk of -- 1.25, with an decreased risk of -- |
| WK 5 A patient who has had a bariatric weight-loss procedure reports diarrhea, nausea, and faintness after meals. Which is the appropriate action taken by the nurse to address these symptoms? | Ask the patient about meal habits Dumping syndrome occurs when gastric contents empty too rapidly into the small intestine. Eating too fast or eating certain foods can trigger dumping syndrome. Contact the surgical provider immediately Instruct pt to |
| WK 5 The nurse is teaching a patient who is having gastric bypass surgery tomorrow. Which information should the nurse address first? | Correct Instruct the patient how to use an incentive spirometer Proper coughing technique, deep breathing, and use of an incentive spirometer will help prevent pulmonary complications after surgery. |
| WK 5 The patient is receiving postoperative care for a bariatric weight-loss procedure the day before. Which patient symptom should cause the nurse to contact the health care provider? | Correct Chest pressure Risk of developing PE after surgery and atherosclerosis from obesity. Chest pressure may be a symptom of decreased oxygenation or an acute myocardial infarction Knee stiffness Abdominal pain Throbbing headache |
| WK 5 The nurse is caring for four post-bariatric surgery patients. Which patient should the nurse assess first? | Correct A patient with a heart rate of 112 bpm and pain radiating to the left shoulder These symptoms are consistent with an anastomosis leak and should be assessed and treated immediately. |
| WK 7 PT admitted following MVA. Pt has oval shaped bruise behind the right ear in the mastoid region, a very runny nose, and is unable to move the muscles in the right side of his face. Which skull fracture do these clinical manifestations correspond to? | Correct Basilar skull fracture Battle’s sign, rhinorrhea, facial paralysis, CSF or brain otorrhea, bulging of tympanic membrane, tinnitus conjugate deviation of gaze, vertigo. Orbital fracture Periorbital ecchymosis & optic nerve injury. Frontal fr |
| WK 7 Why is a CT scan the best diagnostic test for evaluating acute head trauma? | Correct Allows for rapid diagnosis and intervention CT scan is best for evaluating acute head trauma because the procedure is quick and can be performed in an acute care setting |
| WK 7 Upon arrival to ED, pt regained consciousness and spoke with nurses. During the initial assessment the patient complained of a headache immediately before losing consciousness again. These are all classic signs of which head trauma complication? | Correct Epidural hematoma Classic signs include an initial period of unconsciousness at the scene, with a brief lucid interval followed by a decrease in level of consciousness (LOC). Also, headache, nausea and vomiting, or focal findings. |
| WK 7 The nurse is caring for a patient who presents with an actively bleeding head wound. The patient is obtunded, with one fixed pupil. The pulse is thready and respiratory effort is increased. Which provider orders would the nurse anticipate? | Y)Prepare for intubation Y) Administer intravenous (IV) 0.9% saline Help fluid shift from the cerebral space back into cells, decreasing ICP. Insert NG tube Risk for basilar skull fractures & brain trauma. Administer IV dextrose 5% May increa |
| WK 7 A patient is recovering well following a craniectomy. Once the patient has fully recovered, the collaborative care team should expect the patient to undergo which procedure? | Cranioplasty A cranioplasty will be necessary in order to repair the skull and replace the removed bone flap. Ventricular shunt- redirect CSF Burr hole- relief of increased ICP CT scan-diagnostic |
| WK 7 A patient with rapidly increasing ICP had an emergency craniotomy to relieve the pressure. Now that the patient is stable, which action should the care team perform? | Transport to CT scan Once pt stable, team should complete a CT scan to diagnose the reason for the increased ICP. Cranioplasty Will not be completed until condition has been diagnosed. Initiate IV access IV insertion completed prior to placing burr |
| WK 7 A nurse is caring for a pt who recently suffered a traumatic brain injury. Pt complains of severe headache, N/V, and is irritable. The nurse notes increased blood pressure and a fixed right pupil. Which action would the nurse take first? | Correct Elevate the head of the bed The patient’s symptoms indicate worsening ICP. Elevating the head of the bed helps to facilitate drainage of CSF in a patient with increased ICP. |
| WK 7 During assessment of a patient with head trauma, the nurse notes slurred speech and a right sided facial droop. Which action should the nurse take? | Correct Assess pt’s airway patency (ensure patent) Visualize pt's pupillary response help diagnose the location & severity of head trauma. Evaluate the patient’s LOC Assessed for changes that may indicate cerebral hemorrhag Determine the patient’ |
| WK 7 A patient sustained a head injury two days ago. The patient asks the nurse if a hot bath could be provided. How should the nurse respond? | “You should take a lukewarm bath.” Hot baths should be avoided for patients recovering from head injuries because the hot water causes changes in blood pressure which may affect the blood flow to the brain, causing lightheadedness or dizziness. |
| WK 7 Identify the physiologic events which can lead to increased intracranial pressure and accumulation of CO2. | YES Brain abscess, Occipital tumor, Subdural hematoma, Bacterial meningitis, Blunt force trauma to the head NO Hyperventilation-causes hypocapnia. |
| WK 7 The nurse is caring for a patient with a brain tumor and increased intracranial pressure. The initial vital signs were BP 128/88, HR 106, RR 22, Oxygen saturation 98%. Which follow-up vital signs would indicate worsening ICP? | BP 172/98, HR 64, RR 24, oxygen saturation 99% Characteristic of Cushing’s triad, elevated BP and decreased HR, indicating worsening ICP. |
| WK 7 A nurse is caring for a patient with increased ICP due to a subdural hematoma. Upon assessment, the nurse notes one pupil is 3mm and the other is 7mm. Which action should the nurse take next? | Correct Assess the cranial nerves for abnormalities. Nurse would complete a full neurological exam- assessment of the cranial nerves Assess the patient’s lung sounds. Notify the health care provider. Document findings in pt’s medical record. |
| WK 7 Nurse is administering IV dexamethasone to pt w/ a frontal lobe tumor who reports left upper quadrant pain, N/V. Upon assessment, the nurse notes coffee ground emesis and tenderness on palpation. Which provider order would the nurse anticipate? | Insert NG tube Decompress the stomach in a patient with active GI bleeding to prevent aspiration. IV protonix Prevent GI bleeding. PO antibiotics Kill infections, not to treat GI bleeding. Obtain hemoccult Determine bleeding-> GI bleed has |
| WK 7 Nurse is caring for a patient who sustained major head trauma after a motor vehicle collision. The pt’s lab values reveal a BUN of 47, creatinine of 3.1, hemoglobin of 6.8 & potassium level of 6.1. Which provider order would the nurse question? | Correct Give Mannitol IV Mannitol is an osmotic diuretic given to decrease ICP; contraindicated in patients with renal failure. Pt's elevated BUN and creatinine indicate the presence of acute renal failure. The nurse would question this order. Transf |
| WK 7 During the assessment of a pt with a head injury from a fall, the pt reports a sudden severe headache, N/V. The nurse notes right sided weakness, slurred speech and a right facial droop. For which procedure would the nurse expect to prepare the pt? | Correct Burr holes Used to remove localized fluid & blood beneath dura, such as may occur from a hemorrhage. Craniectomy- appropriate for brain swelling not hemorrhaging Cranioplasty- repair of cranial defect resulting from trauma, Sterotactic pr |
| WK 7 A nurse is monitoring a patient with increased intracranial pressure using a ventriculostomy. The patient’s ICP monitor indicates that the P2 wave is higher than the other waves. Which provider order would the nurse anticipate? | Correct Prepare for surgery. When P2 wave depicting relative brain volume is higher than the other waves, it indicates a high ICP with compromised intracranial compliance. The nurse would expect to prepare the patient for surgery to assess/reposition th |
| WK 7 A nurse is caring for a patient after resection of a temporal lobe tumor. The patient begins to complain of headache and nausea. Which action should the nurse take? | Correct Elevate head of patient’s bed Elevating the head of the bed allows for appropriate drainage of CSF and is helpful for the patient with increased ICP. Give oral mannitol Administer an IV fluid bolus Administer narcotic pain medicine |
| WK 7 A nurse is assisting the HCP during a neuro assessment on an unconscious adult pt w/ increased ICP. When holding the eyelids open and moving the pt’s head to right side, the eyes move to right side. How would you report this finding? | Correct Normal oculocephalic reflex Oculocephalic reflex, or dolls eye reflex, is tested by turning the pt’s head briskly to the left or right while holding the eyelids open. A normal response is movement of the eyes across the midline in the direction |
| WK 7 During the assessment of a patient with a brain abscess, the nurse notes elevated blood pressure and altered level of consciousness. Which additional symptoms should the nurse assess for? | Correct Fever- results from infective process Nausea- sign of increased ICP Headache- symptom of increased ICP Drowsiness- symptom of increased ICP Nuchal rigidity- r/t irritation of the meninges, not brain abscess. |
| WK 7 A patient is showing symptoms of encephalitis. Which question should the nurse ask the patient? | Correct “Have you recently spent time in wooded or swampy areas?” Encephalitis is often acquired from tick or mosquito bites that may be obtained while hiking. |
| WK 7 The nurse is caring for a patient with encephalitis who was positive for cytomegalovirus. Which immunocompromising condition is this related to? | Correct HIV Common complication in HIV/AIDS patients. Diabetes Hypertension Sarcoidosis |
| WK 7 The nurse is caring for a patient with encephalitis. The patient reports headache, nausea and irritability. The nurse notes temperature 103.2, BP 138/88, HR 97, Respirations 22, SpO2 96%. Which action would the nurse take first? | Correct Administer Phenytoin IV Phenytoin should be administered as a prophylactic for seizure prevention. Administer Acyclovir IV Give Ceftriaxone IV BID Give a dose of Morphine IV |
| WK 7 A patient with bacterial meningitis has a temperature of 101.2 °F. Which health care provider orders would the nurse anticipate? | Correct Ampicillin IV Used to treat infection causing meningitis. Maintenance IV fluids Prescribed to pts w/ meningitis to prevent dehydration Acetaminophen PO PRN Antipyretics ordered to treat the pt’s fever. Placement of ventricular shunt Ma |
| WK 7 The nurse is caring for a patient with a brain abscess. The patient reports a severe headache, nausea and vomiting. Which nursing intervention should be implemented? | Correct Administer IV antiemetic medication Antiemetics decrease the patient’s nausea and vomiting, thereby decreasing the patient’s ICP. Decreasing the ICP can help relieve the patient’s headache, as well. |
| WK 7 Which actions can the nurse take to decrease environmental stimuli for a patient with bacterial meningitis? | Correct Turn off television Turn off overhead lights Limit patient’s visitors Close the room’s window blinds !!All decrease visual stimuli!! Hang isolation sign on door |
| WK 7 A nurse is caring for a pt w/ encephalitis. When nurse enters pt’s room, pt claims that they “fell asleep in bed, but woke up on the floor” & don’t remember how they got there. Pt showing increased confusion. Which nursing action should be implemente | Correct Assess the patient for Injuries The patient should be thoroughly assessed for signs of injury, since they have had an unwitnessed fall. |
| WK 7 A patient reports of severe headache, projectile vomiting, blurred and doubled vision, sensitivity to light and a fever of 102.5. Which nursing care actions are appropriate for this patient? | Correct Turn off lights to relieve vision symptoms Ensure fluids are given- Increased ICP. Dehydration should be prevented Perform frequent neurological checks to monitor pt cognition Keep pt warm to sweat fever out Lower head of the bed to allow f |
| WK 7 Which complication may occur if the brain tumor obstructs the ventricles? | Correct Hydrocephalus If ventricles are obstructed, the patient may develop hydrocephalus. This can be treated by use of a ventricular shunt. Metastases Spread of tumor cells does not result from obstructed ventricles. Herniation Encephalitis- inf |
| WK 7 A patient with a suspected brain tumor asks the nurse why a CT scan has not been ordered. Which statement, made by the nurse, would be the best response? | Correct “An MRI may a better option for diagnosing your tumor.” MRI is more appropriate for detecting small tumors. The nurse should clearly explain all procedures and treatments and their rationale. |
| WK 7 A patient with a large tumor in the occipital region asks the nurse about the benefits of surgery. Which information would the nurse include in the response? | Correct Removal can relieve symptoms Surgery can reduce the tumor mass Removal of the tumor will decrease ICP Complete surgical removal may not be possible NO Recovery time after brain surgery is relatively short |
| WK 7 When caring for a patient admitted with a temporal lobe tumor, the nurse prepares the patient for which diagnostic procedure? | Correct Biopsy Histology is performed from tissue obtained during surgery or biopsy to definitively diagnose malignancy CT scan-helps to locate tumor Lumbar puncture- tests CSF for abnormalities MRI- used to detect small tumors, not tumors already |
| WK 7 The nurse is caring for a patient with a brain tumor in the temporal region who has developed aphagia. Which action is most important for the nurse to take? | Correct Keep a white board and markers in the pt’s room at all times. Tumors in temporal region affect the pt’s speech & may cause aphagia. Nurse should develop a means of communication, such as use of a white board. Place padding on all 4 side rail |
| WK 7 A patient with a temporal lobe tumor is having trouble communicating with the nurse. What is the appropriate nursing action? | Correct Provide the pt with a pen and paper Providing a pen and paper allows the pt w/ aphagia r/t a temporal lobe tumor to communicate directly with the nurse. Communication difficulty may also indicate progression of the tumor into the parietal lobe. |
| WK 8 A patient undergoing radiation therapy for breast cancer reports feeling fatigued during normal daily activities. The nurse indicates that the patient may be at risk for anemia due to which physiological effect of cancer treatment? | Correct Decreased number of RBC precursors Radiation can decrease the production of RBC precursors, leading to a decrease in the production of RBC, resulting in anemia. Excessive blood loss Destruction of RBCs Decreased synthesis of hemoglobin |
| WK 8 HCP tells pt that she has anemia because her RBC are being destroyed faster than they can be made. The patient asks the nurse for more information on the cause of her condition. The nurse provides information to the patient on which type of anemia? | Correct Hemolytic anemia Hemolytic anemias are d/t an increase in destruction of RBC resulting in a lower RBC count B12 deficiency anemia- decreased production of RBC Thalassemia- decreased production of RBC Acute anemia- d/t acute blood loss |
| WK 8 A patient is diagnosed with iron deficiency anemia. Which laboratory values would the nurse expect to see in the patient’s electronic health record? | Correct Decreased MCV level Increased TIBC Level Decreased serum iron level Decreased folate level-levels are normal Increased ferritin level- ferritin levels are decrease |
| WK 8 A patient is diagnosed with anemia related to iron deficiency. The health care provider orders parenteral iron supplements. When demonstrating the medication administration to the patient, which statement should be included? | Correct “Be sure to pull skin taut b4 injecting the needle &medication.” Pulling the skin taut would be the correct administration technique for an iron injection. This is called the Z-track method. “Make sure you inject the medication and then rub t |
| WK 8 Pt is diagnosed w/ iron deficiency anemia and is prescribed oral iron replacement therapy. Several wks into the therapy the pt’s iron levels are not increasing. Which questions should the nurse ask the pt to ensure the oral supplements are being take | Correct “Are you taking your iron before meals?” “Are you pairing your iron w/ a vitamin C supplement?” “Are you taking your prescribed laxative?" “Are you ingesting the iron through a straw?” "Are you taking 2 300-mg tablets of ferrous sulfate 3 t |
| WK 8 A patient with a B12 deficiency asks the nurse how long B12 injections must be taken. Which is the best response by the nurse? | Correct “You will need to take injections for the rest of your life.” B12 injections are given daily for two weeks, and then weekly until the hematocrit level returns to normal, and then typically monthly for life. |
| W8 Which statement by a patient with iron deficiency anemia would prompt the nurse to provide further patient education? | Correct “I will cluster my activities together in the morning after a good night’s sleep.” In order to prevent fatigue and activity intolerance, the pt should pace activities throughout the day. The nurse would need to provide further teaching if the pt |
| WK 8 A patient with multiple myeloma asks the nurse why this disease developed. Which statement is the best response by the nurse regarding the cause for multiple myeloma? | “There is no primary cause for multiple myeloma, but some risk factors, such as radiation and obesity, are associated w/ the disease.” Although the cause of multiple myeloma is still unknown, risk factors include exposure to radiation, organic chemicals, |
| WK 8 A patient questions a new diagnosis of chronic myelogenous leukemia (CML) because he has no symptoms. Which response by the nurse is appropriate? | Correct “It’s very common for patients with CML to have no symptoms initially.” In CML, patients are typically free of symptoms in the early stages of the disease. |
| WK 8 The nurse is reviewing the laboratory results of a patient who received chemotherapy for acute myelogenous leukemia (AML). Which laboratory finding would compel the nurse take the grapes off the patient’s lunch tray? | Correct White blood cell count (WBC) of 1.6 cells/μL A low WBC count places the patient at risk for infection. When a patient’s WBC count is this low, neutropenia precautions are implanted, and fresh fruits or vegetables are not allowed. |
| WK 8 Which collaborative care treatment modality should the nurse include in the plan of care to prevent complications for the patient with multiple myeloma? | Prescribe weight-bearing exercises with physical therapy The patient with multiple myeloma is at risk for osteoporosis. Weight-bearing exercises with physical therapy will help the bones reabsorb calcium. |
| WK 8 A patient has undergone radiation therapy for leukemia. Which assessments should the nurse complete to determine whether a patient has experienced adverse effects of this therapy? | Examine skin color and appearance After radiation therapy, the skin of the radiated area is assessed for irritation, hair loss, and inflammation or swelling. Describing the skin color and appearance is part of this skin assessment. |
| WK 8 A woman with Hodgkin’s lymphoma is receiving patient education from the nurse. Which recommendation for follow-up care is important to prevent future malignancies? | “Make sure you have routine mammograms.” One of the most common secondary malignancies is breast cancer, having routine mammograms is important for early detection. “Continue to have yearly positron emission tomography (PET) scans.” “A bone marrow ex |
| WK 8 A nurse is caring for a patient with multiple myeloma who is experiencing significant skeletal pain. The patient expresses an interest in nonpharmacological pain relief. About which therapy would the nurse provide the patient more information? | Correct Use of a back brace Orthopedic support may help to reduce skeletal pain and does not require use of drugs. |
| WK 8 The nurse is preparing to provide patient and family education to a patient with multiple myeloma who will be discharged the following day. Which is the most appropriate teaching to ensure patient safety after discharge? | Correct “Ensure adequate support when walking.” Because of the risk for fractures, pt must have adequate physical support, w/ assistance from caregiver or cane, when walking. Make sure you take the prescribed analgesics.” “Drink plenty of water ever |
| WK 8 Which term reflects the chromosomal number and appearance of cells? | Ploidy Ploidy describes cancer cells by their chromosomal number and appearance. |
| WK 8 Which nursing documentation reflects the cellular aspect of cancer? | Correct Grade 2 Grading is based on the cellular aspect of cancer. Grade 2 indicates that the cells are moderately differentiated. |
| WK 8 Which cancer stage reflects distant metastasis? | Stage 4 Stage IV: Metastasis |
| WK 8 Which nursing student statement regarding cancer risk requires further education? | “Infections are not related to cancer development.” Infections can be related to cancer development. For example, certain sexual viruses can increase the risk for cervical cancer. This student statement requires further education. |
| WK 8 Which nursing action demonstrates a primary prevention strategy for cancer? | Correct Administering the HPV vaccine Administering the HPV vaccine is primary prevention because it prevents cancer from ever developing. |
| WK 8 Which dietary suggestion will the nurse include when teaching about cancer risk reduction? | Correct Incorporate whole grain bread into your diet. Avoid high fat, low fiber diets because they are associated w/ colon, breast, and ovarian cancer. Encourage eating of fruits, vegetables, and dietary whole grains. Whole grain bread is a good sourc |
| W8 What is the primary objective of palliation therapy? | To enhance quality of life Palliation takes place when the goal of care is to relieve symptoms associated with the cancer while maintaining the quality of life as the primary objective. |
| W8 The amount of radiation absorbed by the tissue is referred to as what term? | Correct Radiation dose The amount of radiation absorbed by the tissue is the radiation dose. Brachytherapy Brachytherapy is radiation delivered by an internal device or seed |
| W8 A patient asks the nurse how chemotherapy works to treat cancer. Which nursing response is appropriate? | Correct “Chemotherapy damages the cellular DNA, which causes the cancer cells to die.” Chemotherapy damages cellular DNA, which causes the cancer cells to die. |
| W8 Which clinical manifestations of disseminated intravascular coagulation (DIC) are due to the depletion of clotting factors? | Purple spots(Petechiae), HR 120bpm, BP 88/54 ///BP110/66 or Gangrene(only thrombotic) |
| W8 A patient is diagnosed with disseminated intravascular coagulation (DIC). Which laboratory results would the nurse expect to see for this patient? | Elevated FSP lvls & D-dimer, Reduced fibrinogen lvl /// lowered D-dimer & elevated fibrinogen |
| WK 8 A family member asks the nurse why a patient with disseminated intravascular coagulation (DIC) is receiving heparin. Which response by the nurse is appropriate? | Pt has a thrombotic form of DIC, therefore heparin is needed to treat prevent further clotting.” Heparin helps prevent further clotting if the pt is in a thrombotic state. Monitor carefully, since DIC can alternate between bleeding & clotting states. |
| W8 The nurse is caring for a patient being treated for disseminated intravascular coagulation (DIC) exhibiting the clinical manifestations of thrombosis. Which treatment would the nurse most likely prepare to administer to this patient? | Heparin & Antithrombin III Need to prevent further thrombus formation outweighs the risk of bleeding. |
| WK 8 A patient with disseminated intravascular coagulation (DIC) is actively hemorrhaging. On assessment, the nurse determines that the patient’s condition is unstable. Which blood products should the nurse prepare to administer to this patient? | Platelets-Correct thrombocytopenia & prevent bleeding Cryoprecipitate- Replace factor VIII & fibrinogen lost through bleeding Fresh frozen plasma (FFP)- Replace clotting factors -> Priority for the prevention of excessive life-threatening hemorrhaging. |
| W8 The acute care nurse is assessing a patient being treated for sepsis. Which assessment finding would prompt the nurse to alert the provider immediately? | Absent bowel sounds Absent bowel sounds may indicate paralytic ileus as a result of thrombotic disseminated intravascular coagulation (DIC). This finding should be reported to the provider immediately |
| W8 A patient with disseminated intravascular coagulation (DIC) who is being treated with heparin begins to develop oozing from an intravenous (IV) site. Which nursing interventions are most appropriate? | Check BP- BP can fall & lead to shock Admin. blood products- Priority for a pt w/ a bleeding episode Hold pressure on IV site- helps slow bleeding & promotes clotting Monitor for further bleeding episodes- may develop an acute bleed, monitored closely. |
| WK 8 A nurse is monitoring a patient who has been diagnosed with disseminated intravascular coagulation (DIC). Which assessment finding indicates a complication of DIC and merits further assessment by the nurse? | Altered cognitive ability- change in neuro status = intracranial bleeding // HT- hypotension is comp of blood loss r/t DIC Loose bowels- constipation =paralytic ileus in pt w/ DIC Increased urine output= decreased indicates renal damage (comp of DIC) |
| W 8 Which intervention will the nurse select to prevent mucositis? | Oral cryotherapy- Holding ice chips in mouth while infusing mucositis-causing agents prevent mucositis // administering antiemetics, limiting visitors, avoiding sunlight |
| W8 Which nursing assessment data requires immediate intervention for the patient with cancer? | Redness around IV site following chemo- Prevention of extravasation (chemical damages tissue on contact) // nausea, hair loss, decreased sensation in lower extremities r/t chemo-induced peripheral neuropathy |
| W8 Which nursing intervention will the nurse select for a patient with cancer and dysgeusia (ALTERED TASTE) ? | Discuss alternative seasonings for food /// frequent oral care, apply lotion to the skin, test the stool for occult blood. |
| W8 Which information will the nurse include in discharge teaching for a patient with cancer? | Avoid large crowds- decrease risk of infection, Protein shakes-increase protein intake, Inspect your mouth daily- assess oral cavity daily for bleeding/mucositis Don't reuse cups/dishes w/o washing them- wash all dishes in between uses to decrease inf |
| W8 Which teaching will the nurse include regarding skin care following radiation therapy? | Use gentle soap to wash irradiated area-Wash area w/ mild soap daily, using HAND not washcloth (irritates tissue), Dont expose the area to sunlight- protectarea from extremes in temp, Dont apply heating pads to area, Soft clothing suggested |
| W8 What will the nurse include when teaching about the development of cancer cells? | Cancer cells have loose adherence which helps cancer spread- they lack the protein needed to stick together, allowing cancer cells to spread// exhibit differentiated function, respect boundaries of cells, demonstrate euploidy (complete set of chromosomes) |
| W8 What stages are part of the cancer development process? | Initiation- first stage Promotion-second stage Progression- third and final stage in cancer development. |
| W8 During which stage of cancer development are oncogenes activated? | Initiation- mutation in cell’s genetic structure-> changes can activate oncogenes & damage suppressor genes, leading to cell division// promotion-reversible proliferation of altered cells, progression- increased growth & metastasis,exposure-not a stage |
| W8 Which cancer can significantly impair immunity? | Bone marrow cancer- alter immunity -> where blood cells are formed //// GI tumors-increase need for nutrients, spinal tumors- alter peripheral nerve function, brain cancer, brain cancer-cause motor, sensory & cognitive alterations. |
| W8 What assessment data will the nurse anticipate with advanced gastrointestinal cancer? | Cachexia- sign of extreme malnutrition, occurs w/ advanced GI cancer/////// nagging cough- associated w/ respiratory cancer, painful urination- associated w/ urinary cancer, vaginal bleeding- associated with reproductive system cancer |
| W8 A nurse is caring for a patient with sickle cell disease. The nurse realizes the patient’s hypoxemia and dehydration are primarily caused by which characteristic of sickle cell disease? | Vessel occlusion Vessel occlusion- Sickled erythrocytes are prevented from passing through capillaries// inheritance aspect- not a cause, diuresis-a helpful way to treat a patient, not a cause, acute pain- symptoms not a cause |
| W8 The nurse is receiving a report on a patient with sickle cell disease being admitted from the emergency department. Which question by the nurse exhibits an awareness of the primary symptom of the disease? | When did pt last receive pain medications?- pain is the most common symptom of SCD /// “Is pt receiving oxygen?”, “What was the last hemoglobin and hematocrit?”, “Has pt voided yet?”- although important, doesnt demonstrate awareness of primary symptom |
| W8 The nurse is caring for an older adult patient who has been admitted with abdominal distension and has a history of sickle cell anemia. Which findings would the nurse expect to see on an abdominal x-ray report? | Small to nonexistent spleen- spleen in SC patient becomes dysfunctional & small bc of repeated scarring /// enlarged spleen, enlarged kidney, liver atrophy (pt may have enlarged liver or cirrhosis, not liver atrophy) |
| W8 A pt with sickle cell disease is admitted to hospital for the second time in 4 months, has an oral temp of 100.9° F & is experiencing severe pain. Hydroxyurea is being added to pt’s medication regimen. Which pt outcome shows medication is effective? | Pt experiences a reduced # of sickle cell crises, Hydroxyurea is only drug clinically beneficial for antisickling -> reduction in hemolysis, increase Hgb & decrease painful crises. # of admissions will reduced //temp normal, HR increases, O2 between 85% |
| W8 Which nursing intervention has the highest priority for the nurse caring for a patient experiencing a sickle cell crisis? | Administer IV fluids- Hydration important to decrease blood viscosity & prevent renal failure///// monitor appetite, provide frequent rest periods ( important, pt is in sickle cell crisis now), instruct pt about coping methods |
| W8 The nurse is explaining why deferasirox for thalassemia is being added to a patient’s oral medication regimen. Which patient statement demonstrates the patient’s need for further education? | “Deferasirox will prevent me from having frequent crises”- Deferasirox is a medication that decreases iron in blood & given w/ blood transfusions (iron overload) // deferasirox doesn’t replace my blood transfusions, if deferasirox works, it will reduce ir |
| W8 A patient presents with thrombocytopenia secondary to heparin administration. The nurse should assess the patient for which potential complication(s)? | Venous thrombosis- major comp. - life-threatening, Altered cognitive status- occur as part of thrombotic stroke ////// epistaxis (nasal bleeding), gingival bleeding, bleeding from IV site (all- platelet count rarely drops below 60,000) |
| W8 A patient presents with symptoms of thrombocytopenia and a platelet count of 50,000/µL. To differentiate thrombocytopenia from a myeloproliferative disorder, which diagnostic study would the nurse anticipate being prescribed for this patient? | Bone marrow biopsy- necessary to rule out leukemia, aplastic anemia & other myeloproliferative disorders & differentiate thrombocytopenia ///// urinalysis, CBC, platelet activation assay (used to differentiate types of thrombocytopenia |
| W8 A 44-year-old pt presents to the ED with a fever, blood clots, and history of an abnormal enzyme deficiency. The patient has not taken any medications in the past month. Why is this patient also likely to experience pain with the condition? | Pt w/ signs of thrombotic thrombocytopenic purpura (TTP)- fever (w/o cause), history of enzyme deficiency (ADAMTS13) needed to break down von Willebrand factor. TTP pts need to be monitored for microthrombi = cause ischemia & pain // HIT, DIC, TP |
| W8 A pt presents to clinic w/ possible immune thrombocytopenic purpura (ITP) due to a rash on upper legs & arm & also recovering from a bad case of strep throat. Pt has no medical history. Nurse should anticipate which medication will be admin. to pt? | Prednisone- Pt is presenting w/ signs of ITP. Many cases will resolve on their own, but if needed, the best medication for this patient would be a low-dose steroid/// heparin, platelets, antibiotic (strep throat already resolving) |
| W8 A patient diagnosed with immune thrombocytopenic purpura (ITP) will be undergoing a splenectomy. A family member asks why this procedure is necessary. Which response by the nurse is appropriate? | “Removal of spleen will stop unwarranted destruction of your platelets”- ITP is autoimmune , pt w/chronic ITP benefits from splenectomy since it's a major source of autoantibody production // “Enable production of ADAMTS13” TTP, not ITP, "Decrease # of p |
| W8 A pt with a history of chronic immune thrombocytopenic purpura (ITP) comes to the nurse for dietary advice. You understand that an important goal for this pt is to reduce mouth soreness and irritation. Which intervention would be helpful for this pt? | Soft, bland food A diet of soft, bland foods will be most helpful to patients and help prevent mouth discomfort and irritation. |
| W8 A patient diagnosed with metastasizing cancer has a history of immune thrombocytopenic purpura (ITP) controlled with prednisone. Which information will need to be covered in the education plan for this patient? | Information on chemo since some drugs will cause thrombocytopenia /// NO- Interaction w/ steroids & chemo as there is a synergistic effect, Interaction w/ steroids & radiation since it causes bleeding, Info on radiation it leads to hypercoagulable states |
| W9 A patient will undergo which type of surgical procedure to determine if a tumor is cancerous? | Diagnostic-conducted to determine/ confirm a diagnosis, such as malignancy ///// Ablative- removal of diseased body part (not yet), palliative, transplant |
| W9 Which type of surgical procedure will a patient undergo to restore appearance following breast removal for cancer? | Reconstructive- performed to restore appearance or function ///// ablative, palliative, constructive(restores body function that has been lost or reduced, not appearance) |
| W9 Which type of surgical procedure will an older adult patient undergo to alleviate hip pain from terminal cancer? | Palliative Palliative surgery is performed for the purpose of improving comfort and/or alleviating pain, but does not cure. It is most often performed on patients with terminal diseases to relieve pain. |
| W9 Lasik eye surgery that corrects vision and eliminates the need for eye glasses is which type of procedure? | Constructive- restores body function that has been lost or reduced (Lasik) /// ablative, diagnostic, reconstructive (restores function and/or appearance of traumatized tissue does not restore a function lost or reduced such as vision |
| W9 Which surgical procedure is restorative? | Carpal ligament reconstruction- repairs function of a previously damaged/ diseased body part (restorative) // excisional biopsy, heart transplantation, congenital heart defect repair (repair lost/reduced function d/t congenital defect =constructive |
| W9 A tonsillectomy is considered which type of surgery? | Elective Elective surgery is performed to improve the patient’s health and is planned in advance by the patient and surgeon. Tonsillectomies are usually elective unless the patient has a serious infection. |
| W9 Which surgical procedure is classified as minor surgery? | Breast biopsy- biopsies require little to no anesthesia/respiratory assistance, minimal risk to the pt /// colon resection (major), cleft palate repair (high risk/major), finger amputation (removal requires anesthesia/resp. assist (major) |
| W9 What information does a previous surgical history provide about the patient’s current surgical risk? | Risk for surgical & anesthesia complications- history can help determine pt’s risk for surg/anesthetic complications. Pts who experienced comp. w/ one surgery are likely to experience same problem again unless different meds, anesthesia & techniques used |
| W9 Which surgical procedure is classified as major surgery? | Colon resection- requires anesthesia & respiratory assistance (high risk, major surg) // cataract removal, lesion removal, breast biopsy |
| W9 When the nurse is addressing surgical risk during the preoperative phase of surgery, which cultural factor takes priority? | Language barrier- Pt’s language barrier takes priority during the preop phase of surgery. The patient’s inability to understand teaching and understand what is happening can increase stress and anxiety and thereby increase the patient’s surgical risk. |
| W9 Which age-related characteristic increases the surgical risk for older adults? | Lack of subcutaneous tissue- older adults lose subq tissue as they age, at risk for pressure injuries r/t positioning during long surgical procedures/// smaller airways, small circulatory volume, immature sympathetic NS (infants) |
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