ATI PN CAPSTONE 4
(VERIFIED QUESTIONS AND ANSWERS)
1. Which intervention is appropriate for the nurse caring for a male client in severe pain
... [Show More] receiving a continuous I.V. infusion of morphine?
a. Assisting with a naloxone challenge test before therapy begins
b. Discontinuing the drug immediately if signs of dependence appear
c. Changing the administration route to P.O. if the client can tolerate fluids
d. Obtaining baseline vital signs before administrating the first dose.
2. When caring for a client who has a colostomy created as part of a regimen to treat colon cancer, which activities would help to support the client in accepting changes in appearance or function? Select all that apply.
a. Explain to the client that the colostomy is only temporary
b. Encourage the client to participate in changing the ostomy
c. Obtain a psychiatric consultation
d. Offer to have a person who is coping with a colostomy visit
e. Encourage the client and family members to express their feelings and concerns.
3. The nurse has received in report that the client receiving chemotherapy has severe neutropenia. Which of the following does the nurse plan to implement? Select all that apply.
a. Assess for fever
b. Observe for bleeding
Administer Neulasta
Do not permit fresh flowers or plants in the room
c.
d.
e. Do not allow his 16 year old son to visit
f. Teach the client to omit raw fruits and vegetables from his diet.
4. Which of the following findings would alarm the nurse when caring for a client receiving chemotherapy who has a platelet count of 17,000/mm3
a. Increasing shortness of breath
b. Diminished bilateral breath sounds
c. Change in mental status
d. Weight gain of 4 pounds in 1 day
5. A 35 years old client with ovarian cancer is prescribed hydroxyurea (Hydrea), an antimetabolite drug. Anti-metabolites are a diverse group of antineoplastic agents that interfere with various metabolic actions of the cells. The mechanism of action of antimetabolites interferes with:
a. Cell division or mitosis during the M phase of the cell cycle
b. Normal cellular processes during the S phase of the cell cycle
c. The chemical structure of deoxyribonucleic acid (DNA) and chemical binding between DNA molecules (Cell cycle-nonspecific).
d. One or more stage of ribonucleic acid (RNA) synthesis, DNA synthesis, or both
(cell cycle-nonspecific)
6. The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A stand for?
a. Actinic
b. Asymmetry
c. Arcus
d. Assessment
7. When caring for a male client diagnosed with a brain tumor of the parental lobe, the nurse expects to assess:
a. Short-term memory impairment
b. Tactile agnosia
c. Seizures
d. Contralateral homonymous hemianopia
8. A female client is undergoing tests for multiple myeloma. Diagnostic study findings in multiple myeloma include:
a. A decreased serum creatinine level
b. Hypocalcemia
c. Bence Jones protein in the urine
d. A low serum protein level
9. A 35 year old client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis (inflammation of the mouth)?
a. White, cottage cheese-like patches on the tongue
b. Yellow tooth discoloration
c. Red, open sores on the oral mucosa
d. Rust-colored sputum
10. During chemotherapy, an oncology client has a nursing diagnosis of impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?
a. Recommending that the client discontinue chemotherapy
b. Proving a solution of hydrogen peroxide and water for use as a mouth rinse
c. Monitoring the client’s platelet and leukocyte counts
d. Checking regularly for signs and symptoms of stomatitis
11. What should a male client over age 52 do to help ensure early identification of prostate cancer?
a. Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly.
b. Have a transrectal ultrasound every 5 years
c. Perform monthly testicular self-examinations, especially after age 50
d. Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine levels checked yearly
12. A male client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss and fatigue. Suspecting gallbladder disease, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing diagnosis may be appropriate for this client?
a. Anticipatory grieving
b. Impaired swallowing
c. Disturbed body image
d. Chronic low self-esteem
13. A male client is in isolation after receiving an internal radioactive implant to treat cancer. Two hours later, the nurse discovers the implant in the bed linens. What should the nurse do first?
a. Stand as far away from the implant as possible and call for help
b. Pick up the implant with long-handled forceps and place it in a lead-linen container
c. Leave the room and notify the radiation therapy department immediately
d. Put the implant back in place, using forceps and a shield for self-protection, and call for help
14. Jeovina with advance breast cancer is prescribed tamoxifen (Nolvadex). When teaching the client about this drug, the nurse should emphasize the importance of reporting which adverse reaction immediately?
a. Vision changes
b. Hearing loss
c. Headache
d. Anorexia
15. A female client with cancer is being evaluated for possible metastasis. Which of the following is one of the most common metastasis sites for cancer cells?
a. Liver
b. Colon
c. Reproductive tract
d. White blood cells (WBCs)
16. A 34-year old female client is requesting information about mammograms and breast cancer. She isn’t considered at high risk for breast cancer. What should the nurse tell this client?
a. She should have had a baseline mammogram before age 30
b. She should eat a low-fat diet to further decrease her risk of breast cancer
c. She should perform breast self-examination during the first 5 days of each menstrual cycle.
d. When she begins having yearly mammograms, breast self-examination will no longer be necessary.
17. Nurse Brian is developing a plan of care for marrow suppression, the major doselimiting adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow suppression become noticeable?
a. 24 hours
b. 2 to 4 days
c. 7 to 14 days
d. 21 to 28 days
18. You are caring for an infant with a diagnosis of sepsis. Which is the priority assessment for this infant?
a. Skin integrity
b. Temperature
c. Jaundice
d. Respiratory function
19. You are changing the tape on a tracheostomy tube when the patient coughs, and the tube becomes dislodged. The initial action of the nurse should be:
a. Cover the site with a sterile dressing
b. Notify the physician
c. Grasp the retention sutures and spread the opening
d. Notify the respiratory therapist
20. You are caring for a patient who is being admitted to the psychiatric unit. Which of the following would present the most concern to the nurse?
a. Presence of bruises on the patient’s body
b. Reports by the patient that they can’t eat or sleep
c. Reports by the patient of suicidal thoughts
d. Significant other’s disapproval of treatment
21. You are preparing a teaching session on tuberculosis. What is one of the first symptoms that the group might notice in someone who has tuberculosis?
a. Bloody, productive cough
b. Cough with mucoid sputum
c. Chest pain
d. Dyspnea
22. You have drawn an arterial blood gas on your patient. In reviewing the results you note the flowing: pH 7.45, PCO2 of 30, mm Hg, and bicarbonate of 22mEq/L. What do you interpret these results to mean?
a. Metabolic acidosis, compensated
b. Metabolic alkalosis, compensated
c. Respiratory acidosis, compensated
d. Respiratory alkalosis, compensated
23. You have delegated care of a patient in restraints to a nursing assistant. How often should the nursing assistant assess skin integrity for this patient?
a. Every 30 minutes
b. Every 2 hours
c. Every 3 hours
d. Every 4 hours
24. Which of the following assessments by the nurse would indicate a possible manifestation of dementia?
a. Presence of personal hygienic care
b. Improvement in sleeping
c. Absence of sundown syndrome
d. Confabulation
25. You are caring for a patient who has been sexual assaulted. The patient has become quiet and calm. What defense mechanism does this indicate to the nurse?
a. Denial
b. Projection
c. Rationalization
d. Intellectualization
26. What nursing action would the nurse take when caring for a patient with enucleation with bright red drainage?
a. Notify the physician
b. Continue to monitor the drainage
c. Document the finding
d. Mark the drainage on the dressing
27. Your patient has been stung by a bee. What signs and symptoms would you see if the patient has an allergic reaction to the sting?
a. Normal respiratory rate
b. Prolonged expiratory phase
c. Wheezing on inspiration
d. Decreased respiratory rate
28. You are caring for a patient who demands to be released from the hospital immediately. The patient was admitted voluntary for an anxiety disorder. What actions should the nurse take next?
a. Tell the patient that discharge is not possible at this time
b. Call the patient’s family
c. Notify the physician
d. Persuade the patient to stay
29. The nurse is preparing for a female client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose threat to the client?
a. The client lies still
b. The client asks questions
c. The client hears thumping sounds
d. The client wears a watch and wedding band
30. A client state that she is afraid of receiving vitamin B12 injections because of the potential toxic reactions. What is the nurse’s best response to relieve these fears?
a. “Vitamin B12 will cause ringing in the eats before a toxic level is reached.”
b. “Vitamin B12 may cause a very mild skin rash initially.”
c. “Vitamin B12 may cause mild nausea but nothing toxic.”
d. “Vitamin B12 is generally free of toxicity because it is water soluble.”
31. A client with microcytic anemia is having trouble selecting food items from the hospital menu. Which food is best for the nurse to suggest for satisfying the nutritional needs and personal preferences?
a. Egg yolks
b. Brown rice
c. Vegetables
d. Tea
32. A client with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad. What is the nurse’s first response?
a. Assess for potential abuse
b. Check for diminished sensations
c. Document the findings
d. Clean and dress the area
33. Which of the following nursing assessments is a late symptom of polycythemia vera?
a. Headache
b. Dizziness
c. Pruritis
d. Shortness of breath
34. The nurse is teaching a client with polycythemia Vera about potential complications from this disease. Which manifestations would the nurse include in the client’s teaching plan? Select all that apply.
a. Hearing loss
b. Visual disturbance
c. Headache
d. Orthopnea
e. Gout
f. Weight loss
35. When a client is diagnosed with aplastic anemia, the nurse monitors for changes in which of the following physiological functions?
a. Bleeding tenderness
b. Intake and output
c. Peripheral sensation
d. Bowel function
36. Which of the following blood components is decrease in anemia?
a. Erythrocytes
b. Granulocytes
c. Leukocytes
d. Platelets
37. A client with anemia may be tired due to a tissue deficiency of which of the following substances?
a. Carbon dioxide
b. Factor VIII
c. Oxygen
d. T-cell antibodies
38. Which of the following cells is the precursor to the red blood cells (RBC)?
a. B cell
b. Macrophage
c. Stem cell
d. T cell
39. Which of the following symptoms is expected with hemoglobin of 10 g/dl?
a. None
b. Pallor
c. Palpations
d. Shortness of breath
40. Which of the following diagnostic findings are most likely for a client with aplastic anemia?
a. Decreased production of T-helper cells
b. Decreased levels of white blood cells, red blood cells, and platelets
c. Increased levels of WBCs, RBCs, and platelets
d. Reed-Sternberg cells and lymph node enlargement
41. A client with iron deficiency anemia is scheduled for discharge. Which instruction about prescribed ferrous gluconate therapy should the nurse include in the teaching plan?
a. “Take the medication with an antacid.”
b. “Take the medication with a glass of milk.”
c. “Take the medication with cereal.”
d. “Take the medication on an empty stomach.”
42. Which of the following disorders results from a deficiency of factor VIII?
a. Sickle cell disease
b. Christmas disease
c. Hemophilia A
d. Hemophilia B
43. The nurse explains to the parents of a 1-year-old child admitted to the hospital in a sickle cell crisis that the local tissue damage the child has on admission is caused by which of the following?
a. Autoimmune reaction complicated by hypoxia
b. Lack of oxygen in the red blood cells
c. Obstruction to circulation
d. Elevated serum bilirubin concentration [Show Less]