- A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event?
a. Provide water and healthy snacks for energy throughout the event.
b. Schedule 16-hour shifts to allow for greater rest between shifts.
c. Encourage counseling upon deactivation of the emergency response plan. d. Assign staff to different roles and units within the medical facility.
To prevent staff post-traumatic stress disorder during a mass casualty event, the nurses should use available counseling, encourage and support co-workers, monitor each others stress level and performance, take breaks when needed, talk about feelings with staff and managers, and drink plenty of water and eat healthy snacks for energy. Nurses should also keep in touch with family, friends, and significant others, and not work for more than 12 hours per day. Encouraging counseling upon deactivation of the plan, or after the emergency response is over, does not prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may increase situational stress and is not an approach to prevent post-traumatic stress disorder.
- An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event?
a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims.
b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in.
c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED.
d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.
The ED charge nurse should direct additional nursing staff to help care for current ED clients while the ED staff prepares to receive mass casualty victims; however, they should not be assigned to the most critically ill or injured clients. The house supervisor and unit directors would collaborate to discharge stable clients. The hospital incident commander is responsible for mobilizing resources and would have the responsibility for calling in staff. The medical command physician would be the person best able to communicate with on-scene personnel regarding the ability to take more clients.
- The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation?
a. You are free to express your feelings; whatever is said here stays here.
b. Lets evaluate what went wrong and develop policies for future incidents.
c. This session is only for nursing and medical staff, not for
d. Lets pass around the written policy compliance form for everyone.
Strict confidentiality during stress debriefing is essential so that staff members can feel comfortable sharing their feelings, which should be accepted unconditionally. Brainstorming improvements and discussing policies would occur during an administrative review. Any employee present during a mass casualty situation is eligible for critical incident stress management services.
- A hospital prepares for a mass casualty event. Which functions are correctly paired with the personnel role? (Select all that apply.)
a. Paramedic Decides the number, acuity, and resource needs of clients
b. Hospital incident commander Assumes overall leadership for implementing the emergency plan
c. Public information officer Provides advanced life support during transportation to the hospital
d. Triage officer Rapidly evaluates each client to determine priorities for treatment
e. Medical command physician Serves as a liaison between the health care facility and the media
ANS: B, D
The hospital incident commander assumes overall leadership for implementing the emergency plan. The triage officer rapidly evaluates each client to determine priorities for treatment. The paramedic provides advanced life support during transportation to the hospital. The public information officer serves as a liaison between the health care facility and the media. The medical command physician decides the number, acuity, and resource needs of clients.
7. A hospital unit is participating in a bioterrorism drill. A client
is admitted with inhalation anthrax. Under
what type of precautions does the charge nurse admit the client?
a. Airborne Precautions
b. Contact Precautions
c. Droplet Precautions
d. Standard Precautions
Only Standard Precautions are needed. No other special precautions are required for the client because
inhalation anthrax is not spread person to person.
9. A client is admitted with fever, myalgia, and a papular rash on
the face, palms, and soles of the feet. What
action should the nurse take first?
a. Obtain cultures of the lesions.
b. Place the client on Airborne Precautions.
c. Prepare to administer antibiotics.
d. Provide comfort measures for the rash.
This client has manifestations of smallpox, a public health emergency, and should be placed on Airborne
Precautions first before other care measures are implemented.
6. After teaching a client who is prescribed voice rest therapy for
vocal cord polyps, a nurse assesses the clients
understanding. Which statement indicates the client needs further teaching?
a. I will stay away from smokers to minimize inhalation of secondhand smoke.
b. When I speak, I will whisper rather than use a normal tone of voice.
c. For the next several weeks, I will not lift more than 10 pounds.
d. I will drink at least three quarts of water each day to stay hydrated.
Treatment for vocal cord polyps includes no speaking, no lifting, and no smoking. The client has to be
educated not to even whisper when resting the voice. It is also appropriate for the client to stay out of rooms
where people are smoking, to stay hydrated, and to use stool softeners.
8. A nurse cares for a client after radiation therapy for lung
cancer. The client reports a sore throat. Which
action should the nurse take first?
a. Ask the client to gargle with mouthwash containing lidocaine.
b. Administer prescribed intravenous pain medications.
c. Explain that soreness is normal and will improve in a couple days.
d. Assess the clients neck for redness and swelling.
Mouthwashes and throat sprays containing a local anesthetic agent such as lidocaine or diphenhydramine can
provide relief from a sore throat after radiation therapy. Intravenous pain medications may be used if local
anesthetics are unsuccessful. The nurse should explain to the client that this is normal and assess the clients
neck, but these options do not decrease the clients discomfort.
9. A nurse cares for a client who had a partial laryngectomy 10 days
ago. The client states that all food tastes
bland. How should the nurse respond?
a. I will consult the speech therapist to ensure you are swallowing properly.
b. This is normal after surgery. What types of food do you like to eat?
c. I will ask the dietitian to change the consistency of the food in your diet.
d. Replacement of protein, calories, and water is very important after surgery.
Many clients experience changes in taste after surgery. The nurse should identify foods that the client wants to
eat to ensure the client maintains necessary nutrition. Although the nurse should collaborate with the speech
therapist and dietitian to ensure appropriate replacement of protein, calories, and water, the other responses do
not address the clients concerns.
10. A nurse cares for a client who is scheduled for a total
laryngectomy. Which action should the nurse take
prior to surgery?
a. Assess airway patency, breathing, and circulation.
b. Administer prescribed intravenous pain medication.
c. Assist the client to choose a communication method.
d. Ambulate the client in the hallway to assess gait.
The client will not be able to speak after surgery. The nurse should assist the client to choose a communication
method that he or she would like to use after surgery. Assessing the clients airway and administering IV pain
medication are done after the procedure. Although ambulation promotes health and decreases the
complications of any surgery, this clients gait should not be impacted by a total laryngectomy and therefore is
not a priority.
14. A nurse teaches a client to use a room humidifier after a
laryngectomy. Which statement should the nurse
include in this clients teaching?
a. Add peppermint oil to the humidifier to relax the airway.
b. Make sure you clean the humidifier to prevent infection.
c. Keep the humidifier filled with water at all times.
d. Use the humidifier when you sleep, even during daytime naps.
Priority teaching related to the use of a room humidifier focuses on infection control. Clients should be taught
to meticulously clean the humidifier to prevent the spread of mold or other sources of infection. Peppermint oil
should not be added to a humidifier. The humidifier should be refilled with water as needed and should be used
while awake and asleep.
4. A registered nurse (RN) cares for clients on a surgical unit.
Which clients should the RN delegate to a
licensed practical nurse (LPN)? (Select all that apply.)
a. A 32-year-old who had a radical neck dissection 6 hours ago
b. A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago
c. A 55-year-old who needs discharge teaching after a laryngectomy
d. A 67-year-old who is awaiting preoperative teaching for laryngeal cancer
e. An 88-year-old with esophageal cancer who is awaiting gastric tube placement
ANS: B, E
The nurse can delegate stable clients to the LPN. The client who had a biopsy 2 days ago and the client who is
awaiting gastric tube placement are stable. The client who is 6 hours post-surgery is not yet stable. The RN is
the only one who can perform discharge and preoperative teaching; teaching cannot be delegated.
5. A nurse cares for a client who has developed esophagitis after
undergoing radiation therapy for lung cancer.
Which diet selection should the nurse provide for this client?
a. Spaghetti with meat sauce, ice cream
b. Chicken soup, grilled cheese sandwich
c. Omelet, soft whole wheat bread
d. Pasta salad, custard, orange juice
Side effects of radiation therapy may include inflammation of the esophagus. Clients should be taught that
bland, soft, high-calorie foods are best, along with liquid nutritional supplements. Tomato sauce may prove too
spicy for a client with esophagitis. A grilled cheese sandwich is too difficult to swallow with this condition,
and orange juice and other foods with citric acid are too caustic.
6. The nurse is caring for a client with lung cancer who states, I
dont want any pain medication because I am
afraid Ill become addicted. How should the nurse respond?
a. I will ask the provider to change your medication to a drug that is less potent.
b. Would you like me to use music therapy to distract you from your pain?
c. It is unlikely you will become addicted when taking medicine for pain.
d. Would you like me to give you acetaminophen (Tylenol) instead?
Clients should be encouraged to take their pain medications; addiction usually is not an issue with a client in
pain. The nurse would not request that the pain medication be changed unless it was not effective. Other
methods to decrease pain can be used, in addition to pain medication.
10. While assessing a client who is 12 hours postoperative after a
thoracotomy for lung cancer, a nurse notices
that the lower chest tube is dislodged. Which action should the nurse take first?
a. Assess for drainage from the site.
b. Cover the insertion site with sterile gauze.
c. Contact the provider and obtain a suture kit.
d. Reinsert the tube using sterile technique.
Immediately covering the insertion site helps prevent air from entering the pleural space and causing a
pneumothorax. The area will not reseal quickly enough to prevent air from entering the chest. The nurse should
not leave the client to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax. The site
should only be assessed after the insertion site is covered. The provider should be called to reinsert the chest
tube or prescribe other treatment options.
13. A nurse cares for a client who had a chest tube placed 6 hours
ago and refuses to take deep breaths because
of the pain. Which action should the nurse take?
a. Ambulate the client in the hallway to promote deep breathing.
b. Auscultate the clients anterior and posterior lung fields.
c. Encourage the client to take shallow breaths to help with the pain.
d. Administer pain medication and encourage the client to take deep breaths.
A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse should provide
pain medication to minimize discomfort and encourage the client to take deep breaths. The other responses do
not address the clients discomfort and need to take deep breaths to prevent complications.
14. A nurse cares for a client who has a chest tube. When would this
client be at highest risk for developing a
a. When the insertion site becomes red and warm to the touch
b. When the tube drainage decreases and becomes sanguineous
c. When the client experiences pain at the insertion site
d. When the tube becomes disconnected from the drainage system
Intrathoracic pressures are less than atmospheric pressures; therefore, if the chest tube becomes disconnected
from the drainage system, air can be sucked into the pleural space and cause a pneumothorax. A red, warm,
and painful insertion site does not increase the clients risk for a pneumothorax. Tube drainage should decrease
and become serous as the client heals. Sanguineous drainage is a sign of bleeding but does not increase the
clients risk for a pneumothorax.
2. A nurse assesses a client who has a mediastinal chest tube. Which
symptoms require the nurses immediate
intervention? (Select all that apply.)
a. Production of pink sputum
b. Tracheal deviation
c. Pain at insertion site
d. Sudden onset of shortness of breath
e. Drainage greater than 70 mL/hr
f. Disconnection at Y site
ANS: B, D, E, F
Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension
pneumothorax. Sudden shortness of breath could indicate dislodgment of the tube, occlusion of the tube, or
pneumothorax. Drainage greater than 70 mL/hr could indicate hemorrhage. Disconnection at the Y site could
result in air entering the tubing. Production of pink sputum, oxygen saturation less than 95%, and pain at the
insertion site are not signs/symptoms that would require immediate intervention.
8. A nursing student is caring for a client with leukemia. The
student asks why the client is still at risk for
infection when the clients white blood cell count (WBC) is high. What response by the registered nurse is best?
a. If the WBCs are high, there already is an infection present.
b. The client is in a blast crisis and has too many WBCs.
c. There must be a mistake; the WBCs should be very low.
d. Those WBCs are abnormal and dont provide protection.
In leukemia, the WBCs are abnormal and do not provide protection to the client against infection. The other
statements are not accurate.
10. A nurse is caring for a client who is about to receive a bone
marrow transplant. To best help the client cope
with the long recovery period, what action by the nurse is best?
a. Arrange a visitation schedule among friends and family.
b. Explain that this process is difficult but must be endured.
c. Help the client find things to hope for each day of recovery.
d. Provide plenty of diversionary activities for this time.
Providing hope is an essential nursing function during treatment for any disease process, but especially during
the recovery period after bone marrow transplantation, which can take up to 3 weeks. The nurse can help the
client look ahead to the recovery period and identify things to hope for during this time. Visitors are important
to clients, but may pose an infection risk. Telling the client the recovery period must be endured does not
acknowledge his or her feelings. Diversionary activities are important, but not as important as instilling hope.
11. A nursing student is struggling to understand the process of
graft-versus-host disease. What explanation by the nurse instructor is
a. Because of immunosuppression, the donor cells take over.
b. Its like a transfusion reaction because no perfect matches exist.
c. The clients cells are fighting donor cells for dominance.
d. The donors cells are actually attacking the clients cells.
Graft versus host disease is an autoimmune-type process in which the donor cells recognize the clients cells as
foreign and begin attacking them. The other answers are not accurate.
12. The nurse is caring for a client with leukemia who has the
priority problem of fatigue. What action by the
client best indicates that an important goal for this problem has been met?
a. Doing activities of daily living (ADLs) using rest periods
b. Helping plan a daily activity schedule
c. Requesting a sleeping pill at night
d. Telling visitors to leave when fatigued
Fatigue is a common problem for clients with leukemia. This client is managing his or her own ADLs using
rest periods, which indicates an understanding of fatigue and how to control it. Helping to plan an activity
schedule is a lesser indicator. Requesting a sleeping pill does not help control fatigue during the day. Asking
visitors to leave when tired is another lesser indicator. Managing ADLs using rest periods demonstrates the
most comprehensive management strategy.
13. A nurse is caring for a young male client with lymphoma who is to
begin treatment. What teaching topic is
a. Genetic testing
b. Infection prevention
c. Sperm banking
d. Treatment options
All teaching topics are important to the client with lymphoma, but for a young male, sperm banking is of
particular concern if the client is going to have radiation to the lower abdomen or pelvis.
17. A client has a platelet count of 9000/mm3. The nurse finds the
client confused and mumbling. What action
a. Calling the Rapid Response Team
b. Delegating taking a set of vital signs
c. Instituting bleeding precautions
d. Placing the client on bedrest
With a platelet count this low, the client is at high risk of spontaneous bleeding. The most disastrous
complication would be intracranial bleeding. The nurse needs to call the Rapid Response Team as this client
has manifestations of a sudden neurologic change. The nurse should not delegate the vital signs as the client is no longer stable. Bleeding precautions will not address the immediate situation. Placing the client on bedrest or
putting the client back into bed is important, but the critical action is to call for immediate medical attention.
21. A client has thrombocytopenia. What client statement indicates
the client understands self-management of this condition?
a. I brush and use dental floss every day.
b. I chew hard candy for my dry mouth.
c. I usually put ice on bumps or bruises.
d. Nonslip socks are best when I walk.
The client should be taught to apply ice to areas of minor trauma. Flossing is not recommended. Hard foods
should be avoided. The client should wear well-fitting shoes when ambulating.
25. A nurse is caring for four clients with leukemia. After hand-off
report, which client should the nurse see
a. Client who had two bloody diarrhea stools this morning
b. Client who has been premedicated for nausea prior to chemotherapy
c. Client with a respiratory rate change from 18 to 22 breaths/min
d. Client with an unchanged lesion to the lower right lateral malleolus
The client who had two bloody diarrhea stools that morning may be hemorrhaging in the gastrointestinal (GI)
tract and should be assessed first. The client with the change in respiratory rate may have an infection or
worsening anemia and should be seen next. The other two clients are not a priority at this time.
26. A client has frequent hospitalizations for leukemia and is
worried about functioning as a parent to four
small children. What action by the nurse would be most helpful?
a. Assist the client to make sick day plans for household responsibilities.
b. Determine if there are family members or friends who can help the client.
c. Help the client inform friends and family that they will have to help out.
d. Refer the client to a social worker in order to investigate respite child care
While all options are reasonable choices, the best option is to help the client make sick day plans, as that is
more comprehensive and inclusive than the other options, which focus on a single item.
2. A student studying leukemias learns the risk factors for
developing this disorder. Which risk factors does
this include? (Select all that apply.)
a. Chemical exposure
b. Genetically modified foods
c. Ionizing radiation exposure
e. Viral infections
ANS: A, C, E
Chemical and ionizing radiation exposure and viral infections are known risk factors for developing leukemia.
Eating genetically modified food and receiving vaccinations are not known risk factors
3. A client has Hodgkins lymphoma, Ann Arbor stage Ib. For what
manifestations should the nurse assess the
client? (Select all that apply.)
b. Night sweats
c. Persistent fever
d. Urinary frequency
e. Weight loss
ANS: B, C, E
In this stage, the disease is located in a single lymph node region or a single nonlymph node site. The client
displays night sweats, persistent fever, and weight loss. Headache and urinary problems are not related.
4. A client has a platelet count of 25,000/mm3. What actions does the
nurse delegate to the unlicensed assistive
personnel (UAP)? (Select all that apply.)
a. Assist with oral hygiene using a firm toothbrush.
b. Give the client an enema if he or she is constipated.
c. Help the client choose soft foods from the menu.
d. Shave the male client with an electric razor.
e. Use a lift sheet when needed to re-position the client.
ANS: C, D, E
This client has thrombocytopenia and requires bleeding precautions. These include oral hygiene with a soft-
bristled toothbrush or swabs, avoiding rectal trauma, eating soft foods, shaving with an electric razor, and
using a lift sheet to re-position the client.
10. A client has received a bone marrow transplant and is waiting for
engraftment. What actions by the nurse
are most appropriate? (Select all that apply.)
a. Not allowing any visitors until engraftment
b. Limiting the protein in the clients diet
c. Placing the client in protective precautions
d. Teaching visitors appropriate hand hygiene
e. Telling visitors not to bring live flowers or plants
ANS: C, D, E
The client waiting for engraftment after bone marrow transplant has no white cells to protect him or her against
infection. The client is on protective precautions and visitors are taught hand hygiene. No fresh flowers or
plants are allowed due to the standing water in the vase or container that may harbor organisms. Limiting
protein is not a healthy option and will not promote engraftment.
1. A client is admitted with Guillain-Barr syndrome (GBS). What
assessment takes priority?
a. Bladder control
b. Cognitive perception
c. Respiratory system
d. Sensory functions
Clients with GBS have muscle weakness, possibly to the point of paralysis. If respiratory muscles are
paralyzed, the client may need mechanical ventilation, so the respiratory system is the priority. The nurse will
complete urinary, cognitive, and sensory assessments as part of a thorough evaluation.
2. The nurse learns that the pathophysiology of Guillain-Barr
syndrome includes segmental demyelination. The
nurse should understand that this causes what?
a. Delayed afferent nerve impulses
b. Paralysis of affected muscles
c. Paresthesia in upper extremities
d. Slowed nerve impulse transmission
Demyelination leads to slowed nerve impulse transmission. The other options are not correct.
3. A client with Guillain-Barr syndrome is admitted to the hospital.
The nurse plans caregiving priority to
interventions that address which priority client problem?
b. Low fluid volume
c. Inadequate airway
d. Potential for skin breakdown
Airway takes priority. Anxiety is probably present, but a physical diagnosis takes priority over a psychosocial
one. The client has no reason to have low fluid volume unless he or she has been unable to drink for some time.
If present, airway problems take priority over a circulation problem. An actual problem takes precedence over
a risk for a problem.
11. A client is receiving plasmapheresis. What action by the nurse
best prevents infection in this client?
a. Giving antibiotics prior to treatments
b. Monitoring the clients vital signs
c. Performing appropriate hand hygiene
d. Placing the client in protective isolation
Plasmapheresis is an invasive procedure, and the nurse uses good hand hygiene before and after client contact
to prevent infection. Antibiotics are not necessary. Monitoring vital signs does not prevent infection but could
alert the nurse to its possibility. The client does not need isolation.
12. An older client is hospitalized with Guillain-Barr syndrome. A
family member tells the nurse the client is
restless and seems confused. What action by the nurse is best?
a. Assess the clients oxygen saturation.
b. Check the medication list for interactions.
c. Place the client on a bed alarm.
d. Put the client on safety precautions.
In the older adult, an early sign of hypoxia is often confusion and restlessness. The nurse should first assess the
clients oxygen saturation. The other actions are appropriate, but only after this assessment occurs.
4. An older adult client is hospitalized with Guillain-Barr syndrome.
The client is given amitriptyline (Elavil).
After receiving the hand-off report, what actions by the nurse are most important? (Select all that apply.)
a. Administering the medication as ordered
b. Advising the client to have help getting up
c. Consulting the provider about the drug
d. Cutting the dose of the drug in half
e. Placing the client on safety precautions
ANS: B, C, E
Amitriptyline is a tricyclic antidepressant and is considered inappropriate for use in older clients due to
concerns of anticholinergic effects, confusion, and safety risks. The nurse should tell the client to have help
getting up, place the client on safety precautions, and consult the provider. Since this drug is not appropriate
for older clients, cutting the dose in half is not warranted.
5. The nurse caring for a client with Guillain-Barr syndrome has
identified the priority client problem of
decreased mobility for the client. What actions by the nurse are best? (Select all that apply.)
a. Ask occupational therapy to help the client with activities of daily living.
b. Consult with the provider about a physical therapy consult.
c. Provide the client with information on support groups.
d. Refer the client to a medical social worker or chaplain.
e. Work with speech therapy to design a high-protein diet.
ANS: A, B, E
Improving mobility and strength involves the collaborative assistance of occupational therapy, physical
therapy, and speech therapy. While support groups, social work, or chaplain referrals may be needed, they do
not help with mobility.
5. A client is being taught about drug therapy for Helicobacter
pylori infection. What assessment by the nurse
is most important?
a. Alcohol intake of 1 to 2 drinks per week
b. Family history of H. pylori infection
c. Former smoker still using nicotine patches
d. Willingness to adhere to drug therapy
Treatment for this infection involves either triple or quadruple drug therapy, which may make it difficult for
clients to remain adherent. The nurse should assess the clients willingness and ability to follow the regimen.
The other assessment findings are not as critical.
10. A client is scheduled for a total gastrectomy for gastric cancer.
What preoperative laboratory result should
the nurse report to the surgeon immediately?
a. Albumin: 2.1 g/dL
b. Hematocrit: 28%
c. Hemoglobin: 8.1 mg/dL
d. International normalized ratio (INR): 4.2
An INR as high as 4.2 poses a serious risk of bleeding during the operation and should be reported. The
albumin is low and is an expected finding. The hematocrit and hemoglobin are also low, but this is expected in
11. A client has a recurrence of gastric cancer and is in the
gastrointestinal clinic crying. What response by the nurse is most
a. Do you have family or friends for support?
b. Id like to know what you are feeling now.
c. Well, we knew this would probably happen.
d. Would you like me to refer you to hospice?
The nurse assesses the clients emotional state with open-ended questions and statements and shows a
willingness to listen to the clients concerns. Asking about support people is very limited in nature, and yes-or-
no questions are not therapeutic. Stating that this was expected dismisses the clients concerns. The client may
or may not be ready to hear about hospice, and this is another limited, yes-or-no question.
15. A client has dumping syndrome after a partial gastrectomy. Which
action by the nurse would be most
a. Arrange a dietary consult.
b. Increase fluid intake.
c. Limit the clients foods.
d. Make the client NPO.
The client with dumping syndrome after a gastrectomy has multiple dietary needs. A referral to the registered
dietitian will be extremely helpful. Food and fluid intake is complicated and needs planning. The client should
not be NPO.
16. An older client has gastric cancer and is scheduled to have a
partial gastrectomy. The family does not want
the client told about her diagnosis. What action by the nurse is best?
a. Ask the family why they feel this way.
b. Assess family concerns and fears.
c. Refuse to go along with the familys wishes.
d. Tell the family that such secrets cannot be kept.
The nurse should use open-ended questions and statements to fully assess the familys concerns and fears.
Asking why questions often puts people on the defensive and is considered a barrier to therapeutic
communication. Refusing to follow the familys wishes or keep their confidence will not help move this family
from their position and will set up an adversarial relationship.
3. The student nurse learns about risk factors for gastric cancer.
Which factors does this include? (Select all
b. Chronic atrophic gastritis
c. Helicobacter pylori infection
d. Iron deficiency anemia
e. Pernicious anemia
ANS: A, B, C, E
Achlorhydria, chronic atrophic gastritis, H. pylori infection, and pernicious anemia are all risk factors for
developing gastric cancer. Iron deficiency anemia is not a risk factor.
4. A client has dumping syndrome. What menu selections indicate the
client understands the correct diet to
manage this condition? (Select all that apply.)
a. Canned unsweetened apricots
b. Coffee cake
c. Milk shake
d. Potato soup
e. Steamed broccoli
ANS: A, D
Canned apricots and potato soup are appropriate selections as they are part of a high-protein, high-fat, low- to
moderate-carbohydrate diet. Coffee cake and other sweets must be avoided. Milk products and sweet drinks
such as shakes must be avoided. Gas-forming foods such as broccoli must also be avoided.
6. A client who had a partial gastrectomy has several expected
nutritional problems. What actions by the nurse
are best to promote better nutrition? (Select all that apply.)
a. Administer vitamin B12 injections.
b. Ask the provider about folic acid replacement.
c. Educate the client on enteral feedings.
d. Obtain consent for total parenteral nutrition.
e. Provide iron supplements for the client.
ANS: A, B, E
After gastrectomy, clients are at high risk for anemia due to vitamin B12 deficiency, folic acid deficiency, or
iron deficiency. The nurse should provide supplements for all these nutrients. The client does not need enteral
feeding or total parenteral nutrition.
5. A nurse assesses clients at a community health center. Which
client is at highest risk for the development of
a. A 37-year-old who drinks eight cups of coffee daily
b. A 44-year-old with irritable bowel syndrome (IBS)
c. A 60-year-old lawyer who works 65 hours per week
d. A 72-year-old who eats fast food frequently
Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food
tends to be high in fat and low in fiber, increasing the risk for colon cancer. Coffee intake, IBS, and a heavy
workload do not increase the risk for colon cancer.
6. A nurse assessing a client with colorectal cancer auscultates
high-pitched bowel sounds and notes the
presence of visible peristaltic waves. Which action should the nurse take?
a. Ask if the client is experiencing pain in the right shoulder.
b. Perform a rectal examination and assess for polyps.
c. Contact the provider and recommend computed tomography.
d. Administer a laxative to increase bowel movement activity.
The presence of visible peristaltic waves, accompanied by high-pitched or tingling bowel sounds, is indicative
of partial obstruction caused by the tumor. The nurse should contact the provider with these results and
recommend a computed tomography scan for further diagnostic testing. This assessment finding is not
associated with right shoulder pain; peritonitis and cholecystitis are associated with referred pain to the right
shoulder. The registered nurse is not qualified to complete a rectal examination for polyps, and laxatives would
not help this client.
7. A nurse prepares a client for a colonoscopy scheduled for
tomorrow. The client states, My doctor told me
that the fecal occult blood test was negative for colon cancer. I dont think I need the colonoscopy and would
like to cancel it. How should the nurse respond?
a. Your doctor should not have given you that information prior to the colonoscopy.
b. The colonoscopy is required due to the high percentage of false negatives with the blood test.
c. A negative fecal occult blood test does not rule out the possibility of colon cancer.
d. I will contact your doctor so that you can discuss your concerns about the procedure.
A negative result from a fecal occult blood test does not completely rule out the possibility of colon cancer. To determine whether the client has colon cancer, a colonoscopy should be performed so the entire colon can be
visualized and a tissue sample taken for biopsy. The client may want to speak with the provider, but the nurse
should address the clients concerns prior to contacting the provider.
8. A nurse cares for a client newly diagnosed with colon cancer who
has become withdrawn from family
members. Which action should the nurse take?
a. Contact the provider and recommend a psychiatric consult for the client.
b. Encourage the client to verbalize feelings about the diagnosis.
c. Provide education about new treatment options with successful outcomes.
d. Ask family and friends to visit the client and provide emotional support.
The nurse recognizes that the client may be expressing feelings of grief. The nurse should encourage the client
to verbalize feelings and identify fears to move the client through the phases of the grief process. A psychiatric
consult is not appropriate for the client. The nurse should not brush aside the clients feelings with discussions
related to cancer prognosis and treatment. The nurse should not assume that the client desires family or friends
to visit or provide emotional support.
9. A nurse cares for a client with colon cancer who has a new
colostomy. The client states, I think it would be
helpful to talk with someone who has had a similar experience. How should the nurse respond?
a. I have a good friend with a colostomy who would be willing to talk with you.
b. The enterostomal therapist will be able to answer all of your questions.
c. I will make a referral to the United Ostomy Associations of America.
d. Youll find that most people with colostomies dont want to talk about them.
Nurses need to become familiar with community-based resources to better assist clients. The local chapter of he United Ostomy Associations of America has resources for clients and their families, including Ostomates
(specially trained visitors who also have ostomies). The nurse should not suggest that the client speak with a personal contact of the nurse. Although the enterostomal therapist is an expert in ostomy care, talking with him
or her is not the same as talking with someone who actually has had a colostomy. The nurse should not brush aside the clients request by saying that most people with colostomies do not want to talk about them. Many people are willing to share their ostomy experience in the hope of helping others.
11. A nurse cares for a client who states, My husband is repulsed by
my colostomy and refuses to be intimate
with me. How should the nurse respond?
a. Lets talk to the ostomy nurse to help you and your husband work through this.
b. You could try to wear longer lingerie that will better hide the ostomy appliance.
c. You should empty the pouch first so it will be less noticeable for your husband.
d. If you are not careful, you can hurt the stoma if you engage in sexual activity.
The nurse should collaborate with the ostomy nurse to help the client and her husband work through intimacy
issues. The nurse should not minimize the clients concern about her husband with ways to hide the ostomy.
The client will not hurt the stoma by engaging in sexual activity.
15. A nurse assesses a client who is prescribed 5-fluorouracil (5-FU)
chemotherapy intravenously for the
treatment of colon cancer. Which assessment finding should alert the nurse to contact the health care provider?
a. White blood cell (WBC) count of 1500/mm3
c. Nausea and diarrhea
d. Mucositis and oral ulcers
Common side effects of 5-FU include fatigue, leukopenia, diarrhea, mucositis and mouth ulcers, and peripheral neuropathy. However, the clients WBC count is very low (normal range is 5000 to 10,000/mm3), so the provider should be notified. He or she may want to delay chemotherapy by a day or two. Certainly the client is at high risk for infection. The other assessment findings are consistent with common side effects of 5-FU that would not need to be reported immediately.
16. A nurse cares for a client who had a colostomy placed in the
ascending colon 2 weeks ago. The client
states, The stool in my pouch is still liquid. How should the nurse respond?
a. The stool will always be liquid with this type of colostomy.
b. Eating additional fiber will bulk up your stool and decrease diarrhea.
c. Your stool will become firmer over the next couple of weeks.
d. This is abnormal. I will contact your health care provider.
The stool from an ascending colostomy can be expected to remain liquid because little large bowel is available
to reabsorb the liquid from the stool. This finding is not abnormal. Liquid stool from an ascending colostomy
will not become firmer with the addition of fiber to the clients diet or with the passage of time.
18. A nurse teaches a client who is recovering from a colon
resection. Which statement should the nurse
include in this clients plan of care?
a. You may experience nausea and vomiting for the first few weeks.
b. Carbonated beverages can help decrease acid reflux from anastomosis sites.
c. Take a stool softener to promote softer stools for ease of defecation.
d. You may return to your normal workout schedule, including weight lifting.
Clients recovering from a colon resection should take a stool softener as prescribed to keep stools a soft
consistency for ease of passage. Nausea and vomiting are symptoms of intestinal obstruction and perforation
and should be reported to the provider immediately. The client should be advised to avoid gas-producing foods
and carbonated beverages, and avoid lifting heavy objects or straining on defecation.
19. A nurse teaches a client who is at risk for colon cancer. Which
dietary recommendation should the nurse
teach this client?
a. Eat low-fiber and low-residual foods.
b. White rice and bread are easier to digest.
c. Add vegetables such as broccoli and cauliflower to your new diet.
d. Foods high in animal fat help to protect the intestinal mucosa.
The client should be taught to modify his or her diet to decrease animal fat and refined carbohydrates. The
client should also increase high-fiber foods and Brassica vegetables, including broccoli and cauliflower, which
help to protect the intestinal mucosa from colon cancer.
20. A nurse cares for a client who has a new colostomy. Which action
should the nurse take?
a. Empty the pouch frequently to remove excess gas collection.
b. Change the ostomy pouch and wafer every morning.
c. Allow the pouch to completely fill with stool prior to emptying it.
d. Use surgical tape to secure the pouch and prevent leakage.
The nurse should empty the new ostomy pouch frequently because of excess gas collection, and empty the
pouch when it is one-third to one-half full of stool. The ostomy pouch does not need to be changed every
morning. Ostomy wafers with paste should be used to secure and seal the ostomy appliance; surgical tape
should not be used.
21. A nurse cares for a client who has a family history of colon
cancer. The client states, My father and my
brother had colon cancer. What is the chance that I will get cancer? How should the nurse respond?
a. If you eat a low-fat and low-fiber diet, your chances decrease significantly.
b. You are safe. This is an autosomal dominant disorder that skips generations.
c. Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer.
d. You should have a colonoscopy more frequently to identify abnormal polyps early.
The nurse should encourage the client to have frequent colonoscopies to identify abnormal polyps and
cancerous cells early. The abnormal gene associated with colon cancer is an autosomal dominant gene
mutation that does not skip a generation and places the client at high risk for cancer. Changing the clients diet,
preemptive chemotherapy, and removal of polyps will decrease the clients risk but will not prevent cancer.
However, a client at risk for colon cancer should eat a low-fat and high-fiber diet.
2. After teaching a client who is recovering from a colon resection,
the nurse assesses the clients
understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that
a. I must change the ostomy appliance daily and as needed.
b. I will use warm water and a soft washcloth to clean around the stoma.
c. I might start bicycling and swimming again once my incision has healed.
d. Cutting the flange will help it fit snugly around the stoma to avoid skin breakdown.
e. I will check the stoma regularly to make sure that it stays a deep red color.
f. I must avoid dairy products to reduce gas and odor in the pouch.
ANS: B, C, D
The ostomy appliance should be changed as needed when the adhesive begins to decrease, placing the
appliance at risk of leaking. Changing the appliance daily can cause skin breakdown as the adhesive will still
be secured to the clients skin. The client should avoid using soap to clean around the stoma because it might
prevent effective adhesion of the ostomy appliance. The client should use warm water and a soft washcloth
instead. The tissue of the stoma is very fragile, and scant bleeding may occur when the stoma is cleaned. The flange should be cut to fit snugly around the stoma to reduce contact between excretions and the clients skin.
Exercise (other than some contact sports) is important for clients with an ostomy. The stoma should remain a
soft pink color. A deep red or purple hue indicates ischemia and should be reported to the surgeon right away.
Yogurt and buttermilk can help reduce gas in the pouch, so the client need not avoid dairy products.
2. The nurse is examining a womans breast and notes multiple small
mobile lumps. Which question would be
the most appropriate for the nurse to ask?
a. When was your last mammogram at the clinic?
b. How many cans of caffeinated soda do you drink in a day?
c. Do the small lumps seem to change with your menstrual period?
d. Do you have a first-degree relative who has breast cancer?
The most appropriate question would be one that relates to benign lesions that usually change in response to
hormonal changes within a menstrual cycle. Reduction of caffeine in the diet has been shown to give relief in
fibrocystic breast conditions, but research has not found that it has a significant impact. Questions related to the
clients last mammogram or breast cancer history are not related to the nurses assessment.
4. Which finding in a female client by the nurse
would receive the highest priority of further diagnostics?
a. Tender moveable masses throughout the breast tissue
b. A 3-cm firm, defined mobile mass in the lower quadrant of the
c. Nontender immobile mass in the upper outer quadrant of the breast
d. Small, painful mass under warm reddened skin
Malignant lesions are hard, nontender, and usually located in the upper outer quadrant of the breast and would
be the priority for further diagnostic study. The other lesions are benign breast disorders. The tender moveable
masses throughout the breast tissue could be a fibrocystic breast condition. A firm, defined mobile mass in the
lower quadrant of the breast is a fibroadenoma, and a painful mass under warm reddened skin could be a local
abscess or ductal ectasia.
7. With a history of breast cancer in the family, a 48-year-old
female client is interested in learning about the
modifiable risk factors for breast cancer. After the nurse explains this information, which statement made by
the client indicates that more teaching is needed?
a. I am fortunate that I breast-fed each of my three children for 12 months.
b. It looks as though I need to start working out at the gym more often.
c. I am glad that we can still have wine with every evening meal.
d. When I have menopausal symptoms, I must avoid hormone replacement therapy.
Modifiable risk factors can help prevent breast cancer. The client should lessen alcohol intake and not have
wine 7 days a week. Breast-feeding, regular exercise, and avoiding hormone replacement are also strategies for
breast cancer prevention.
8. A 37-year-old Nigerian woman is at high risk for breast cancer and
is considering a prophylactic
mastectomy and oophorectomy. What action by the nurse is most appropriate?
a. Discourage this surgery since the woman is still of childbearing age.
b. Reassure the client that reconstructive surgery is as easy as breast augmentation.
c. Inform the client that this surgery removes all mammary tissue and cancer risk.
d. Include support people, such as the male partner, in the decision making.
The cultural aspects of decision making need to be considered. In the Nigerian culture, the man often makes
the decisions for care of the female. Women with a high risk for breast cancer can consider prophylactic
surgery. If reconstructive surgery is considered, the procedure is more complex and will have more
complications compared to a breast augmentation. There is a small risk that breast cancer can still develop in
the remaining mammary tissue.
9. A 35-year-old woman is diagnosed with stage III breast cancer. She
seems to be extremely anxious. What
action by the nurse is best?
a. Encourage the client to search the Internet for information tonight.
b. Ask the client if sexuality has been a problem with her partner.
c. Explore the idea of a referral to a breast cancer support group.
d. Assess whether there has been any mental illness in her past.
Support for the diagnosis would be best with a referral to a breast cancer support group. The Internet may be a
good source of information, but the day of diagnosis would be too soon. The nurse could assess the frequency
and satisfaction of sexual relations but should not assume that there is a problem in that area. Assessment of
mental illness is not an appropriate action.
10. A client has just returned from a right radical mastectomy. Which
action by the unlicensed assistive
personnel (UAP) would the nurse consider unsafe?
a. Checking the amount of urine in the urine catheter collection bag
b. Elevating the right arm on a pillow
c. Taking the blood pressure on the right arm
d. Encouraging the client to squeeze a rolled washcloth
Health care professionals need to avoid the arm on the side of the surgery for blood pressure measurement,
injections, or blood draws. Since lymph nodes are removed, lymph drainage would be compromised. The
pressure from the blood pressure cuff could promote swelling. Infection could occur with injections and blood
draws. Checking urine output, elevation of the affected arm on a pillow, and encouraging beginning exercises
11. A client is discharged to home after a modified radical
mastectomy with two drainage tubes. Which
statement by the client would indicate that further teaching is needed?
a. I am glad that these tubes will fall out at home when I finally shower.
b. I should measure the drainage each day to make sure it is less than an ounce.
c. I should be careful how I lie in bed so that I will not kink the tubing.
d. If there is a foul odor from the drainage, I should contact my doctor.
The drainage tubes (such as a Jackson-Pratt drain) lie just under the skin but need to be removed by the health
care professional in about 1 to 3 weeks at an office visit. Drainage should be less than 25 mL in a days time.
The client should be aware of her positioning to prevent kinking of the tubing. A foul odor from the drainage
may indicate an infection; the doctor should be contacted immediately.
2. What comfort measure can only be performed by a nurse, as opposed
to an unlicensed assistive personnel
(UAP), for a client who returned from a left modified radical mastectomy 4 hours ago?
a. Placing the head of bed at 30 degrees
b. Elevating the left arm on a pillow
c. Administering morphine for pain at a 4 on a 0-to-10 scale
d. Supporting the left arm while initially ambulating the client
Only the nurse is authorized to administer medications, but the UAP could inform the nurse about the rating of
pain by the client. The UAP could position the bed to 30 degrees and elevate the clients arm on a pillow to
facilitate lymphatic fluid drainage return. The clients arm should be supported while walking at first but then
allowed to hang straight by the side. The UAP could support the arm while walking the client.
14. A client is starting hormonal therapy with tamoxifen (Nolvadex)
to lower the risk for breast cancer. What
information needs to be explained by the nurse regarding the action of this drug?
a. It blocks the release of luteinizing hormone.
b. It interferes with cancer cell division.
c. It selectively blocks estrogen in the breast.
d. It inhibits DNA synthesis in rapidly dividing cells.
Tamoxifen (Nolvadex) reduces the estrogen available to breast tumors to stop or prevent growth. This drug
does not block the release of luteinizing hormone to prevent the ovaries from producing estrogen; leuprolide
(Lupron) does this. Chemotherapy agents such as ixabepilone (Ixempra) interfere with cancer cell division, and
doxorubicin (Adriamycin) inhibits DNA synthesis in susceptible cells.
15. A client is placed on a medical regimen of doxorubicin
(Adriamycin), cyclophosphamide (Cytoxan), and
fluorouracil (5-FU) for breast cancer. Which side effect seen in the client should the nurse report to the
a. Shortness of breath
b. Nausea and vomiting
c. Hair loss
Doxorubicin (Adriamycin) can cause cardiac problems with symptoms of extreme fatigue, shortness of breath,
chronic cough, and edema. These need to be reported as soon as possible to the provider. Nausea, vomiting,
hair loss, and mucositis are common problems associated with chemotherapy regimens.
17. A woman diagnosed with breast cancer had these laboratory tests performed at an office visit:
Alkaline phosphatase 125 U/L
Total calcium 12 mg/dL
Hemoglobin 14 g/dL
Which test results indicate to the nurse that some further diagnostics are needed?
a. Elevated alkaline phosphatase and calcium suggests bone involvement.
b. Only alkaline phosphatase is decreased, suggesting liver metastasis.
c. Hematocrit and hemoglobin are decreased, indicating anemia.
d. The elevated hematocrit and hemoglobin indicate dehydration.
The alkaline phosphatase (normal value 30 to 120 U/L) and total calcium (normal value 9 to 10.5 mg/dL)
levels are both elevated, suggesting bone metastasis. Both the hematocrit and hemoglobin are within normal
limits for females.
1. The nurse is taking a history of a 68-year-old woman. What
assessment findings would indicate a high risk
for the development of breast cancer? (Select all that apply.)
a. Age greater than 65 years
b. Increased breast density
e. Genetic factors
ANS: A, B, E
The high risk factors for breast cancer are age greater than 65 with the risk increasing until age 80; an increase
in breast density because of more glandular and connective tissue; and inherited mutations of BRCA1 and/or
BRCA2 genes. Osteoporosis and multiparity are not risk factors for breast cancer. A high postmenopausal
bone density and nulliparity are moderate and low increased risk factors, respectively.
2. The nurse is formulating a teaching plan according to
evidence-based breast cancer screening guidelines for
a 50-year-old woman with low risk factors. Which diagnostic methods should be included in the plan? (Select
all that apply.)
a. Annual mammogram
b. Magnetic resonance imaging (MRI)
c. Breast ultrasound
d. Breast self-awareness
e. Clinical breast examination
ANS: A, D, E
Guidelines recommend a screening annual mammogram for women ages 40 years and older, breast self-
awareness, and a clinical breast examination. An MRI is recommended if there are known high risk factors. A
breast ultrasound is used if there are problems discovered with the initial screening or dense breast tissue.
3. After a breast examination, the nurse is documenting assessment
findings that indicate possible breast
cancer. Which abnormal findings need to be included as part of the clients electronic medical record? (Select
all that apply.)
a. Peau dorange
b. Dense breast tissue
c. Nipple retraction
d. Mobile mass at two oclock
e. Nontender axillary nodes
ANS: A, C, D
In the documentation of a breast mass, skin changes such as dimpling (peau dorange), nipple retraction, and
whether the mass is fixed or movable are charted. The location of the mass should be stated by the face of a
clock. Dense breast tissue and nontender axillary nodes are not abnormal assessment findings that may indicate
4. A woman has been using acupuncture to treat the nausea and
vomiting caused by the side effects of
chemotherapy for breast cancer. Which conditions would cause the nurse to recommend against further use of
acupuncture? (Select all that apply.)
b. Bleeding tendencies
c. Low white blood cell count
d. Elevated serum calcium
e. High platelet count
ANS: A, B, C
Acupuncture could be unsafe for the client if there is poor drainage of the extremity with lymphedema or if
there was a bleeding tendency and low white blood cell count. Coagulation would be compromised with a
bleeding disorder, and the risk of infection would be high with the use of needles. An elevated serum calcium
and high platelet count would not have any contraindication for acupuncture.
10. A client has recently been diagnosed with stage III endometrial
cancer and asks the nurse for an
explanation. What response by the nurse is correct about the staging of the cancer?
a. The cancer has spread to the mucosa of the bowel and bladder.
b. It has reached the vagina or lymph nodes.
c. The cancer now involves the cervix.
d. It is contained in the endometrium of the cervix.
Stage III of endometrial cancer reaches the vagina or lymph nodes. Stage I is confined to the endometrium.
Stage II involves the cervix, and stage IV spreads to the bowel or bladder mucosa and/or beyond the pelvis.
11. The client is emotionally upset about the recent diagnosis of
stage IV endometrial cancer. Which action by
the nurse is best?
a. Let the client alone for a long period of reflection time.
b. Ask friends and relatives to limit their visits.
c. Tell the client that an emotional response is unacceptable.
d. Create an atmosphere of acceptance and discussion.
Discussion of a clients concerns about the presence of cancer and the potential for recurrence will provide
emotional support and allay fears. Coping behaviors are encouraged with the support of friends and relatives.
An emotional response should be accepted.
12. A client has scheduled brachytherapy sessions and states that she
feels as though she is not safe around her
family. What is the best response by the nurse?
a. You are only reactive when the radioactive implant is in place.
b. To be totally safe, it is a good idea to sleep in a separate room.
c. It is best to stay a safe distance from friends or family between treatments.
d. You should use a separate bathroom from the rest of the family.
In brachytherapy, the surgeon inserts an applicator into the uterus. After placement is verified, the radioactive
isotope is placed in the applicator for several minutes for a single treatment. There are no restrictions for the
woman to stay away from her family or the public between treatments
14. A 20-year-old client is interested in protection from the human
papilloma virus (HPV) since she may
become sexually active. Which response from the nurse is the most accurate?
a. You are too old to receive an HPV vaccine.
b. Either Gardasil or Cervarix can provide protection.
c. You will need to have three injections over a span of 1 year.
d. The most common side effect of the vaccine is itching at the injection site.
Current HPV vaccines are Gardasil and Cervarix, which should be given before the first sexual contact to
protect against the highest risk HPV types associated with cervical cancer. The client is not too old since it is
recommended that young women up to 26 years should receive an HPV vaccine. The entire series consists of
three injections over 6 months, not 1 year. Local pain and redness surrounding the injection site are very
common, but this does not include itching.
3. The nurse is taking the history of a 24-year-old client diagnosed
with cervical cancer. What possible risk
factors would the nurse assess? (Select all that apply.)
b. Multiple sexual partners
c. Poor diet
e. Younger than 18 at first intercourse
ANS: A, B, C, E
Smoking, multiple sexual partners, poor diet, and age less than 18 for first intercourse are all risk factors for
cervical cancer. Nulliparity is a risk factor for endometrial cancer.
4. A client is scheduled to start external beam radiation therapy
(EBRT) for her endometrial cancer. Which
teaching by the nurse is accurate? (Select all that apply.)
a. You will need to be hospitalized during this therapy.
b. Your skin needs to be inspected daily for any breakdown.
c. It is not wise to stay out in the sun for long periods of time.
d. The perineal area may become damaged with the radiation.
e. The technician applies new site markings before each treatment.
ANS: B, C, D
EBRT is usually performed in ambulatory care and does not require hospitalization. The client needs to know
to evaluate the skin, especially in the perineal area, for any breakdown, and avoid sunbathing. The technician
does not apply new site markings, so the client needs to avoid washing off the markings that indicate the
5. The nurse is teaching a client who is undergoing brachytherapy
about what to immediately report to her
health care provider. Which signs and symptoms would be included in this teaching? (Select all that apply.)
a. Constipation for 3 days
b. Temperature of 99 F
c. Abdominal pain
d. Visible blood in the urine
e. Heavy vaginal bleeding
ANS: C, D, E
Health teaching for a client having brachytherapy should emphasize reporting abdominal pain, visible blood in
the urine, and heavy vaginal bleeding. Severe diarrhea (not constipation), urethral burning, extreme fatigue,
and a fever over 100 F should also be reported.
6. A postmenopausal client is experiencing low back and pelvic pain,
fatigue, and bloody vaginal discharge.
What laboratory tests would the nurse expect to see ordered for this client if endometrial cancer is suspected?
(Select all that apply.)
a. Cancer antigen-125 (CA-125)
b. White blood cell (WBC) count
c. Hemoglobin and hematocrit (H&H)
d. International normalized ratio (INR)
e. Prothrombin time (PT)
ANS: A, C
Serum tumor markers such as CA-125 assess for metastasis, especially if elevated. H&H would evaluate the
possibility of anemia, a common finding with postmenopausal bleeding with endometrial cancer. WBC count
is not indicated since there are no signs of infection. The INR and PT are coagulation tests to measure the time
it takes for a fibrin clot to form. They are used to evaluate the extrinsic pathway of coagulation in clients
receiving oral warfarin.
2. A client is diagnosed with benign prostatic hyperplasia and seems
sad and irritable. After assessing the
clients behavior, which statement by the nurse would be the most appropriate?
a.The urine incontinence should not prevent you from socializing.
b.You seem depressed and should seek more pleasant things to do.
c. It is common for men at your age to have changes in mood.
d. Nocturia could cause interruption of your sleep and cause changes in mood.
Frequent visits to the bathroom during the night could cause sleep interruptions and affect the clients mood and
mental status. Incontinence could cause the client to feel embarrassment and cause him to limit his activities
outside the home. The social isolation could lead to clinical depression and should be treated professionally.
The nurse should not give advice before exploring the clients response to his change in behavior. The statement about age has no validity.
You seem depressed and should seek more pleasant things to do.
It is common for men at your age to have changes in mood.
Nocturia could cause interruption of your sleep and cause changes in mood.
3. A 55-year-old African-American client is having a visit with his
health care provider. What test should the nurse discuss with the
client as an option to screen for prostate cancer, even though
screening is not routinely
a. Complete blood count
b. Culture and sensitivity
c. Prostate-specific antigen
The prostate-specific antigen test should be discussed as an option for prostate cancer screening. A complete
blood count and culture and sensitivity laboratory test will be ordered if infection is suspected. A cystoscopy
would be performed to assess the effect of a bladder neck obstruction.
4. The nurse is teaching a client with benign prostatic hyperplasia (BPH). What statement indicates a lack of understanding by the client?
a. There should be no problem with a glass of wine with dinner each night.
b. I am so glad that I weaned myself off of coffee about a year
c. I need to inform my allergist that I cannot take my normal decongestant.
d. My normal routine of drinking a quart of water during exercise needs to change.
This client did not associate wine with the avoidance of alcohol, and requires additional teaching. The nurse must teach a client with BPH to avoid alcohol, caffeine, and large quantities of fluid in a short amount of time to prevent overdistention of the bladder. Decongestants also need to be avoided to lower the chance for urinary retention. I am so glad that I weaned myself off of coffee about a year ago. I need to inform my allergist that I cannot take my normal decongestant. My normal routine of drinking a quart of water during exercise needs to change.
5. A client has returned from a transurethral resection of the
prostate with a continuous bladder irrigation. Which action by the
nurse is a priority if bright red urinary drainage and clots are noted
5 hours after the surgery?
a.Review the hemoglobin and hematocrit as ordered.
b. Take vital signs and notify the surgeon immediately.
c. Release the traction on the three-way catheter.
d. Remind the client not to pull on the catheter.
Bright red urinary drainage with clots may indicate arterial bleeding. Vital signs should be taken and the
surgeon notified. The traction on the three-way catheter should not be released since it places pressure at the
surgical site to avoid bleeding. The nurses review of hemoglobin and hematocrit and reminding the client not
to pull on the catheter are good choices, but not the priority at this time.
6. A nurse and an unlicensed assistive personnel (UAP) are caring for
a client with an open radical
prostatectomy. Which comfort measure could the nurse delegate to the UAP?
a. Administering an antispasmodic for bladder spasms
b. Managing pain through patient-controlled analgesia
c. Applying ice to a swollen scrotum and penis
d. Helping the client transfer from the bed to the chair
The UAP could aid the client in transferring from the bed to the chair and with ambulation. The nurse would be
responsible for medication administration, assessment of swelling, and the application of ice if needed.
7. A client is diagnosed with metastatic prostate cancer. The client
asks the nurse the purpose of his treatment
with the luteinizing hormonereleasing hormone (LH-RH) agonist leuprolide (Lupron) and the bisphosphonate
pamidronate (Aredia). Which statement by the nurse is most appropriate?
a. The treatment reduces testosterone and prevents bone fractures.
b. The medications prevent erectile dysfunction and increase libido.
c. There is less gynecomastia and osteoporosis with this drug regimen.
d. These medications both inhibit tumor progression by blocking androgens.
Lupron, an LH-RH agonist, stimulates the pituitary gland to release luteinizing hormone (LH) to the point that the gland is depleted of LH and testosterone production is lessened. This may decrease the prostate cancer since it is hormone dependent. Lupron can cause osteoporosis, which results in the need for Aredia to prevent bone loss. Erectile dysfunction, decreased libido, and gynecomastia are side effects of the LH-RH medications. Antiandrogen drugs inhibit tumor progression by blocking androgens at the site of the prostate.
8. The nurse is administering sulfamethoxazole-trimethoprim (Bactrim)
to a client diagnosed with bacterial
prostatitis. Which finding causes the nurse to question this medication for this client?
a. Urinary tract infection
b. Allergy to sulfa medications
d. Elevated serum white blood cells
Before administering sulfamethoxazole-trimethoprim, the nurse must assess if the client is allergic to sulfa drugs. Urinary tract infection, hematuria, and elevated serum white blood cells are common problems
associated with bacterial prostatitis that require long-term antibiotic therapy.
9. A 55-year-old male client is admitted to the emergency department
with symptoms of a myocardial
infarction. Which question by the nurse is the most appropriate before administering nitroglycerin?
a. On a scale from 0 to 10, what is the rating of your chest pain?
b. Are you allergic to any food or medications?
c. Have you taken any drugs like Viagra recently?
d. Are you light-headed or dizzy right now?
Phosphodiesterase-5 inhibitors such as sildenafil (Viagra) relax smooth muscles to increase blood flow to the penis for treatment of erectile dysfunction. In combination with nitroglycerin, there can be extreme hypotension with reduction of blood flow to vital organs. The other questions are appropriate but not the highest priority before administering nitroglycerin.
10. A 34-year-old client comes to the clinic with concerns about an
enlarged left testicle and heaviness in his
lower abdomen. Which diagnostic test would the nurse expect to be ordered to confirm testicular cancer?
a. Alpha-fetoprotein (AFP)
b. Prostate-specific antigen (PSA)
c. Prostate acid phosphatase (PAP)
d. C-reactive protein (CRP)
AFP is a glycoprotein that is elevated in testicular cancer. PSA and
PAP testing is used in the screening of
prostate cancer. CRP is diagnostic for inflammatory conditions.
11. A 25-year-old client has recently been diagnosed with testicular
cancer and is scheduled for radiation
therapy. Which intervention by the nurse is best?
a. Ask the client about his support system of friends and relatives.
b. Encourage the client to verbalize his fears about sexual performance.
c. Explore with the client the possibility of sperm collection.
d. Provide privacy to allow time for reflection about the treatment.
Sperm collection is a viable option for a client diagnosed with testicular cancer and should be completed before radiation therapy, chemotherapy, or radical lymph node dissection. The other options would promote psychosocial support but are not the priority intervention.
12. A 70-year-old client returned from a transurethral resection of
the prostate 8 hours ago with a continuous bladder irrigation. The
nurse reviews his laboratory results as follows:
Sodium 128 mEq/L
Hemoglobin 14 g/dL
Red blood cell count 4.5
What action by the nurse is the most appropriate?
a. Consider starting a blood transfusion.
b. Slow down the bladder irrigation if the urine is pink.
c. Report the findings to the surgeon immediately.
d. Take the vital signs every 15 minutes.
The serum sodium is decreased due to large-volume bladder irrigation (normal is 136 to 145 mEq/L). By slowing the irrigation, there will be less fluid overload and sodium dilution. The hemoglobin and hematocrit values are a low normal, with a slight decrease in the red blood cell count. Therefore, a blood transfusion or frequent vital signs should not be necessary. Immediate report to the surgeon is not necessary.
1. The nurse is administering finasteride (Proscar) and doxazosin
(Cardura) to a 67-year-old client with benign prostatic hyperplasia.
What precautions are related to the side effects of these medications?
(Select all that apply.)
a. Assessing for blood pressure changes when lying, sitting, and arising from the bed
b. Immediately reporting any change in the alanine aminotransferase laboratory test
c. Teaching the client about the possibility of increased libido with these medications
d. Taking the clients pulse rate for a minute in anticipation of bradycardia
e. Asking the client to report any weakness, light-headedness, or dizziness
ANS: A, B, E
Both the 5-alpha-reductase inhibitor (5-ARI) and the alpha1-selective blocking agents can cause orthostatic (postural) hypotension and liver dysfunction. The 5-ARI agent (Proscar) can cause a decreased libido rather than an increased sexual drive. The alpha-blocking drug (Cardura) can cause tachycardia rather than bradycardia.
2. A client is interested in learning about the risk factors for
prostate cancer. Which factors does the nurse
include in the teaching? (Select all that apply.)
a.Family history of prostate cancer
d. Advanced age
e. Eating too much red meat
ANS: A, D, E, F
Advanced family history of prostate cancer, age, a diet high in animal fat, and race are all risk factors for prostate cancer. Smoking and obesity are not known risk factors.
3. A client came to the clinic with erectile dysfunction. What are
some possible causes of this condition that the nurse could discuss
with the client during history taking? (Select all that
a. Recent prostatectomy
b. Long-term hypertension
c. Diabetes mellitus
d. Hour-long exercise sessions
e. Consumption of beer each night
ANS: A, B, C, E
Organic erectile dysfunction can be caused by surgical procedures, hypertension and its treatment, diabetes
mellitus, and alcohol consumption. There is no evidence that exercise is related to this problem.
ANS: A, B, C, E
Organic erectile dysfunction can be caused by surgical procedures, hypertension and its treatment, diabetes
mellitus, and alcohol consumption. There is no evidence that exercise is related to this problem.
1. Post transurethral resection of the prostate, a client has a
three-way catheter with a continuous bladder irrigation. Over the last
12 hours, there has been 1400 mL of irrigation solution infused and
2000 mL measured
in output from the drainage bag. What is the recording of the urinary output for the 12-hour period? (Record your answer using a whole number.) ____ mL
ANS: 600 mL
2000 mL from the drainage bag (including both the irrigation fluid and urine) minus the 1400 mL of irrigation fluid equals 600 mL of urine: 2000 mL 1400 mL = 600 mL.