Exam 3 Test Banks

Question 1

An assistive personnel is caring for a client with leukemia and asks why the client is still at risk for infection when the white blood cell count (WBC) is high. What response by the nurse is correct?

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 don’t provide protection.”

Answer 1

d. “Those WBCs are abnormal and don’t provide protection.”

Rationale: In leukemia, the WBCs are abnormal and do not provide protection to the client against infection.
The other statements are not accurate.

Question 2

The family of a neutropenic client reports that the client “is not acting right.” What action by the nurse is the priority?

a. Ask the client about pain.
b. Assess the client for infection.
c. Take a set of vital signs.
d. Review today’s laboratory results.

Answer 2

b. Assess the client for infection.

Rationale: Neutropenic clients often do not have classic manifestations of infection, but infection is the most common cause of death in neutropenic clients.
The nurse would definitely assess for infection.
The nurse would assess for pain but this is not the priority.

Question 3

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.

Answer 3

c. Help the client find things to hope for each day of recovery.

Rationale: 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 that the recovery period must be endured does not acknowledge his or her feelings.
Diversionary activities are important, but not as important as instilling hope.

Question 4

A client asks about the process of graft-versus-host disease. What explanation by the nurse is correct?

a. “Because of immunosuppression, the donor cells take over.”
b. “It’s like a transfusion reaction because no perfect matches exist.”
c. “The patient’s cells are fighting donor cells for dominance.”
d. “The donor’s cells are actually attacking the patient’s cells.”

Answer 4

d. “The donor’s cells are actually attacking the patient’s cells.”

Rationale: Graft-versus-host disease is an autoimmune-type process in which the donor cells recognize the client’s cells as foreign and begin attacking them.
The other answers are not accurate.

Question 5

The nurse is caring for a patient with leukemia who has severe fatigue. What action by the client best indicates that an important outcome to manage 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

Answer 5

a. Doing activities of daily living (ADLs) using rest periods

Rationale: 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.

Question 6

A client has a platelet count of 9000/mm 3 (9 × 109 /L). The nurse finds the client confused and mumbling. What nursing action takes
priority at this time?

a. Call the Rapid Response Team.
b. Take a set of vital signs.
c. Institute bleeding precautions.
d. Place the client on bedrest.

Answer 6

a. Call the Rapid Response Team.

Rationale: 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.
Bleeding precautions will not address the immediate situation.
Placing the client on bedrest is important, but the critical action is to call for immediate medical attention.

Question 7

A nurse is preparing to administer a blood transfusion. What action is most important?

a. Correctly identify client using two identifiers.
b. Ensure that informed consent is obtained.
c. Hang the blood product with Ringer’s lactate.
d. Stay with the client for the entire transfusion.

Answer 7

b. Ensure that informed consent is obtained.

Rationale: If the facility requires informed consent for transfusions, this action is most important because it precedes the other actions taken during the transfusion.
Correctly identifying the client and blood product is a National Patient Safety Goal, and is the most important action after obtaining informed consent.
Ringer’s lactate is not used to transfuse blood. The nurse does not need to stay with the client for the duration of the transfusion.

Question 8

A nurse is preparing to administer a blood transfusion. Which action is most important?

a. Document the transfusion.
b. Place the client on NPO status.
c. Place the client in isolation.
d. Put on a pair of gloves.

Answer 8

d. Put on a pair of gloves.

Rationale: To prevent bloodborne illness, the nurse should don a pair of gloves prior to hanging the blood.
Documentation is important but not
the priority at this point.
NPO status and isolation are not needed.

Question 9

A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important?

a. Document the events in the client’s medical record.
b. Double-check the client and blood product identification.
c. Place the client on strict bedrest until the pain subsides.
d. Review the client’s medical record for known allergies.

Answer 9

b. Double-check the client and blood product identification.

Rationale: This client most likely had a hemolytic transfusion reaction, most commonly caused by blood type or Rh incompatibility.
The nurse should double-check all identifying information for both the client and blood type.
Documentation occurs after the client is stable.
Bedrest may or may not be needed.
Allergies to medications or environmental items are not related.

Question 10

A client has thrombocytopenia. What statement indicates that 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.”

Answer 10

c. “I usually put ice on bumps or bruises.”

Rationale: 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.

Question 11

A nurse is caring for four clients with leukemia. After the hand-off report, which client would the nurse assess first?

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.

Answer 11

a. Client who had two bloody diarrhea stools this morning.

Rationale: The client who had two bloody diarrhea stools that morning may be hemorrhaging in the gastrointestinal (GI) tract and should be assessed first to monitor for or avoid the client from going into hypovolemic shock.
The client with the slight change in respiratory
rate may have an infection or worsening anemia and should be seen next.
If the client’s respiratory rate was greater than 28 to 30 breaths/min, the client may need the initial assessment.
Marked tachypnea is an early sign of a deteriorating client condition.
The other two clients are not a priority at this time.

Question 12

Which statement by a client with leukemia indicates a need for further teaching by the nurse?

a. “I will use a soft-bristled toothbrush and avoid flossing.”
b. “I will not take aspirin or any aspirin product.”
c. “I will use an electric shaver instead of my manual one.”
d. “I will take a daily laxative to prevent constipation.”

Answer 12

d. “I will take a daily laxative to prevent constipation.”

Rationale: The client experiencing leukemia needs to prevent injury to prevent bleeding, including avoiding hard-bristled toothbrushes, floss, aspirin, and straight or manual safety razors.
However, although constipation can cause hemorrhoids or rectal bleeding, laxatives
can cause fluid and electrolyte imbalances and abdominal cramping.
Stool softeners would be a better option to allow the passage of soft stool.

Question 13

Which risk factor(s) places a client at risk for leukemia? (Select all that apply.)

a. Chemical exposure
b. Genetically modified foods
c. Ionizing radiation exposure
d. Vaccinations
e. Viral infections

Answer 13

a. Chemical exposure
c. Ionizing radiation exposure
e. Viral infections

Rationale: 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.

Question 14

The nurse is assessing a client with chronic leukemia. Which laboratory test result(s) is (are) expected for this client? (Select all
that apply.)

a. Decreased hematocrit
b. Abnormal white blood cell count
c. Low platelet count
d. Decreased hemoglobin
e. Increased albumin

Answer 14

a. Decreased hematocrit
b. Abnormal white blood cell count
c. Low platelet count
d. Decreased hemoglobin

Rationale: Chronic leukemia affects all types of blood cells causing a decrease in red blood cells (RBCs) and platelets.
When the number of RBCs decreases, the client’s hemoglobin and hematocrit also decrease.
White blood cell counts are also abnormal depending on disease progression and management.

Question 15

A client has received a bone marrow transplant and is waiting for engraftment. What action(s) by the nurse are most appropriate? (Select all that apply.)

a. Not allowing any visitors until engraftment
b. Limiting the protein in the client’s diet
c. Placing the client in protective precautions
d. Teaching visitors appropriate hand hygiene
e. Telling visitors not to bring live flowers or plants

Answer 15

c. Placing the client in protective precautions
d. Teaching visitors appropriate hand hygiene
e. Telling visitors not to bring live flowers or plants

Rationale: The client waiting for engraftment after a 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; clients are also told not to work with houseplants in the home.
Limiting protein is not a healthy option and will not promote engraftment.

Question 16

A child with acute myeloblastic leukemia is scheduled to have a bone marrow transplant (BMT). The donor is the child’s own umbilical cord blood that had been previously harvested and banked. This type of BMT is termed

A. Autologous
B. Allogeneic
C. Syngeneic
D. Stem cell

Answer 16

A. Autologous

Rationale: In an autologous transplant, the child’s own marrow or previously harvested and banked cord blood is used.

Question 17

What should the nurse teach parents about oral hygiene for the child receiving chemotherapy?

A. Brush the teeth briskly to remove bacteria
B. Use a mouthwash that contains alcohol
C. Inspect the child’s mouth daily for ulcers
D. Perform oral hygiene twice a day

Answer 17

C. Inspect the child’s mouth daily for ulcers

Rationale: The child’s mouth is inspected regularly for ulcers.
At the first sign of ulceration, an antifungal drug is initiated.

Question 18

A nurse assesses clients at a community health center. Which client is at highest risk for developing colorectal cancer?

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.

Answer 18

d. A 72-year-old who eats fast food frequently.

Rationale: 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.

Question 19

A nurse cares for a client with colorectal 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 would the nurse respond?

a. “I have a good friend with a colostomy who would be willing to talk with you.”
b. “The ostomy nurse will be able to answer all of your questions.”
c. “I will make a referral to the United Ostomy Associations of America.”
d. “You’ll find that most people with colostomies don’t want to talk about them.”

Answer 19

c. “I will make a referral to the United Ostomy Associations of America.”

Rationale: Nurses need to become familiar with community-based resources to better assist clients.
The local chapter of the United Ostomy
Associations of America has resources for clients and their families, including ostomates (specially trained visitors who also have
ostomies).
The nurse would not suggest that the client speak with a personal contact of the nurse. Although the ostomy nurse 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 would not brush aside the client’s 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.

Question 20

A nurse cares for a client who states, “My husband is repulsed by my colostomy and refuses to be intimate with me.” How would
the nurse respond?

a. “Let’s 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.”

Answer 20

a. “Let’s talk to the ostomy nurse to help you and your husband work through this.”

Rationale: The nurse would collaborate with the ostomy nurse to help the client and her husband work through intimacy issues.
The nurse would not minimize the client’s concern about her husband with ways to hide the ostomy.
The client will not hurt the stoma by
engaging in sexual activity.

Question 21

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 would 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 primary health care provider.”

Answer 21

a. “The stool will always be liquid with this type of colostomy.”

Rationale: 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 client’s diet or with the passage of time.

Question 22

A nurse teaches a client who is at risk for colorectal cancer. Which dietary recommendation would the nurse teach the 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 diet.”
d. “Foods high in animal fat help to protect the intestinal mucosa.”

Answer 22

c. “Add vegetables such as broccoli and cauliflower to your diet.”

Rationale: The client would 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.

Question 23

A nurse cares for a client who has a new colostomy. Which action would the nurse take?

a. Empty the pouch frequently to remove excess gas collection.
b. Change the ostomy pouch and barrier 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.

Answer 23

a. Empty the pouch frequently to remove excess gas collection.

Rationale: The nurse would 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 barriers would be used to secure and seal the ostomy appliance; surgical tape would not be used.

Question 24

A nurse cares for a client who has a family history of colorectal cancer. The client states, “My father and my brother had colon
cancer. What is the chance that I will get cancer?” How would 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.”

Answer 24

d. “You should have a colonoscopy more frequently to identify abnormal polyps early.”

Rationale: The nurse would encourage the patient 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 client’s diet to more high-fiber (not low-fiber) and preemptive chemotherapy may decrease the client’s risk of colon cancer but will not prevent it.

Question 25

The nurse is examining a woman’s breast and notes multiple small mobile lumps. Which question would be 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?”

Answer 25

c. “Do the small lumps seem to change with your menstrual period?”

Rationale: 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 changes, but research has not found that it has a significant impact.
Questions related to the client’s last mammogram or breast cancer history are not
related to the nurse’s assessment.

Question 26

Which finding in a female client by the nurse would receive the highest priority for further diagnostics?

a. Tender moveable masses throughout the breast tissue
b. Nipple discharge without a palpable mass
c. Nontender fixed mass in the upper outer quadrant of the breast
d. Small, painful mass under warm reddened skin and nipple discharge

Answer 26

c. Nontender fixed mass in the upper outer quadrant of the breast

Rationale: Malignant lesions are fixed, hard and irregularly shaped and this lesion would be the priority for further diagnostic study. The other lesions are benign breast disorders. The client with nipple discharge but no palpable mass most likely has intraductal papilloma.
The client who has nipple discharge but also has a mass under warm, red, edematous skin most likely has ductal ectasia.

Question 27

A nurse has taught a female client about the modifiable risk factors for breast cancer. 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.”

Answer 27

c. “I am glad that we can still have wine with every evening meal.”

Rationale: 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, maintaining a normal weight, and avoiding hormone replacement are also strategies for breast
cancer prevention.

Question 28

A younger woman from an unfamiliar culture 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. Offer to include support people, such as the male partner, in the decision-making.

Answer 28

d. Offer to include support people, such as the male partner, in the decision-making.

Rationale: The cultural aspects of decision-making need to be considered.
In some cultures, the man often makes the decision to care for the female.
The woman may want to make the decision with other support people or by herself.
The nurse must maintain sensitivity to
cultural, religious, and personal beliefs when it comes to this personal decision.
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 breast augmentation.
There is a small risk that breast cancer can still develop in the remaining mammary tissue.

Question 29

A client has just returned from a right radical mastectomy. Which action by the assistive personnel (AP) would require the nurse
consider to intervene?

a. Checking the amount of urine in the 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

Answer 29

c. Taking the blood pressure on the right arm

Rationale: 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 are all safe postoperative interventions.

Question 30

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 (30 mL).”
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 will contact my primary health care provider.”

Answer 30

a. “I am glad that these tubes will fall out at home when I finally shower.”

Rationale: 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 30 mL for three consecutive days.
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 primary health care would be contacted immediately.

Question 31

During dressing changes, the nurse assesses a client who had breast reconstruction. Which finding would cause the nurse to take
immediate action?

a. Slightly reddened incisional area
b. Blood pressure of 128/75 mm Hg
c. Temperature of 99° F (37.2° C)
d. Dusky color of the breast flap

Answer 31

d. Dusky color of the breast flap

Rationale: A dusky color of the breast flap could indicate poor tissue perfusion. The nurse would notify the primary health care provider to preserve the tissue.
It is normal to have a slightly reddened incision as the skin heals.
The blood pressure is within normal limits
and the temperature is slightly elevated but would be monitored.

Question 32

A client is concerned about the risk of lymphedema after a mastectomy. Which response by the nurse is best?

a. “You do not need to worry about lymphedema since you did not have radiation
therapy.”
b. “Be careful not to injure that arm or get any infection in that arm.”
c. “Numbness, tingling, and swelling are common sensations after a mastectomy.”
d. “The risk for lymphedema is a real threat and can be very self-limiting.”

Answer 32

b. “Be careful not to injure that arm or get any infection in that arm.”

Rationale: Injury and infection are risk factors for lymphedema; therefore, the client needs to be cautious with activities using the affected arm.
Radiation therapy is just one of the factors that could cause lymphedema.
Other risk factors include obesity and presence of axillary disease.
The symptoms of lymphedema are heaviness, aching, fatigue, numbness, tingling, and swelling, and are not common after the surgery.
Women with lymphedema live fulfilling lives.

Question 33

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
c. Osteoporosis
d. Multiparity
e. Genetic factors
f. Early menarche

Answer 33

a. Age greater than 65 years
b. Increased breast density
e. Genetic factors
f. Early menarche

Rationale: Risk factors for breast cancer include advancing age, family and genetic history, early menarche, late menopause, postmenopausal obesity, physical inactivity, combined hormonal therapies, alcohol consumption, and lack of breast feeding

Question 34

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 would 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
f. Self-breast examination

Answer 34

a. Annual mammogram
d. Breast self-awareness
e. Clinical breast examination

Rationale: Guidelines from the American Cancer Society include annual mammograms for low-risk women starting at the age of 45 and continuing through the age of 54. At 55, women can continue annual mammography or change to every 2 years.
MRI and ultrasound are done for abnormal findings or for high-risk women.
Breast self-awareness is important so women can detect changes early.
Current data shows that SBE is not a valuable screening tool.
Asymptomatic women 40 and older should have a clinical breast exam annually.

Question 35

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 client’s electronic medical record? (Select all that apply.)

a. Peau d’orange
b. Dense breast tissue
c. Nipple retraction
d. Mobile mass at 2 o’clock
e. Non-tender axillary nodes
f. Skin ulceration

Answer 35

a. Peau d’orange
c. Nipple retraction
d. Mobile mass at 2 o’clock
f. Skin ulceration

Rationale: In the documentation of a breast mass, skin changes such as dimpling (peau d’orange), 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.” Skin ulceration is also a common sign.
Dense breast tissue and non-tender axillary nodes are not abnormal assessment findings that may indicate breast cancer.

Question 36

Adjuvant treatment with tamoxifen may be recommended for patients with breast cancer if the tumor is

a. smaller than 5 cm.
b. located in the upper outer quadrant only.
c. contained only in the breast.
d. estrogen receptive.

Answer 36

d. estrogen receptive.

Rationale: Tamoxifen is antiestrogen therapy for tumors stimulated by estrogen.
Tamoxifen is used depending on age, stage, and hormone receptor status, not size. Location of the cancer does not determine the usefulness of tamoxifen.
Stage of the cancer is a consideration, but more important is its sensitivity to estrogen.

Question 37

The nurse who is teaching a group of women about breast cancer should tell the women that

a. risk factors identify almost all women who will develop breast cancer.
b. African-American women have a higher rate of breast cancer.
c. 1 in 10 women in the United States will develop breast cancer in her lifetime.
d. the exact cause of breast cancer is unknown.

Answer 37

d. the exact cause of breast cancer is unknown.

Rationale: The exact cause of breast cancer in unknown.
Risk factors help identify women who may get breast cancer and for whom increased surveillance is recommended; however, breast cancer can occur without risk factors. Caucasian women have a higher incidence of breast cancer; however, African-American women have a higher rate of dying of breast cancer after they are diagnosed.
One in eight women in the United States will develop breast cancer in her lifetime.

Question 38

Which diagnostic test is used to confirm a suspected diagnosis of breast cancer?

a. Mammogram
b. Ultrasound
c. Core needle biopsy
d. MRI

Answer 38

c. Core needle biopsy

Rationale: When a suspicious mammogram is noted or a lump is detected, diagnosis is confirmed by either a core needle biopsy or one of the other types of biopsies.
A mammogram screens for breast cancer.
An ultrasound may be used with or before biopsy.
An MRI might be used in select cases.

Question 39

When discussing estrogen replacement therapy (ERT) with a perimenopausal woman, the nurse should include the risks of

a. breast cancer.
b. vaginal and urinary tract atrophy.
c. osteoporosis.
d. arteriosclerosis.

Answer 39

a. breast cancer.

Rationale: Women with a high risk of breast cancer should be counseled against using ERT. Estrogen prevents atrophy of vaginal and urinary tract tissue and protects against the development of osteoporosis.
Estrogen has a favorable effect on circulating lipids, reducing low-density lipoprotein (LDL) and total cholesterol and increasing high-density lipoprotein (HDL).
It also has a direct antiatherosclerotic effect on the arteries.

Question 40

The exact cause of breast cancer remains undetermined. Researchers have found that there are a number of common risk factors that increase a woman’s chance of developing a malignancy. It is essential for the nurse who provides care to women of any age to be aware of which risk factors? (Select all that apply.)

a. Family history
b. Late menarche
c. Early menopause
d. Race
e. Nulliparity or first pregnancy after age 30

Answer 40

a. Family history
d. Race
e. Nulliparity or first pregnancy after age 30

Rationale: Family history, race, and nulliparity or first pregnancy after age 30 are all risk factors for breast cancer.
Early menarche (not late) and late (not early) menopause are also risk factors.

Question 41

Which of the following options should the nurse incorporate into the plan of care as a primary prevention strategy for reduction
of the risk for cancer?

a. Yearly mammography for women aged 40 years and older
b. Using skin protection during sun exposure while at the beach
c. Colonoscopy at age 50 and every 10 years as follow-up
d. Yearly prostate specific antigen (PSA) and digital rectal exam for men aged 50
and over

Answer 41

b. Using skin protection during sun exposure while at the beach

Rationale: Primary prevention of cancer involves avoidance to known causes of cancer, such as sun exposure.
Secondary screening involves physical and diagnostic examination.

Question 42

While the nurse is collecting a health history on a patient admitted for colon cancer, which of the following questions should the
nurse ask as a priority?

a. “Have you noticed any blood in your stool?”
b. “Have you been experiencing nausea?”
c. “Do you have back pain?”
d. “Have you noticed any swelling in your abdomen?”

Answer 42

a. “Have you noticed any blood in your stool?”

Rationale: Early colon cancer is often asymptomatic, with occult or frank blood in the stool being an assessment finding in a patient diagnosed with colon cancer.
If pain is present, it is usually lower abdominal cramping.
Constipation and diarrhea are more frequent findings than nausea or ascites.

Question 43

While planning care for a patient experiencing fatigue due to chemotherapy, which of the following is the most appropriate nursing intervention?

a. Prioritization and administration of nursing care throughout the day
b. Completing all nursing care in the morning so the patient can rest the remainder
of the day
c. Completing all nursing care in the evening when the patient is more rested
d. Limiting visitors, thus promoting the maximal amount of hours for sleep

Answer 43

a. Prioritization and administration of nursing care throughout the day

Rationale: Pacing activities throughout the day conserves energy, and nursing care should be paced as well.
Fatigue is a common side effect of cancer and treatment; and while adequate sleep is important, an increase in the number of hours slept will not resolve the fatigue.
Restriction of visitors does not promote healthy coping and can result in feelings of isolation.

Question 44

The nurse is caring for a patient who received a recent bone marrow transplant. The nurse would monitor for which of the following clinical manifestations could indicate a potentially life-threatening situation.

a. Mucositis
b. Confusion
c. Depression
d. Mild temperature elevation

Answer 44

d. Mild temperature elevation

Rationale: The earliest sign of infection in an immunosuppressed patient can be a mild fever.
Mucositis, confusion, and depression are
possible clinical manifestations but are representative of less life-threatening complications.

Question 45

While the nurse is obtaining the health history of a 75-year-old female patient, which of the following has the greatest
implication for the development of cancer?

a. Being a woman
b. Family history of hypertension
c. Cigarette smoking as a teenager
d. Advancing age

Answer 45

d. Advancing age

Rationale: Aging is a non-modifiable risk factor for the development of cancer with an associated increase seen with aging.
In terms of gender and age, lifetime risk is higher for males than females.
Family history of co-morbidities such as hypertension is not directly correlated with cancer development.
Cigarette smoking as a teenager for the patient is a risk factor but may have
mitigated impact at this point in time based on the patient’s stated age and length of time as a non-smoker.

Question 46

In caring for a patient admitted with lung cancer, which of the following should the nurse expect to find on an assessment?

a. No use of accessory muscles during respirations
b. Orthostatic hypotension upon change of positioning
c. Clear sputum
d. Weight loss compared to last admission

Answer 46

d. Weight loss compared to last admission

Rationale: Common signs/symptoms of lung cancer include coughing, hemoptysis, and weight loss, shortness of breath and chest pain.
The nurse should expect to see weight loss and altered breathing patterns.
Clear sputum and orthostatic blood pressure changes would not be seen.

Question 47

A female patient complains of a “scab that just won’t heal” under her left breast. During your conversation, she also mentions
chronic fatigue, loss of appetite, and slight cough, attributed to allergies. What is the nurse’s best action?

a. Continue to conduct a symptom analysis to better understand the patient’s symptoms and concerns.
b. End the appointment and tell the patient to use skin protection during sun exposure.
c. Suggest further testing with a cancer specialist and provide the appropriate
literature.
d. Tell her to put a bandage on the scab and set a follow-up appointment in 1 week.

Answer 47

a. Continue to conduct a symptom analysis to better understand the patient’s symptoms and concerns.

Rationale: A comprehensive health history is vital to treating and caring for the patient. Often times, symptoms are vague.
The nurse should conduct a symptom analysis to gather as much information as possible. Questions should address the duration of the symptoms and include the location, characteristics, aggravating and relief factors, and any treatments taken thus far.

Question 48

A patient with prostate cancer is taking hormonal therapy to control tumor growth. He reports that his left calf is swollen and
painful. Which of the following would be the nurse’s best action?

a. Instruct the patient to keep the leg elevated.
b. Measure the calf circumference and compare the measurement with the right calf
circumference measurement.
c. Apply ice to the calf after a 10-minute massage of the area.
d. Document assessment findings as an expected response with estrogen therapy.

Answer 48

b. Measure the calf circumference and compare the measurement with the right calf
circumference measurement.

Rationale: A nurse should be aware of potential complications from hormonal therapy such as the development of thrombus formation.
Massaging a calf that is swollen and painful is never correct, because this action might break a clot, causing the formation of an embolus, which could then travel to the lungs.

Question 49

A patient being evaluated for breast cancer is not certain whether she and her family should participate in a genetic screening plan since no one can guarantee the results. What is the nurse’s best response?

a. “If you have a family history of breast cancer, the chances for you to have this
type of cancer increases.”
b. “The decision is up to you in the final analysis.”
c. “If there is no family history, then there is no need to go through the process.”
d. “If your insurance will pay for the screening, then there is no associated risk.”

Answer 49

a. “If you have a family history of breast cancer, the chances for you to have this type of cancer increases.”

Rationale: Individuals with a family history of breast cancer (especially 1st-degree relatives) are at increased risk for disease occurrence.
The nurse should inform the patient of the outcome measures of the screening plan.
The nurse should not dissuade the patient
from the process based on stating there is no family history, as there is no evidence that an adequate family history has been obtained.
Similarly, to correlate the need for genetic testing with insurance and no implied risk cannot be stated equivocally.
Although the decision is up to the patient in the final analysis, that response does not address relevant information about the
purpose of genetic screening.

Question 50

A nurse is reviewing assessment findings for a female patient admitted to the oncology unit. Which finding should alert the nurse
to contact the physician?

a. Blood pressure 130/88
b. Noticeable difference in circumference of lower legs
c. Presence of goiter previously identified on prior admission
d. Negative guaiac test

Answer 50

b. Noticeable difference in circumference of lower legs

Rationale: Examination findings relative to oncology patients and neoplastic growth manifest as visible lesions, physical asymmetry, palpable masses, abnormal sounds or the presence of blood on screening tests.
A blood pressure of 130/88 is within normal range as is a negative guaiac test. Observation of a previous goiter which is consistent with a prior admission is not a concern.
The detection of physical asymmetry as seen by a difference in circumference should be reported to the physician.

Question 51

A client has late-stage colon cancer with metastasis to the spine and bones. Which nursing intervention does the nurse add to the care plan to address a priority problem?

a. Provide six small meals and snacks daily.
b. Offer the client prune juice twice a day.
c. Ensure that the client gets adequate rest.
d. Give the client pain medications around the clock.

Answer 51

d. Give the client pain medications around the clock.

Rationale: Although all interventions might be appropriate, a client with late-stage cancer and bone metastases is at risk for severe pain. Giving the client pain medication around the clock is the best way to manage this type of pain.