Iggy Exam 4

Question 1

1. The student nurse learning about cellular regulation understands that which process occurs during the S
   phase of the cell cycle?

a. Actual division (mitosis)
b. Doubling of DNA
c. Growing extra membrane
d. No reproductive activity

Answer 1

ANS: B
During the S phase, the cell must double its DNA content through DNA synthesis. Actual division, or mitosis,
occurs during the M phase. Growing extra membrane occurs in the G1 phase. During the G0 phase, the cell is
working but is not involved in any reproductive activity.

Question 2

2. A student nurse asks the nursing instructor what apoptosis means. What response by the instructor is best?
   a. Growth by cells enlarging
   b. Having the normal number of chromosomes
   c. Inhibition of cell growth
   d. Programmed cell death

Answer 2

ANS: D
Apoptosis is programmed cell death. With this characteristic, organs and tissues function with cells that are at
their peak of performance. Growth by cells enlarging is hyperplasia. Having the normal number of
chromosomes is euploidy. Inhibition of cell growth is contact inhibition.

Question 3

3. The nursing instructor explains the difference between normal cells and benign tumor cells. What
   information does the instructor provide about these cells?
   a. Benign tumors grow through invasion of other tissue.
   b. Benign tumors have lost their cellular regulation from contact inhibition.
   c. Growing in the wrong place or time is typical of benign tumors.
   d. The loss of characteristics of the parent cells is called anaplasia.

Answer 3

ANS: C
Benign tumors are basically normal cells growing in the wrong place or at the wrong time. Benign cells grow
through hyperplasia, not invasion. Benign tumor cells retain contact inhibition. Anaplasia is a characteristic of cancer cells.

Question 4

4. A group of nursing students has entered a futuristic science contest in which they have developed a cure for
   cancer. Which treatment would most likely be the winning entry?
   a. Artificial fibronectin infusion to maintain tight adhesion of cells
   b. Chromosome repair kit to halt rapid division of cancer cells
   c. Synthetic enzyme transfusion to allow rapid cellular migration
   d. Telomerase therapy to maintain chromosomal immortality

Answer 4

ANS: A
Cancer cells do not have sufficient fibronectin and so do not maintain tight adhesion with other cells. This is
part of the mechanism of metastasis. Chromosome alterations in cancer cells (aneuploidy) consist of having
too many, too few, or altered chromosome pairs. This does not necessarily lead to rapid cellular division.
Rapid cellular migration is part of metastasis. Immortality is a characteristic of cancer cells due to too much
telomerase.

Question 5

5. Which statement about carcinogenesis is accurate?
   a. An initiated cell will always become clinical cancer.
   b. Cancer becomes a health problem once it is 1 cm in size.
   c. Normal hormones and proteins do not promote cancer growth.
   d. Tumor cells need to develop their own blood supply.

Answer 5

ANS: D
Tumors need to develop their own blood supply through a process called angiogenesis. An initiated cell needs
a promoter to continue its malignant path. Normal hormones and proteins in the body can act as promoters. A
1-cm tumor is a detectable size, but other events have to occur for it to become a health problem.

Question 6

6. The nurse caring for oncology clients knows that which form of metastasis is the most common?
   a. Bloodborne
   b. Direct invasion
   c. Lymphatic spread
   d. Via bone marrow

Answer 6

ANS: A
Bloodborne metastasis is the most common way for cancer to metastasize. Direct invasion and lymphatic
spread are other methods. Bone marrow is not a medium in which cancer spreads, although cancer can occur in
the bone marrow.

Question 7

8. A nurse has taught a client about dietary changes that can reduce the chances of developing cancer. What statement by the client indicates the nurse needs to provide additional teaching?
   a. Foods high in vitamin A and vitamin C are important.
   b. Ill have to cut down on the amount of bacon I eat.
   c. I’m so glad I don’t have to give up my juicy steaks.
   d. Vegetables, fruit, and high-fiber grains are important.

Answer 7

ANS: C
To decrease the risk of developing cancer, one should cut down on the consumption of red meats and animal
fat. The other statements are correct.

Question 8

10. A client asks the nurse if eating only preservative- and dye-free foods will decrease cancer risk. What
    response by the nurse is best?
    a. Maybe; preservatives, dyes, and preparation methods may be risk factors.
    b. No; research studies have never shown those things to cause cancer.
    c. There are other things you can do that will more effectively lower your risk.
    d. Yes; preservatives and dyes are well known to be carcinogens.

Answer 8

ANS: A
Dietary factors related to cancer development are poorly understood, although dietary practices are suspected
to alter cancer risk. Suspected dietary risk factors include low fiber intake and a high intake of red meat or
animal fat. Preservatives, preparation methods, and additives (dyes, flavorings, sweeteners) may have cancerpromoting
effects. It is correct to say that other things can lower risk more effectively, but this does not give
the client concrete information about how to do so, and also does not answer the clients question.

Question 9

1. The nursing student learning about cancer development remembers the characteristics of normal cells. Which
   characteristics does this include? (Select all that apply.)
   a. Differentiated function
   b. Large nucleus-to-cytoplasm ratio
   c. Loose adherence
   d. Nonmigratory
   e. Specific morphology

Answer 9

ANS: A, D, E
Normal cells have the characteristics of differentiated function, nonmigratory, specific morphology, a smaller
nucleus-to-cytoplasm ratio, tight adherence, and orderly and well-regulated growth.

Question 10

2. The nurse working with oncology clients understands that interacting factors affect cancer development.
   Which factors does this include? (Select all that apply.)
   a. Exposure to carcinogens
   b. Genetic predisposition
   c. Immune function
   d. Normal doubling time
   e. State of euploidy

Answer 10

ANS: A, B, C
The three interacting factors needed for cancer development are exposure to carcinogens, genetic
predisposition, and immune function.

Question 11

3. A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse
   most likely to engage? (Select all that apply.)
   a. Demonstrating breast self-examination methods to women
   b. Instructing people on the use of chemoprevention
   c. Providing vaccinations against certain cancers
   d. Screening teenage girls for cervical cancer
   e. Teaching teens the dangers of tanning booths

Answer 11

ANS: B, C, E
Primary prevention aims to prevent the occurrence of a disease or disorder, in this case cancer. Secondary
prevention includes screening and early diagnosis. Primary prevention activities include teaching people about
chemoprevention, providing approved vaccinations to prevent cancer, and teaching teens the dangers of
tanning beds. Breast examinations and screening for cervical cancer are secondary prevention methods.

Question 12

4. A nurse is providing community education on the seven warning signs of cancer. Which signs are included?
(Select all that apply.)
a. A sore that does not heal
b. Changes in menstrual patterns
c. Indigestion or trouble swallowing
d. Near-daily abdominal pain
e. Obvious change in a mole

Answer 12

ANS: A, B, C, E
The seven warning signs for cancer can be remembered with the acronym CAUTION: changes in bowel or
bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or lump in the breast or
elsewhere, indigestion or difficulty swallowing, obvious change in a wart or mole, and nagging cough or
hoarseness. Abdominal pain is not a warning sign.

Question 13

1. A nurse in the oncology clinic is providing preoperative education to a client just diagnosed with cancer.
   The client has been scheduled for surgery in 3 days. What action by the nurse is best?
   a. Call the client at home the next day to review teaching.
   b. Give the client information about a cancer support group.
   c. Provide all the preoperative instructions in writing.
   d. Reassure the client that surgery will be over soon.

Answer 13

ANS: A
Clients are often overwhelmed at a sudden diagnosis of cancer and may be more overwhelmed at the idea of a
major operation so soon. This stress significantly impacts the clients ability to understand, retain, and recall
information. The nurse should call the client at home the next day to review the teaching and to answer
questions. The client may or may not be ready to investigate a support group, but this does not help with
teaching. Giving information in writing is important (if the client can read it), but in itself will not be enough.
Telling the client that surgery will be over soon is giving false reassurance and does nothing for teaching.

Question 14

2. A nurse reads on a hospitalized client’s chart that the client is receiving teletherapy. What action by the nurse
   is best?
   a. Coordinate continuation of the therapy.
   b. Place the client on radiation precautions.
   c. No action by the nurse is needed at this time.
   d. Restrict visitors to only adults over age 18.

Answer 14

ANS: A
The client needs to continue with radiation therapy, and the nurse can coordinate this with the appropriate
department. The client is not radioactive, so radiation precautions and limiting visitors are not necessary.

Question 15

3. A new nurse has been assigned a client who is in the hospital to receive iodine-131 treatment. Which action
   by the nurse is best?
   a. Ensure the client is placed in protective isolation.
   b. Handoff a pregnant client to another nurse.
   c. No special action is necessary to care for this client.
   d. Read the policy on handling radioactive excreta.

Answer 15

ANS: D
This type of radioisotope is excreted in body fluids and excreta (urine and feces) and should not be handled
directly. The nurse should read the facility’s policy for handling and disposing of this type of waste. The other
actions are not warranted.

Question 16

4. A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation
   therapy for breast cancer. What response by the nurse is most appropriate?
   a. Are you getting adequate rest and sleep each day?
   b. It is normal to be fatigued even for years afterward.
   c. This is not normal and Ill let the provider know.
   d. Try adding more vitamins B and C to your diet.

Answer 16

ANS: B
Regardless of the cause, radiation-induced fatigue can be debilitating and may last for months or years after
treatment has ended. Rest and adequate nutrition can affect fatigue, but it is most important that the client
understands this is normal.

Question 17

5. A client tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation
   treatments for cancer. What response by the nurse is most appropriate?
   a. Avoid getting salt water on the radiation site.
   b. Do not expose the radiation area to direct sunlight.
   c. Have a wonderful time and enjoy your vacation!
   d. Remember you should not drink alcohol for a year.

Answer 17

ANS: B
The skin overlying the radiation site is extremely sensitive to sunlight after radiation therapy has been
completed. The nurse should inform the client to avoid sun exposure to this area. This advice continues for 1
year after treatment has been completed. The other statements are not appropriate.

Question 18

6. A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important?
   a. Assessing the IV site every hour
   b. Educating the client on side effects
   c. Monitoring the client for nausea
   d. Providing warm packs for comfort

Answer 18

ANS: A
Intravenous chemotherapy can cause local tissue destruction if it extravasates into the surrounding tissues.
Peripheral IV lines are more prone to this than centrally placed lines. The most important intervention is
prevention, so the nurse should check hourly to ensure the IV site is patent, or frequently depending on facility
policy. Education and monitoring for side effects such as nausea are important for all clients receiving
chemotherapy. Warm packs may be helpful for comfort, but if the client reports that an IV site is painful, the
nurse needs to assess further.

Question 19

7. A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the
   clients oral chemotherapy medications. What action by the nurse is most appropriate?
   a. Crush the medications if the client cannot swallow them.
   b. Give one medication at a time with a full glass of water.
   c. No special precautions are needed for these medications.
   d. Wear personal protective equipment when handling the medications.

Answer 19

ANS: D
During the administration of oral chemotherapy agents, nurses must take the same precautions that are used when administering IV chemotherapy. This includes using personal protective equipment. These medications
cannot be crushed, split, or chewed. Giving one at a time is not needed.

Question 20

8. The nurse working with oncology clients understands that which age-related change increases the older
   clients susceptibility to infection during chemotherapy?
   a. Decreased immune function
   b. Diminished nutritional stores
   c. Existing cognitive deficits
   d. Poor physical reserves

Answer 20

ANS: A
As people age, there is an age-related decrease in immune function, causing the older adult to be more
susceptible to infection than other clients. Not all older adults have diminished nutritional stores, cognitive
dysfunction, or poor physical reserves.

Question 21

9. After receiving the hand-off report, which client should the oncology nurse see first?
   a. Client who is afebrile with a heart rate of 108 beats/min
   b. Older client on chemotherapy with mental status changes
   c. Client who is neutropenic and in protective isolation
   d. Client scheduled for radiation therapy today

Answer 21

ANS: B
Older clients often do not exhibit classic signs of infection, and often mental status changes are the first
observation. Clients on chemotherapy who become neutropenic also often do not exhibit classic signs of
infection. The nurse should assess the older client first. The other clients can be seen afterward.

Question 22

10. A client has a platelet count of 9800/mm3. What action by the nurse is most appropriate?
    a. Assess the client for calf pain, warmth, and redness.
    b. Instruct the client to call for help to get out of bed.
    c. Obtain cultures as per the facilitys standing policy.
    d. Place the client on protective isolation precautions.

Answer 22

ANS: B
A client with a platelet count this low is at high risk for serious bleeding episodes. To prevent injury, the client
should be instructed to call for help prior to getting out of bed. Calf pain, warmth, and redness might indicate a deep vein thrombosis, not associated with low platelets. Cultures and isolation relate to low white cell counts.

Question 23

11. A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL. What medication should the nurse
prepare to administer?
a. Epoetin alfa (Epogen)
b. Filgrastim (Neupogen)
c. Mesna (Mesnex)
d. Oprelvekin (Neumega)

Answer 23

ANS: A
The clients hemoglobin is low, so the nurse should prepare to administer epoetin alfa, a colony-stimulating
factor that increases production of red blood cells. Filgrastim is for neutropenia. Mesna is used to decrease
bladder toxicity from some chemotherapeutic agents. Oprelvekin is used to increase platelet count.

Question 24

12. A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority?
    a. Helping clients adjust to their appearance
    b. Reassuring clients that this change is temporary
    c. Referring clients to a reputable wig shop
    d. Teaching measures to prevent scalp injury

Answer 24

ANS: D
All of the actions are appropriate for clients with alopecia. However, the priority is client safety, so the nurse
should first teach ways to prevent scalp injury.

Question 25

13. A client is receiving interleukins along with chemotherapy. What assessment by the nurse takes priority?
    a. Blood pressure
    b. Lung assessment
    c. Oral mucous membranes
    d. Skin integrity

Answer 25

ANS: A
Interleukins can cause capillary leak syndrome and fluid shifting, leading to intravascular volume depletion.
Although all assessments are important in caring for clients with cancer, blood pressure and other assessments
of fluid status take priority.

Question 26

14. A client is receiving rituximab (Rituxan) and asks how it works. What response by the nurse is best?
    a. It causes rapid lysis of the cancer cell membranes.
    b. It destroys the enzymes needed to create cancer cells.
    c. It prevents the start of cell division in the cancer cells.
    d. It sensitizes certain cancer cells to chemotherapy.

Answer 26

ANS: C

Rituxan prevents the initiation of cancer cell division. The other statements are not accurate.

Question 27

15. Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients should the nurse
    assess first?
    a. Client with dry, itchy, peeling skin
    b. Client with a serum calcium of 9.2 mg/dL
    c. Client with a serum potassium of 2.8 mEq/L
    d. Client with a weight gain of 0.5 pound (1.1 kg) in 1 day

Answer 27

ANS: C
TKIs can cause electrolyte imbalances. This potassium level is very low, so the nurse should assess this client
first. Dry, itchy, peeling skin can be a problem in clients receiving biologic response modifiers, and the nurse
should assess that client next because of the potential for discomfort and infection. This calcium level is
normal. TKIs can also cause weight gain, but the client with the low potassium level is more critical.

Question 28

16. A nurse is assessing a female client who is taking progestins. What assessment finding requires the nurse to
notify the provider immediately?
a. Irregular menses
b. Edema in the lower extremities
c. Ongoing breast tenderness
d. Red, warm, swollen calf

Answer 28

ANS: D
All clients receiving progestin therapy are at risk for thromboembolism. A red, warm, swollen calf is a
manifestation of deep vein thrombosis and should be reported to the provider. Irregular menses, edema in the
lower extremities, and breast tenderness are common side effects of the therapy.

Question 29

17. A client with a history of prostate cancer is in the clinic and reports new onset of severe low back pain.
    What action by the nurse is most important?
    a. Assess the clients gait and balance.
    b. Ask the client about the ease of urine flow.
    c. Document the report completely.
    d. Inquire about the clients job risks.

Answer 29

ANS: A
This client has manifestations of spinal cord compression, which can be seen with prostate cancer. This may
affect both gait and balance and urinary function. For client safety, assessing gait and balance is the priority.
Documentation should be complete. The client may or may not have occupational risks for low back pain, but
with his history of prostate cancer, this should not be where the nurse starts investigating.

Question 30

18. The nurse has taught a client with cancer ways to prevent infection. What statement by the client indicates
    that more teaching is needed?
    a. I should take my temperature daily and when I dont feel well.
    b. I will wash my toothbrush in the dishwasher once a week.
    c. I wont let anyone share any of my personal items or dishes.
    d. Its alright for me to keep my pets and change the litter box.

Answer 30

ANS: D
Clients should wash their hands after touching their pets and should not empty or scoop the cat litter box. The
other statements are appropriate for self-management.

Question 31

19. A client has received a dose of ondansetron (Zofran) for nausea. What action by the nurse is most
    important?
    a. Assess the client for a headache.
    b. Assist the client in getting out of bed.
    c. Instruct the client to reduce salt intake.
    d. Weigh the client daily before the client eats.

Answer 31

ANS: B
Ondansetron side effects include postural hypotension, vertigo, and bradycardia, all of which increase the
clients risk for injury. The nurse should assist the client when getting out of bed. Headache and fluid retention
are not side effects of this drug.

Question 32

20. A nurse working with clients who experience alopecia knows that which is the best method of helping
    clients manage the psychosocial impact of this problem?
    a. Assisting the client to pre-plan for this event
    b. Reassuring the client that alopecia is temporary
    c. Teaching the client ways to protect the scalp
    d. Telling the client that there are worse side effects

Answer 32

ANS: A
Alopecia does not occur for all clients who have cancer, but when it does, it can be devastating. The best action
by the nurse is to teach the client about the possibility and to give the client multiple choices for preparing for
this event. Not all clients will have the same reaction, but some possible actions the client can take are buying a
wig ahead of time, buying attractive hats and scarves, and having a hairdresser modify a wig to look like the
clients own hair. Teaching about scalp protection is important but does not address the psychosocial impact.
Reassuring the client that hair loss is temporary and telling him or her that there are worse side effects are both
patronizing and do not give the client tools to manage this condition.

Question 33

22. A client is having a catheter placed in the femoral artery to deliver yttrium-90 beads into a liver tumor.
    What action by the nurse is most important?
    a. Assessing the clients abdomen beforehand
    b. Ensuring that informed consent is on the chart
    c. Marking the clients bilateral pedal pulses
    d. Reviewing client teaching done previously

Answer 33

ANS: B
This is an invasive procedure requiring informed consent. The nurse should ensure that consent is on the chart.
The other actions are also appropriate but not the priority.

Question 34

23. A nurse works on an oncology unit and delegates personal hygiene to an unlicensed assistive personnel
    (UAP). What action by the UAP requires intervention from the nurse?
    a. Allowing a very tired client to skip oral hygiene and sleep
    b. Assisting clients with washing the perianal area every 12 hours
    c. Helping the client use a soft-bristled toothbrush for oral care
    d. Reminding the client to rinse the mouth with water or saline

Answer 34

ANS: A
Even though clients may be tired, they still need to participate in hygiene to help prevent infection. The other
options are all appropriate.

Question 35

24. A client with cancer has anorexia and mucositis, and is losing weight. The clients family members
    continually bring favorite foods to the client and are distressed when the client wont eat them. What action by
    the nurse is best?
    a. Explain the pathophysiologic reasons behind the client not eating.
    b. Help the family show other ways to demonstrate love and caring.
    c. Suggest foods and liquids the client might be willing to try to eat.
    d. Tell the family the client isnt able to eat now no matter what they bring.

Answer 35

ANS: B
Families often become distressed when their loved ones wont eat. Providing food is a universal sign of caring,
and to some people the refusal to eat signifies worsening of the condition. The best option for the nurse is to
help the family find other ways to demonstrate caring and love, because with treatment-related anorexia and
mucositis, the client is not likely to eat anything right now. Explaining the rationale for the problem is a good
idea but does not suggest to the family anything that they can do for the client. Simply telling the family the
client is not able to eat does not give them useful information and is dismissive of their concerns.

Question 36

25. A client in the emergency department reports difficulty breathing. The nurse assesses the clients appearance as depicted below:
    What action by the nurse is the priority?
    a. Assess blood pressure and pulse.
    b. Attach the client to a pulse oximeter.
    c. Have the client rate his or her pain.
    d. Start high-dose steroid therapy.

Answer 36

ANS: A
This client has superior vena cava syndrome, in which venous return from the head, neck, and trunk is blocked.
Decreased cardiac output can occur. The nurse should assess indicators of cardiac output, including blood
pressure and pulse, as the priority. The other actions are also appropriate but are not the priority.

Question 37

1. The student nurse caring for clients who have cancer understands that the general consequences of cancer
   include which client problems? (Select all that apply.)
   a. Clotting abnormalities from thrombocythemia
   b. Increased risk of infection from white blood cell deficits
   c. Nutritional deficits such as early satiety and cachexia
   d. Potential for reduced gas exchange
   e. Various motor and sensory deficits

Answer 37

ANS: B, C, D, E
The general consequences of cancer include reduced immunity and blood-producing functions, altered GI
structure and function, decreased respiratory function, and motor and sensory deficits. Clotting problems often
occur due to thrombocytopenia (not enough platelets), not thrombocythemia (too many platelets).

Question 38

2. A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (Select all that
   apply. )
   a. Chemo gloves
   b. Facemask
   c. Isolation gown
   d. N95 respirator
   e. Shoe covers

Answer 38

ANS: A, B, C
The Occupational Safety and Health Administration (OSHA) and the Oncology Nurses Society have developed
safety guidelines for those preparing or administering IV chemotherapy. These include double gloves (or
chemo gloves), a facemask, and a gown. An N95 respirator and shoe covers are not required.

Question 39

3. A client on interferon therapy is reporting severe skin itching and irritation. What actions does the nurse
   delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
   a. Apply moisturizers to dry skin.
   b. Apply steroid creams to the skin.
   c. Bathe the client using mild soap.
   d. Help the client with a hot water bath.
   e. Teach the client to avoid sunlight.

Answer 39

ANS: A, C
The nurse can delegate applying unscented moisturizer and using mild soap for bathing. Steroid creams are not
used for this condition. Hot water will worsen the irritation. Client teaching is a nursing function.

Question 40

4. A client has thrombocytopenia. What actions does the nurse delegate to the unlicensed assistive personnel
   (UAP)? (Select all that apply.)
   a. Apply the clients shoes before getting the client out of bed.
   b. Assist the client with ambulation.
   c. Shave the client with a safety razor only.
   d. Use a lift sheet to move the client up in bed.
   e. Use the Waterpik on a low setting for oral care.

Answer 40

ANS: A, B, D
Clients with thrombocytopenia are at risk of significant bleeding even with minor injuries. The nurse instructs
the UAP to put the clients shoes on before getting the client out of bed, assist with ambulation, shave the client
with an electric razor, use a lift sheet when needed to reposition the client, and use a soft-bristled toothbrush
for oral care.

Question 41

5. A client has mucositis. What actions by the nurse will improve the clients nutrition? (Select all that apply.)
   a. Assist with rinsing the mouth with saline frequently.
   b. Encourage the client to eat room-temperature foods.
   c. Give the client hot liquids to hold in the mouth.
   d. Provide local anesthetic medications to swish and spit.
   e. Remind the client to brush teeth gently after each meal.

Answer 41

ANS: A, B, D, E
Mucositis can interfere with nutrition. The nurse can help with rinsing the mouth frequently with water or
saline; encouraging the client to eat cool, slightly warm, or room-temperature foods; providing swish-and-spit
anesthetics; and reminding the client to keep the mouth clean by brushing gently after each meal. Hot liquids
would be painful for the client.

Question 42

6. A clients family members are concerned that telling the client about a new finding of cancer will cause
   extreme emotional distress. They approach the nurse and ask if this can be kept from the client. What actions
   by the nurse are most appropriate? (Select all that apply.)
   a. Ask the family to describe their concerns more fully.
   b. Consult with a social worker, chaplain, or ethics committee.
   c. Explain the clients right to know and ask for their assistance.
   d. Have the unit manager take over the care of this client and family.
   e. Tell the family that this secret will not be kept from the client.

Answer 42

ANS: A, B, C
The clients right of autonomy means that the client must be fully informed as to his or her diagnosis and
treatment options. The nurse cannot ethically keep this information from the client. The nurse can ask the
family to explain their concerns more fully so everyone understands the concerns. A social worker, chaplain, or
ethics committee can become involved to assist the nurse, client, and family. The nurse should explain the
clients right to know and ask the family how best to proceed. The nurse should not abdicate responsibility for
this difficult situation by transferring care to another nurse. Simply telling the family that he or she will not
keep this secret sets up an adversarial relationship. Explaining this fact along with the concept of autonomy
would be acceptable, but this by itself is not.

Question 43

7. A client receiving chemotherapy has a white blood cell count of 1000/mm3. What actions by the nurse are
   most appropriate? (Select all that apply.)
   a. Assess all mucous membranes every 4 to 8 hours.
   b. Do not allow the client to eat meat or poultry.
   c. Listen to lung sounds and monitor for cough.
   d. Monitor the venous access device appearance with vital signs.
   e. Take and record vital signs every 4 to 8 hours.

Answer 43

ANS: A, C, D, E
Depending on facility protocol, the nurse should assess this client for infection every 4 to 8 hours by assessing
all mucous membranes, listening to lung sounds, monitoring for cough, monitoring the appearance of the
venous access device, and recording vital signs. Eating meat and poultry is allowed.

Question 44

5. A nurse assesses clients at a community health center. Which client is at highest risk for the development of
   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 44

ANS: D
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 45

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.

Answer 45

ANS: C
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.

Question 46

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.

Answer 46

ANS: C
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.

Question 47

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.

Answer 47

ANS: B
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.

Question 48

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.

Answer 48

ANS: C
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 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.

Question 49

10. An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across
    the clients lower abdomen. Which action should the nurse take first?
    a. Measure the clients abdominal girth.
    b. Assess for abdominal guarding or rigidity.
    c. Check the clients hemoglobin and hematocrit.
    d. Obtain the clients complete health history.

Answer 49

ANS: B
On noticing the ecchymotic areas, the nurse should check to see if abdominal guarding or rigidity is present,
because this could indicate major organ injury. The nurse should then notify the provider. Measuring abdominal girth or obtaining a complete health history is not appropriate at this time. Laboratory test results
can be checked after assessment for abdominal guarding or rigidity.

Question 50

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.

Answer 50

ANS: A
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.

Question 51

14. A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An
    hour later the client reports constant abdominal pain. Which action should the nurse take next?
    a. Administer intravenous opioid medications.
    b. Position the client with knees to chest.
    c. Insert a nasogastric tube for decompression.
    d. Assess the clients bowel sounds.

Answer 51

ANS: D
A change in the nature and timing of abdominal pain in a client with a bowel obstruction can signal peritonitis
or perforation. The nurse should immediately check for rebound tenderness and the absence of bowel sounds.
The nurse should not medicate the client until the provider has been notified of the change in his or her
condition. The nurse may help the client to the knee-chest position for comfort, but this is not the priority
action. The nurse need not insert a nasogastric tube for decompression.

Question 52

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
    b. Fatigue
    c. Nausea and diarrhea
    d. Mucositis and oral ulcers

Answer 52

ANS: A
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.

Question 53

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.

Answer 53

ANS: A
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.

Question 54

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.

Answer 54

ANS: C
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.

Question 55

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.

Answer 55

ANS: C
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.

Question 56

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.

Answer 56

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.

Question 57

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.

Answer 57

ANS: D
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.

Question 58

1. A nurse inserts a nasogastric (NG) tube for an adult client who has a bowel obstruction. Which actions does
   the nurse perform correctly? (Select all that apply.)
   a. Performs hand hygiene and positions the client in high-Fowlers position, with pillows behind the head and
   shoulders
   b. Instructs the client to extend the neck against the pillow once the NG tube has reached the oropharynx
   c. Checks for correct placement by checking the pH of the fluid aspirated from the tube
   d. Secures the NG tube by taping it to the clients nose and pinning the end to the pillowcase
   e. Connects the NG tube to intermittent medium suction with an anti-reflux valve on the air vent

Answer 58

ANS: A, C, E
The clients head should be flexed forward once the NG tube has reached the oropharynx. The NG tube should
be secured to the clients gown, not to the pillowcase, because it could become dislodged easily. All the other
actions are appropriate.

Question 59

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
   apply. )
   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 re

Answer 59

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.

Question 60

5. A nurse cares for a client who has been diagnosed with a small bowel obstruction. Which assessment
   findings should the nurse correlate with this diagnosis? (Select all that apply.)
   a. Serum potassium of 2.8 mEq/L
   b. Loss of 15 pounds without dieting
   c. Abdominal pain in upper quadrants
   d. Low-pitched bowel sounds
   e. Serum sodium of 121 mEq/L

Answer 60

ANS: A, C, E
Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The client is hypokalemic
(normal range is 3.5 to 5.0 mEq/L) and hyponatremic (normal range is 136 to 145 mEq/L). Abdominal pain
across the upper quadrants is associated with small bowel obstruction. Dramatic weight loss without dieting
followed by bowel obstruction leads to the probable development of colon cancer. High-pitched sounds may be
noted with small bowel obstructions.

Question 61

7. A nurse plans care for a client who has chronic diarrhea. Which actions should the nurse include in this
   clients plan of care? (Select all that apply.)
   a. Using premoistened disposable wipes for perineal care
   b. Turning the client from right to left every 2 hours
   c. Using an antibacterial soap to clean after each stool
   d. Applying a barrier cream to the skin after cleaning
   e. Keeping broken skin areas open to air to promote healing

Answer 61

ANS: A, B, D
The nurse should use premoistened disposable wipes instead of toilet paper for perineal care, or mild soap and
warm water after each stool. Antibacterial soap would be too abrasive and damage good bacteria on the skin.
The nurse should apply a thin layer of a medicated protective barrier after cleaning the skin. The client should
be re-positioned frequently so that he or she is kept off the affected area, and open skin areas should be covered
with DuoDerm or Tegaderm occlusive dressing to promote rapid healing.

Question 62

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?

Answer 62

ANS: C
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.

Question 63

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 breast
c. Nontender immobile mass in the upper outer quadrant of the breast
d. Small, painful mass under warm reddened skin

Answer 63

ANS: C
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.

Question 64

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.

Answer 64

ANS: C
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.

Question 65

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.

Answer 65

ANS: D
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.

Question 66

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.

Answer 66

ANS: C
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.

Question 67

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

Answer 67

ANS: C
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 68

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.

Answer 68

ANS: A
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.

Question 69

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

Answer 69

ANS: C
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.

Question 70

During dressing changes, the nurse assesses a client who has 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 flap

Answer 70

ANS: D
A dusky color of the breast flap could indicate poor tissue perfusion and a decreased capillary refill. The nurse
should notify the surgeon 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 should be
monitored.

Question 71

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.

Answer 71

ANS: C
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.

Question 72

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. A risk factor for lymphedema is infection, so wear gloves when gardening outside.
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 72

ANS: B
Infection can create lymphedema; therefore, the client needs to be cautious with activities using the affected
arm, such as gardening. Radiation therapy is just one of the factors that could cause lymphedema. Other risk
factors include obesity and the 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 73

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

Answer 73

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.

Question 74

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

Answer 74

ANS: A, D, E
Guidelines recommend a screening annual mammogram for women ages 40 years and older, breast selfawareness,
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.

Question 75

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

Answer 75

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
breast cancer.

Question 76

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.)
a. Lymphedema
b. Bleeding tendencies
c. Low white blood cell count
d. Elevated serum calcium
e. High platelet count

Answer 76

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.

Question 77

After hiatal hernia repair surgery, a client is on IV pantoprazole (Protonix). The client asks the nurse why
this medication is given since there is no history of ulcers. What response by the nurse is best?
a. Bacteria can often cause ulcers.
b. This operation often causes ulcers.
c. The medication keeps your blood pH
low.
d. It prevents stress-related ulcers.

Answer 77

ANS: D
After surgery, anti-ulcer medications such as pantoprazole are often given to prevent stress-related ulcers. The
other responses are incorrect.

Question 78

13.A nurse works on the surgical unit. After receiving the hand-off report, which client should the nurse see
first?
a. Client who underwent diverticula removal with a pulse of 106/min
b. Client who had esophageal dilation and is attempting first postprocedure oral
intake
c. Client who had an esophagectomy with a respiratory rate of 32/min
d. Client who underwent hernia repair, reporting incisional pain of 7/10

Answer 78

ANS: C
The client who had an esophagectomy has a respiratory rate of 32/min, which is an early sign of sepsis; this
client needs to be assessed first. The client who underwent diverticula removal has a pulse that is out of the
normal range (106/min), but not terribly so. The client reporting pain needs pain medication, but the client with
the elevated respiratory rate needs investigation first. The nurse should see the client who had esophageal
dilation prior to and during the first attempt at oral feedings, but this can wait until the other clients are cared
for.

Question 79

The nurse is aware that which factors are related to the development of gastroesophageal reflux disease
(GERD)? (Select all that apply.)
a. Delayed gastric emptying
b. Eating large meals
c. Hiatal hernia
d. Obesity
e. Viral infections

Answer 79

ANS: A, B, C, D
Many factors predispose a person to GERD, including delayed gastric emptying, eating large meals, hiatal
hernia, and obesity. Viral infections are not implicated in the development of GERD, although infection with
Helicobacter pylori is.

Question 80

The nurse has taught a client about lifestyle modifications for gastroesophageal reflux disease (GERD). What
statements by the client indicate good understanding of the teaching? (Select all that apply.)
a. I just joined a gym, so I hope that helps me lose weight.
b. I sure hate to give up my coffee, but I guess I have to.
c. I will eat three small meals and three small snacks a
day.
d. Sitting upright and not lying down after meals will help.
e. Smoking a pipe is not a problem and I dont have to stop.

Answer 80

ANS: A, B, C, D
Lifestyle modifications can help control GERD and include losing weight if needed; avoiding chocolate,
caffeine, and carbonated beverages; eating frequent small meals or snacks; and remaining upright after meals.
Tobacco is a risk factor for GERD and should be avoided in all forms.

Question 81

A nurse is teaching clients with gastroesophageal reflux disease (GERD) about foods to avoid. Which foods
should the nurse include in the teaching? (Select all that apply.)
a. Chocolate
b. Decaffeinated
coffee
c. Citrus fruits
d. Peppermint
e. Tomato sauce

Answer 81

ANS: A, C, D, E
Chocolate, citrus fruits such as oranges and grapefruit, peppermint and spearmint, and tomato-based products
all contribute to the reflux associated with GERD. Caffeinated teas, coffee, and sodas should be avoided.

Question 82

1. The nurse is caring for a client with peptic ulcer disease who reports sudden onset of sharp abdominal pain.
   On palpation, the clients abdomen is tense and rigid. What action takes priority?
   a. Administer the prescribed pain medication.
   b. Notify the health care provider immediately.
   c. Percuss all four abdominal quadrants.
   d. Take and document a set of vital signs.

Answer 82

ANS: B
This client has manifestations of a perforated ulcer, which is an emergency. The priority is to get the client
medical attention. The nurse can take a set of vital signs while someone else calls the provider. The nurse
should not percuss the abdomen or give pain medication since the client may need to sign consent for surgery.

Question 83

A client with peptic ulcer disease is in the emergency department and reports the pain has gotten much
worse over the last several days. The clients blood pressure when lying down was 122/80 mm Hg and when
standing was 98/52 mm Hg. What action by the nurse is most appropriate?
a. Administer ibuprofen (Motrin).
b. Call the Rapid Response Team.
c. Start a large-bore IV with normal saline.
d. Tell the client to remain lying down.

Answer 83

ANS: C
This client has orthostatic changes to the blood pressure, indicating fluid volume loss. The nurse should start a
large-bore IV with isotonic solution. Ibuprofen will exacerbate the ulcer. The Rapid Response Team is not
needed at this point. The client should be put on safety precautions, which includes staying in bed, but this is
not the priority.

Question 84

A client with a bleeding gastric ulcer is having a nuclear medicine scan. What action by the nurse is most appropriate?

a. Assess the client for iodine or shellfish allergies.
b. Educate the client on the side effects of sedation.
c. Inform the client a second scan may be needed.
d. Teach the client about bowel preparation for the scan.

Answer 84

ANS: C
A second scan may be performed in 1 to 2 days to see if interventions have worked. The nuclear medicine scan
does not use iodine-containing contrast dye or sedation. There is no required bowel preparation.

Question 85

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

Answer 85

ANS: D
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.

Question 86

A nurse answers a clients call light and finds the client in the bathroom, vomiting large amounts of bright
red blood. Which action should the nurse take first?
a. Assist the client back to bed.
b. Notify the provider immediately.
c. Put on a pair of gloves.
d. Take a set of vital signs.

Answer 86

ANS: C
All of the actions are appropriate; however, the nurse should put on a pair of gloves first to avoid
contamination with blood or body fluids.

Question 87

A client with peptic ulcer disease asks the nurse about taking slippery elm supplements. What response by
the nurse is best?
a. Slippery elm has no benefit for this problem.
b. Slippery elm is often used for this disorder.
c. There is no evidence that this will work.
d. You should not take any herbal remedies.

Answer 87

ANS: B
There are several complementary and alternative medicine regimens that are used for gastritis and peptic ulcer
disease. Most have been tested on animals but not humans. Slippery elm is a common supplement used for this
disorder.

Question 88

The student nurse studying stomach disorders learns that the risk factors for acute gastritis include which of
the following? (Select all that apply.)
a. Alcohol
b. Caffeine
c. Corticosteroids
d. Fruit juice
e. Nonsteroidal anti-inflammatory drugs (NSAIDs)

Answer 88

ANS: A, B, C, E
Risk factors for acute gastritis include alcohol, caffeine, corticosteroids, and chronic NSAID use. Fruit juice is
not a risk factor, although in some people it does cause distress.

Question 89

A nurse working with a client who has possible gastritis assesses the clients gastrointestinal system. Which
findings indicate a chronic condition as opposed to acute gastritis? (Select all that apply.)
a. Anorexia
b. Dyspepsia
c. Intolerance of fatty foods
d. Pernicious anemia
e. Nausea and vomiting

Answer 89

ANS: C, D
Intolerance of fatty or spicy foods and pernicious anemia are signs of chronic gastritis. Anorexia and
nausea/vomiting can be seen in both conditions. Dyspepsia is seen in acute gastritis.

Question 90

A nurse assesses a client who is hospitalized with an exacerbation of Crohns disease. Which clinical
manifestation should the nurse expect to find?
a. Positive Murphys sign with rebound tenderness to palpitation
b. Dull, hypoactive bowel sounds in the lower abdominal quadrants
c. High-pitched, rushing bowel sounds in the right lower quadrant
d. Reports of abdominal cramping that is worse at night

Answer 90

ANS: C
The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohns disease.
A positive Murphys sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis.
Dullness in the lower abdominal quadrants and hypoactive bowel sounds are not commonly found with Crohns
disease. Nightly worsening of abdominal cramping is not consistent with Crohns disease.

Question 91

After teaching a client with diverticular disease, a nurse assesses the clients understanding. Which menu
selection made by the client indicates the client correctly understood the teaching?
a. Roasted chicken with rice pilaf and a cup of coffee with cream
b. Spaghetti with meat sauce, a fresh fruit cup, and hot tea
c. Garden salad with a cup of bean soup and a glass of low-fat milk
d. Baked fish with steamed carrots and a glass of apple juice

Answer 91

ANS: D
Clients who have diverticular disease are prescribed a low-residue diet. Whole grains (rice pilaf), uncooked
fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup of bean soup) should be avoided with a
low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is
acceptable for a low-residue diet.

Question 92

A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment should the nurse
complete first?
a. Inspection of oral mucosa
b. Recent dietary intake
c. Heart rate and rhythm
d. Percussion of abdomen

Answer 92

ANS: C
Although the client with severe diarrhea may experience skin irritation and hypovolemia, the client is most at
risk for cardiac dysrhythmias secondary to potassium and magnesium loss from severe diarrhea. The client
should have her or his electrolyte levels monitored, and electrolyte replacement may be necessary. Oral
mucosa inspection, recent dietary intake, and abdominal percussion are important parts of physical assessment
but are lower priority for this client than heart rate and rhythm.

Question 93

A nurse assesses a client with Crohns disease and colonic strictures. Which clinical manifestation should
alert the nurse to urgently contact the health care provider?
a. Distended abdomen
b. Temperature of 100.0 F (37.8 C)
c. Loose and bloody stool
d. Lower abdominal cramps

Answer 93

ANS: A
The presence of strictures predisposes the client to intestinal obstruction. Abdominal distention may indicate
that the client has developed an obstruction of the large bowel, and the clients provider should be notified right
away. Low-grade fever, bloody diarrhea, and abdominal cramps are common symptoms of Crohns disease.

Question 94

A nurse reviews the chart of a client who has Crohns disease and a draining fistula. Which documentation
should alert the nurse to urgently contact the provider for additional prescriptions?
a. Serum potassium of 2.6 mEq/L
b. Client ate 20% of breakfast meal
c. White blood cell count of 8200/mm3
d. Clients weight decreased by 3 pounds

Answer 94

ANS: A
Fistulas place the client with Crohns disease at risk for hypokalemia which can lead to serious dysrhythmias.
This potassium level is low and should cause the nurse to intervene. The white blood cell count is normal. The
other two findings are abnormal and also warrant intervention, but the potassium level takes priority.

Question 95

After teaching a client who has diverticulitis, a nurse assesses the clients understanding. Which statement
made by the client indicates a need for additional teaching?
a. Ill ride my bike or take a long walk at least three times a week.
b. I must try to include at least 25 grams of fiber in my diet every day.
c. I will take a laxative nightly at bedtime to avoid becoming constipated.
d. I should use my legs rather than my back muscles when I lift heavy objects.

Answer 95

ANS: C
Laxatives are not recommended for clients with diverticulitis because they can increase pressure in the bowel,
causing additional outpouching of the lumen. Exercise and a high-fiber diet are recommended for clients with
diverticulitis because they promote regular bowel function. Using the leg muscles rather than the back for
lifting prevents abdominal straining.

Question 96

A nurse plans care for a client with Crohns disease who has a heavily draining fistula. Which intervention
should the nurse indicate as the priority action in this clients plan of care?
a. Low-fiber diet
b. Skin protection
c. Antibiotic administration
d. Intravenous glucocorticoids

Answer 96

ANS: B
Protecting the clients skin is the priority action for a client who has a heavily draining fistula. Intestinal fluid
enzymes are caustic and can cause skin breakdown or fungal infections if the skin is not protected. The plan of
care for a client who has Crohns disease includes adequate nutrition focused on high-calorie, high-protein,
high-vitamin, and low-fiber meals, antibiotic administration, and glucocorticoids

Question 97

A nurse assesses a client who is recovering from an ileostomy placement. Which clinical manifestation
should alert the nurse to urgently contact the health care provider?
a. Pale and bluish stoma
b. Liquid stool
c. Ostomy pouch intact
d. Blood-smeared output

Answer 97

ANS: A
The nurse should assess the stoma for color and contact the health care provider if the stoma is pale, bluish, or dark. The nurse should expect the client to have an intact ostomy pouch with dark green liquid stool that may
contain some blood.

Question 98

A nurse cares for a client with a new ileostomy. The client states, I dont think my friends will accept me
with this ostomy. How should the nurse respond?
a. Your friends will be happy that you are alive.
b. Tell me more about your concerns.
c. A therapist can help you resolve your concerns.
d. With time you will accept your new body.

Answer 98

ANS: B
Social anxiety and apprehension are common in clients with a new ileostomy. The nurse should encourage the
client to discuss concerns. The nurse should not minimize the clients concerns or provide false reassurance.

Question 99

A nurse cares for a client with ulcerative colitis. The client states, I feel like I am tied to the toilet. This
disease is controlling my life. How should the nurse respond?
a. Lets discuss potential factors that increase your symptoms.
b. If you take the prescribed medications, you will no longer have diarrhea.
c. To decrease distress, do not eat anything before you go out.
d. You must retake control of your life. I will consult a therapist to help.

Answer 99

ANS: A
Clients with ulcerative colitis often express that the disorder is disruptive to their lives. Stress factors can
increase symptoms. These factors should be identified so that the client will have more control over his or her
condition. Prescription medications and anorexia will not eliminate exacerbations. Although a therapist may
assist the client, this is not an appropriate response.

Question 100

A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their
physiologic processes? (Select all that apply.)
a. Lower gastrointestinal bleeding Erosion of the bowel wall
b. Abscess formation Localized pockets of infection develop in the ulcerated bowel lining
c. Toxic megacolon Transmural inflammation resulting in pyuria and fecaluria
d. Nonmechanical bowel obstruction Paralysis of colon resulting from colorectal cancer
e. Fistula Dilation and colonic ileus caused by paralysis of the colon

Answer 100

ANS: A, B, D
Lower GI bleeding can lead to erosion of the bowel wall. Abscesses are localized pockets of infection that
develop in the ulcerated bowel lining. Nonmechanical bowel obstruction is paralysis of the colon that results
from colorectal cancer. When the inflammation is transmural, fistulas can occur between the bowel and bladder
resulting in pyuria and fecaluria. Paralysis of the colon causing dilation and subsequent colonic ileus is known
as a toxic megacolon.