Quiz 4

Question 1

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

Answer 1

prioritization and administration of nursing care throughout the day

Question 2

the nurse is caring for a patient who received a bone marrow transplant 10 days ago. The nurse would monitor for which of the following clinical manifestations that could indicate a potentially life threatening situation?

Answer 2

mild temperature elevation

Question 3

in caring for a patient following lobectomy for lung cancer, which of the following should the nurse include in the plan of care

Answer 3

instruct the patient to cough and deep breathe

Question 4

what is the priority nursing focus for a patient experiencing chemo induced anemia?

Answer 4

fatigue related to decreased cellular oxygenation

Question 5

the nurse is assigned a group of patients. Which patient finding would the nurse identify as a factor leading to increased risk for impaired gas exchange?

Answer 5

hemoglobin of 8.5 g/dL

Question 6

a nurse plans care for a client who has COPD and thick, tenacious secretions. Which interventions should the nurse include in this client’s plan of care? SATA

Answer 6

• ask the client to drink 2 liters of fluids daily
• add humidity to the prescribed oxygen
• use a vibrating positive expiratory pressure device

Question 7

a nursing student is caring for client with leukemia. The student asks why the client is still at risk for infection when the client’s WBC is high. What response by the RN is best?

Answer 7

those WBCs are abnormal and don’t provide protection

Question 8

based on these ABG and VS for a COPD client, what should be done? pH 7.32, PaCO2 62, PaO2 46, HCO3 28, HR 110, RR 12, BP 145/65, Ox 76%

Answer 8

initiate oxygen therapy

Question 9

the acid base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis?

Answer 9

chronic lung disease with increased carbon dioxide retention

Question 10

the nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? SATA

Answer 10

• oxygen sat is 98%

- nail beds are pink with cap refill <3 sec

Question 11

a client is receiving chemo through a peripheral IV line. What action by the nurse is most important?

Answer 11

assessing the IV site every hour

Question 12

after receiving hand off report, which client should the oncology nurse see first?

Answer 12

older client on chemo with mental status changes

Question 13

a client has a platelet count of 9800 what action by the nurse is most appropriate

Answer 13

instruct the client to call for help to get out of bed

Question 14

a student studying leukemias learns the risk factors for developing this disorder. Which risk factors does this include SATA

Answer 14

• chemical exposure

- ionizing radiation exposure

Question 15

a nurse works on an oncology unit and delegates personal hygiene to an UAP. What action by the UAP requires intervention from the nurse?

Answer 15

allowing a very tired client to skip oral hygiene and sleep

Question 16

a nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection should the nurse provide for this client?

Answer 16

omelet, soft whole wheat bread

Question 17

a nurse cares for a client with COPD. The client states that he no longer enjoys going out with his friends. How should the nurse respond?

Answer 17

please share any thoughts and feelings that cause you to limit social activities

Question 18

while assessing a client who is 12 hours post op after a thoractomy for lung cancer, a nurse notices that the lower chest tube is dislodges. Which action should the nurse take first

Answer 18

cover the insertion site with sterile gauze

Question 19

a nurse is caring for four clients with leukemia. After hand off report which client should the nurse see first

Answer 19

client who had two blood diarrhea stools this morning

Question 20

a nurse cares for a client who has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?

Answer 20

keep padded clamps at the bedside for use if the drainage system is interrupted