TB Exam 3

Question 1

1. A nurse cares for a client who has obstructive jaundice. The client asks, “Why is my skin so itchy?” How should the nurse respond?
   a. “Bile salts accumulate in the skin and cause the itching.”
   b. “Toxins released from an inflamed gallbladder lead to itching.”
   c. “Itching is caused by the release of calcium into the skin.”
   d. “Itching is caused by a hypersensitivity reaction.”

Answer 1

A

Question 2

2. After teaching a client who is recovering from laparoscopic cholecystectomy surgery, the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the teaching?
   a. “Drinking at least 2 liters of water each day is suggested.”
   b. “I will decrease the amount of fatty foods in my diet.”
   c. “Drinking fluids with my meals will increase bloating.”
   d. “I will avoid concentrated sweets and simple carbohydrates.”

Answer 2

B

Question 3

3. A nurse cares for a client who is recovering from laparoscopic cholecystectomy surgery. The client reports pain in the shoulder blades. How should the nurse respond?
   a. “Ambulating in the hallway twice a day will help.”
   b. “I will apply a cold compress to the painful area on your back.”
   c. “Drinking a warm beverage can relieve this referred pain.”
   d. “You should cough and deep breathe every hour.”

Answer 3

A
The client who has undergone a laparoscopic cholecystectomy may report free air pain due to retention of carbon dioxide in the abdomen. The nurse assists the client with early ambulation to promote absorption of the carbon dioxide. Cold compresses and drinking a warm beverage would not be helpful. Coughing and deep breathing are important postoperative activities, but they are not related to discomfort from carbon dioxide.

Question 4

4. After teaching a client who has a history of cholelithiasis, the nurse assesses the client’s understanding. Which menu selection made by the client indicates the client clearly understands the dietary teaching?
   a. Lasagna, tossed salad with Italian dressing, and low-fat milk
   b. Grilled cheese sandwich, tomato soup, and coffee with cream
   c. Cream of potato soup, Caesar salad with chicken, and a diet cola
   d. Roasted chicken breast, baked potato with chives, and orange juice

Answer 4

D

Question 5

5. A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this client’s plan of care to reduce discomfort?
   a. Administer morphine sulfate intravenously every 4 hours as needed.
   b. Maintain nothing by mouth (NPO) and administer intravenous fluids.
   c. Provide small, frequent feedings with no concentrated sweets.
   d. Place the client in semi-Fowler’s position with the head of bed elevated.

Answer 5

B
The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production. IV fluids should be used to prevent dehydration. The client may need a nasogastric tube. Pain medications should be given around the clock and more frequently than every 4 to 6 hours. A fetal position with legs drawn up to the chest will promote comfort.

Question 6

6. After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching?
   a. “The capsules can be opened and the powder sprinkled on applesauce if needed.”
   b. “I will wipe my lips carefully after I drink the enzyme preparation.”
   c. “The best time to take the enzymes is immediately after I have a meal or a snack.”
   d. “I will not mix the enzyme powder with food or liquids that contain protein.”

Answer 6

C

The enzymes should be taken immediately before eating meals or snacks

Question 7

11. A nurse assesses a client who has cholecystitis. Which clinical manifestation indicates that the condition is chronic rather than acute?
    a. Temperature of 100.1° F (37.8° C)
    b. Positive Murphy’s sign
    c. Light-colored stools
    d. Upper abdominal pain after eating

Answer 7

C
Jaundice, clay-colored stools, and dark urine are more commonly seen with chronic cholecystitis. The other symptoms are seen equally with both chronic and acute cholecystitis.

Question 8

13. A nurse cares for a client with acute pancreatitis. The client states, “I am hungry.” How should the nurse reply?
    a. “Is your stomach rumbling or do you have bowel sounds?”
    b. “I need to check your gag reflex before you can eat.”
    c. “Have you passed any flatus or moved your bowels?”
    d. “You will not be able to eat until the pain subsides.”

Answer 8

C
Paralytic ileus is a common complication of acute pancreatitis. The client should not eat until this has resolved. Bowel sounds and decreased pain are not reliable indicators of peristalsis. Instead, the nurse should assess for passage of flatus or bowel movement.

Question 9

A nurse prepares to discharge a client with chronic pancreatitis. Which question should the nurse ask to ensure safety upon discharge?

a. “Do you have a one- or two-story home?”
b. “Can you check your own pulse rate?”
c. “Do you have any alcohol in your home?”
d. “Can you prepare your own meals?”

Answer 9

A
A client recovering from chronic pancreatitis should be limited to one floor until strength and activity increase. The client will need a bathroom on the same floor for frequent defecation. Assessing pulse rate and preparation of meals is not specific to chronic pancreatitis. Although the client should be encouraged to stop drinking alcoholic beverages, asking about alcohol availability is not adequate to assess this client’s safety.

Question 10

2. A nurse assesses a client with cholelithiasis. Which assessment findings should the nurse identify as contributors to this client’s condition? (Select all that apply.)
   a. Body mass index of 46
   b. Vegetarian diet
   c. Drinking 4 ounces of red wine nightly
   d. Pregnant with twins
   e. History of metabolic syndrome
   f. Glycosylated hemoglobin level of 15%

Answer 10

A, D, F

Question 11

A nurse teaches a client who is recovering from acute pancreatitis. Which statements should the nurse include in this client’s teaching? (Select all that apply.)

a. “Take a 20-minute walk at least 5 days each week.”
b. “Attend local Alcoholics Anonymous (AA) meetings weekly.”
c. “Choose whole grains rather than foods with simple sugars.”
d. “Use cooking spray when you cook rather than margarine or butter.”
e. “Stay away from milk and dairy products that contain lactose.”
f. “We can talk to your doctor about a prescription for nicotine patches.”

Answer 11

B, D, F

Question 12

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is in the healing phase of acute pancreatitis. Which statements focused on nutritional requirements should the nurse include when delegating care for this client? (Select all that apply.)

a. “Do not allow the client to eat between meals.”
b. “Make sure the client receives a protein shake.”
c. “Do not allow caffeine-containing beverages.”
d. “Make sure the foods are bland with little spice.”
e. “Do not allow high-carbohydrate food items.”

Answer 12

B, C, D

Question 13

5. After teaching a client who has stress incontinence, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching?
   a. “I will limit my total intake of fluids.”
   b. “I must avoid drinking alcoholic beverages.”
   c. “I must avoid drinking caffeinated beverages.”
   d. “I shall try to lose about 10% of my body weight.”

Answer 13

A

Limiting fluids concentrates urine and can irritate tissues, leading to increased incontinence. Many people try to manage incontinence by limiting fluids. Alcoholic and caffeinated beverages are bladder stimulants. Obesity increases intra-abdominal pressure, causing incontinence.

Question 14

6. A nurse cares for adult clients who experience urge incontinence. For which client should the nurse plan a habit training program?
   a. A 78-year-old female who is confused
   b. A 65-year-old male with diabetes mellitus
   c. A 52-year-old female with kidney failure
   d. A 47-year-old male with arthritis

Answer 14

A

For a bladder training program to succeed in a client with urge incontinence, the client must be alert, aware, and able to resist the urge to urinate. Habit training will work best for a confused client. This includes going to the bathroom (or being assisted to the bathroom) at set times. The other clients may benefit from another type of bladder training.

Question 15

7. After delegating care to an unlicensed assistive personnel (UAP) for a client who is prescribed habit training to manage incontinence, a nurse evaluates the UAP’s understanding. Which action indicates the UAP needs additional teaching?
   a. Toileting the client after breakfast
   b. Changing the client’s incontinence brief when wet
   c. Encouraging the client to drink fluids
   d. Recording the client’s incontinence episodes

Answer 15

B

Question 16

8. A nurse plans care for a client with overflow incontinence. Which intervention should the nurse include in this client’s plan of care to assist with elimination?
   a. Stroke the medial aspect of the thigh.
   b. Use intermittent catheterization.
   c. Provide digital anal stimulation.
   d. Use the Valsalva maneuver.

Answer 16

D
In clients with overflow incontinence, the voiding reflex arc is not intact. Mechanical pressure, such as that achieved through the Valsalva maneuver (holding the breath and bearing down as if to defecate), can initiate voiding.

Question 17

9. A confused client with pneumonia is admitted with an indwelling catheter in place. During interdisciplinary rounds the following day, which question should the nurse ask the primary health care provider?
   a. “Do you want daily weights on this client?”
   b. “Will the client be able to return home?”
   c. “Can we discontinue the indwelling catheter?”
   d. “Should we get another chest x-ray today?”

Answer 17

C

Question 18

19. A nurse teaches a client with functional urinary incontinence. Which statement should the nurse include in this client’s teaching?
    a. “You must clean around your catheter daily with soap and water.”
    b. “Wash the vaginal weights with a 10% bleach solution after each use.”
    c. “Operations to repair your bladder are available, and you can consider these.”
    d. “Buy slacks with elastic waistbands that are easy to pull down.”

Answer 18

D

Question 19

20. An emergency department nurse assesses a client with a history of urinary incontinence who presents with extreme dry mouth, constipation, and an inability to void. Which question should the nurse ask first?
    a. “Are you drinking plenty of water?”
    b. “What medications are you taking?”
    c. “Have you tried laxatives or enemas?”
    d. “Has this type of thing ever happened before?”

Answer 19

B

Question 20

21. A nurse teaches a client who is starting urinary bladder training. Which statement should the nurse include in this client’s teaching?
    a. “Use the toilet when you first feel the urge, rather than at specific intervals.”
    b. “Try to consciously hold your urine until the scheduled toileting time.”
    c. “Initially try to use the toilet at least every half hour for the first 24 hours.”
    d. “The toileting interval can be increased once you have been continent for a week.”

Answer 20

B
The client should try to hold the urine consciously until the next scheduled toileting time. Toileting should occur at specific intervals during the training. The toileting interval should be no less than every hour. The interval can be increased once the client becomes comfortable with the interval.

Question 21

A nurse plans care for clients with urinary incontinence. Which client is correctly paired with the appropriate intervention?

a. A 29-year-old client after a difficult vaginal delivery – Habit training
b. A 58-year-old postmenopausal client who is not taking estrogen therapy – Electrical stimulation
c. A 64-year-old female with Alzheimer’s-type senile dementia – Bladder training
d. A 77-year-old female who has difficulty ambulating – Exercise therapy

Answer 21

B

Question 22

25. A nurse cares for a client with urinary incontinence. The client states, “I am so embarrassed. My bladder leaks like a young child’s bladder.” How should the nurse respond?
    a. “I understand how you feel. I would be mortified.”
    b. “Incontinence pads will minimize leaks in public.”
    c. “I can teach you strategies to help control your incontinence.”
    d. “More women experience incontinence than you might think.”

Answer 22

C

Question 23

3. A nurse teaches clients about the difference between urge incontinence and stress incontinence. Which statements should the nurse include in this education? (Select all that apply.)
   a. “Urge incontinence involves a post-void residual volume less than 50 mL.”
   b. “Stress incontinence occurs due to weak pelvic floor muscles.”
   c. “Stress incontinence usually occurs in people with dementia.”
   d. “Urge incontinence can be managed by increasing fluid intake.”
   e. “Urge incontinence occurs due to abnormal bladder contractions.”

Answer 23

B, E

Question 24

A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their clinical manifestation? (Select all that apply.)

a. Stress incontinence – Urine loss with physical exertion
b. Urge incontinence – Large amount of urine with each occurrence
c. Functional incontinence – Urine loss results from abnormal detrusor contractions
d. Overflow incontinence – Constant dribbling of urine
e. Reflex incontinence – Leakage of urine without lower urinary tract disorder

Answer 24

A, B, D

Question 25

A nurse teaches a female client who has stress incontinence. Which statements should the nurse include about pelvic muscle exercises? (Select all that apply.)

a. “When you start and stop your urine stream, you are using your pelvic muscles.”
b. “Tighten your pelvic muscles for a slow count of 10 and then relax for a slow count of 10.”
c. “Pelvic muscle exercises should only be performed sitting upright with your feet on the floor.”
d. “After you have been doing these exercises for a couple days, your control of urine will improve.”
e. “Like any other muscle in your body, you can make your pelvic muscles stronger by contracting them.”

Answer 25

A, B, E

Question 26

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 26

A

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 27

3. A new nurse has been assigned a client who is in the hospital to receive iodine-131 treatment (brachytherapy). Which action by the nurse is best?
   a. Ensure the client is placed in protective isolation.
   b. Hand off 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 27

D

Question 28

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 I’ll let the provider know.”
   d. “Try adding more vitamins B and C to your diet.”

Answer 28

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 29

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 29

B

Question 30

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 30

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 31

7. A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the client’s 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 31

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 32

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

Answer 32

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 33

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 33

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 34

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 facility’s standing policy.
    d. Place the client on protective isolation precautions.

Answer 34

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 35

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 35

ANS: A
The client’s 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 36

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 36

D

The priority is client safety, so the nurse should first teach ways to prevent scalp injury.

Question 37

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 37

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 38

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 client’s gait and balance.
    b. Ask the client about the ease of urine flow.
    c. Document the report completely.
    d. Inquire about the client’s job risks.

Answer 38

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 39

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 don’t feel well.”
    b. “I will wash my toothbrush in the dishwasher once a week.”
    c. “I won’t let anyone share any of my personal items or dishes.”
    d. “It’s alright for me to keep my pets and change the litter box.”

Answer 39

D

Question 40

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 40

B
Ondansetron side effects include postural hypotension, vertigo, and bradycardia, all of which increase the client’s 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 41

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 41

A

Question 42

21. A client is admitted with superior vena cava syndrome. What action by the nurse is most appropriate?
    a. Administer a dose of allopurinol (Aloprim).
    b. Assess the client’s serum potassium level.
    c. Gently inquire about advance directives.
    d. Prepare the client for emergency surgery.

Answer 42

C
Superior vena cava syndrome is often a late-stage manifestation. After the client is stabilized and comfortable, the nurse should initiate a conversation about advance directives. Allopurinol is used for tumor lysis syndrome. Potassium levels are important in tumor lysis syndrome, in which cell destruction leads to large quantities of potassium being released into the bloodstream. Surgery is rarely done for superior vena cava syndrome.

Question 43

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 43

A

Question 44

24. A client with cancer has anorexia and mucositis, and is losing weight. The client’s family members continually bring favorite foods to the client and are distressed when the client won’t 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 isn’t able to eat now no matter what they bring.

Answer 44

B

Question 45

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 45

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 46

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 46

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 47

4. A client has thrombocytopenia. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
   a. Apply the client’s 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 47

A, B, D

Question 48

5. A client has mucositis. What actions by the nurse will improve the client’s 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 48

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 49

6. A client’s 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 client’s 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 49

A, B, C,

Question 50

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 50

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.