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.
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.
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
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.
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
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.
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
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.
9. A nurse is caring for a client with a history of renal insufficiency who is scheduled for a
computed tomography scan of the head with contrast medium. Which priority intervention
should the nurse implement?
a. Educate the client about strict bedrest after the procedure.
b. Place an indwelling urinary catheter to closely monitor output.
c. Obtain a prescription for intravenous fluids.
d. Contact the provider to cancel the procedure.
ANS: C
If a contrast medium is used, intravenous fluid may be given to promote excretion of the
contrast medium. Contrast medium also may act as a diuretic, resulting in the need for fluid
replacement. The client will not require bedrest. Although urinary output should be monitored
closely, there is no need for an indwelling urinary catheter. There is no need to cancel the
procedure as long as actions are taken to protect the kidneys.
11. A nurse teaches a client who is scheduled for a positron emission tomography scan of the
brain. Which statement should the nurse include in this clients teaching?
a. Avoid caffeine-containing substances for 12 hours before the test.
b. Drink at least 3 liters of fluid during the first 24 hours after the test.
c. Do not take your cardiac medication the morning of the test.
d. Remove your dentures and any metal before the test begins.
ANS: A
Caffeine-containing liquids and foods are central nervous system stimulants and may alter the
test results. No contrast is used; therefore, the client does not need to increase fluid intake. The
client should take cardiac medications as prescribed. Metal does not have to be removed; this
is done for magnetic resonance imaging.
23. A nurse assesses a client with a brain tumor. The client opens his eyes when the nurse calls
his name, mumbles in response to questions, and follows simple commands. How should the
nurse document this clients assessment using the Glasgow Coma Scale shown below?
a. 8 b. 10 c. 12 d. 14
ANS: C
The client opens his eyes to speech (Eye opening: To sound = 3), mumbles in response to
questions (Verbal response: Inappropriate words = 3), and follows simple commands (Motor
response: Obeys commands = 6). Therefore, the clients Glasgow Coma Scale score is: 3 + 3 + 6 =
12.
5. A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodinebased contrast. Which actions should the nurse take to prepare the client for this procedure?
(Select all that apply.)
a. Ensure that an informed consent is present.
b. Ask the client about any allergies.
c. Evaluate the clients renal function.
d. Auscultate bilateral breath sounds.
e. Assess hematocrit and hemoglobin levels.
ANS: A, B, C
A client who is scheduled to receive iodine-based contrast should be asked about allergies,
especially allergies to iodine or shellfish. The clients kidney function should also be evaluated to
determine if it is safe to administer contrast during the procedure. Finally, the nurse should
ensure that an informed consent is present because all clients receiving iodine-based contrast
must give consent. The CT will have no impact on the clients breath sounds or hematocrit and
hemoglobin levels. Findings from these assessments will not influence the clients safety during
the procedure.
7. A nurse delegates care for an older adult client to the unlicensed assistive personnel (UAP).
Which statements should the nurse include when delegating this clients care? (Select all that
apply.)
a. Plan to bathe the client in the evening when the client is most alert.
b. Encourage the client to use a cane when ambulating.
c. Assess the client for symptoms related to pain and discomfort.
d. Remind the client to look at foot placement when walking.
e. Schedule additional time for teaching about prescribed therapies.
ANS: A, B, D
The nurse should tell the UAP to schedule activities when the client is normally awake,
encourage the client to use a cane when ambulating, and remind the client to look where feet
are placed when walking. The nurse should assess the client for symptoms of pain and should
provide sufficient time for older adults to process information, including new teaching. These
are not items the nurse can delegate.
15. A nurse assesses a client after administering prescribed levetiracetam (Keppra). Which
laboratory tests should the nurse monitor for potential adverse effects of this medication?
a. Serum electrolyte levels
b. Kidney function tests
c. Complete blood cell count d. Antinuclear antibodies
ANS: B
Adverse effects of levetiracetam include coordination problems and renal toxicity. The other
laboratory tests are not affected by levetiracetam
18. A nurse assesses a client with Huntington disease. Which motor changes should the nurse
monitor for in this client?
a. Shuffling gait
b. Jerky hand movements
c. Continuous chewing motions
d. Tremors of the hands
ANS: B
An imbalance between excitatory and inhibitory neurotransmitters leads to uninhibited motor
movements, such as brisk, jerky, purposeless movements of the hands, face, tongue, and legs.
Shuffling gait, continuous chewing motions, and tremors are associated with Parkinson disease.
2. The nurse learns that the pathophysiology of Guillain-Barr syndrome includes segmental
demyelination. The nurse should understand that this causes what?
a. Delayed afferent nerve impulses
b. Paralysis of affected muscles
c. Paresthesia in upper extremities
d. Slowed nerve impulse transmission
ANS: D
Demyelination leads to slowed nerve impulse transmission. The other options are not correct.
4. The nurse is preparing a client for a Tensilon (edrophonium chloride) test. What action by the
nurse is most important?
a. Administering anxiolytics
b. Having a ventilator nearby
c. Obtaining atropine sulfate
d. Sedating the client
ANS: C
Atropine is the antidote to edrophonium chloride and should be readily available when a client
is having a Tensilon test. The nurse would not want to give medications that might cause
increased weakness or sedation. A ventilator is not necessary to have nearby, although
emergency equipment should be available.
1. A client with myasthenia gravis is prescribed pyridostigmine (Mestinon). What teaching
should the nurse plan regarding this medication? (Select all that apply.)
a. Do not eat a full meal for 45 minutes after taking the drug.
b. Seek immediate care if you develop trouble swallowing.
c. Take this drug on an empty stomach for best absorption.
d. The dose may change frequently depending on symptoms.
e. Your urine may turn a reddish-orange color while on this drug.
ANS: A, B, D
Pyridostigmine should be given with a small amount of food to prevent GI upset, but the client
should wait to eat a full meal due to the potential for aspiration. If difficulty with swallowing
occurs, the client should seek immediate attention. The dose can change on a day-to-day basis
depending on the clients manifestations. Taking the drug on an empty stomach is not related
although the client needs to eat within 45 to 60 minutes afterwards. The clients urine will not
turn reddish-orange while on this drug.
A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign
tumor and a malignant tumor. Which answer by the nurse is correct?
a.
“Benign tumors do not cause damage to other tissues.”
b.
“Benign tumors are likely to recur in the same location.”
c.
“Malignant tumors may spread to other tissues or organs.”
d.
“Malignant cells reproduce more rapidly than normal cells.”
ANS: C
The major difference between benign and malignant tumors is that malignant tumors invade
adjacent tissues and spread to distant tissues and benign tumors do not metastasize. The other
statements are inaccurate. Both types of tumors may cause damage to adjacent tissues.
Malignant cells do not reproduce more rapidly than normal cells. Benign tumors do not usually
recur.