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Which of the following is an appropriate nursing intervention? a. Give the client 0.5ml of morphine as ordered by the physician. b. Tell the client that this is a normal response to therapy. c. Assess the client as this may be a sign of spinal cord compression d. Turn the client to sides to relieve back pain. 2. The client is receiving radiation therapy to the head due to brain tumor. Which of the following should the nurse prepare the client for? a. Tell the client not to wash the scalp as this may introduce infection. b. Tell the client that hair loss may be permanent. c. Prepare the client for subsequent surgery. d. Tell the client that any subsequent pain experienced is due to the therapy. 3. The lowest point in WBC count reached after chemotherapy, nadir, most commonly occurs during how many days? a. 1-2 weeks b. 2-3 weeks c. 1 month d. 2 months. 4. Which of the following is the most reliable and only sign of infection in clients with neutropenia? a. A WBC count of 30,000/mm3 b. A platelet count of 150,000. c. A temperature of 38°C. d. A heart rate of 80beats per minute. 5. Which of the following, when stated by the nurse, indicates understanding of handling of chemotherapeutic agents?
a. Chemotherapeutic agents are generalized among clients by age groups. b. Chemotherapy has no risk to fetus thus is safe to administer in pregnant patients. c. All materials used for drug administration should be washed properly. d. For powdered medications, wear a mask and eye protection. 6. A client taking cyclophosphamide is at risk for having hemorrhagic cystitis, which of the following is an appropriate nursing intervention? a. Use pursed-lipped breathing b. Encourage increased fluid intake of at least 3000mL. c. Take the medication during hours of sleep. d. Avoid use of laxatives. 7. Which of the following, if stated by the client, indicates understanding regarding teletherapy? a. I should avoid contact with other people until my therapy is completed. b. I should protect my skin during treatment and for at least 2 months after it. c. I should wash the marked area with plain water and pat it dry. d. I should maintain bed rest. 8. Which of the following is an appropriate nursing intervention for managing fluid and electrolyte imbalances? a. Monitor client for diarrhea only b. Administer antiemetics after chemotherapy. c. Administer antiemetics prior to chemotherapy. d. Monitor for constipation. 9. Which of the following should the head nurse intervene if performed by the staff nurse? a. Providing a calm and quiet environment during administration. b. Testing vein patency with chemotherapeutic agents.
c. Monitoring client closely for anaphylactic reactions. d. Placing damp cloth used for wiping spilled medication in a plastic bag, and the bag in another plastic bag. 10. The client has a platelet count of 20,000, which of the following should not be implemented? a. Using nail file instead of nail clippers in cutting nails. b. Avoiding usage of vaginal douches, rectal suppositories, or enemas. c. Avoiding sexual intercourse. d. Administer aspirin for fever. 1. C. Assess as this may be a sign of spinal cord compression. Back and leg pain are signs of spinal cord compression which warrants medical attention. Other signs and symptoms include: coldness, numbness, tingling, paresthesias. 2. B. Hair loss in radiation to the head may be permanent. Washing the scalp does not introduce infection and surgery is not scheduled right after surgery. It is not given that any pain experienced by the client is due to therapy. 3. A. Nadir most commonly occurs during 7 to 14 days or 1 to 2 weeks. 4. C. A fever with a temperature of 38°C or 100.4°F is the most reliable indicator of neutropenia. A WBC count of 30,000mm3 is not a possible value with clients with neutropenia. A platelet count of 150,000 is normal and is not indicative of infection but bleeding risk. A heart rate of 80bpm is normal. 5. D. Mask and eye protection should be worn when administering powdered medications. Chemotherapeutic agents are individualized according to body weight or body surface area. These agents carries possible risks to fetus and is not administered to pregnant women. Materials used for drug administration are incinerated and not washed. 6. B. A fluid intake of 3000mL reduces risk of hemorrhagic cystitis. Pursed-lipped breathing is an intervention for pulmonary toxicity. Medications are taken early in day. Avoiding use of laxatives is an intervention for constipation. 7. C. Washing the marked area with plain water only is correct. Interventions A and D are for brachytherapy or internal radiation. Protecting the skin should continue up to a year after therapy. 8. C. Administering antiemetics prior to chemotherapy is an appropriate intervention. Administering antiemetics after chemotherapy is not effective as the medication takes time to take effect. The client should be monitored for both diarrhea and constipation.
9. B. Vein patency is not tested using chemotherapeutic agents. Other choices are correct interventions are appropriate in handling chemotherapeutic agents. 10. D. Aspirin and other NSAIDs are contraindicated in cases of thrombocytopenia. Avoiding intercourse is avoided when platelet count falls below 50,000/mm3. Others are appropriate interventions. QUESTIONS & ANSWERS - RATIONALE 1. You are the charge nurse in an emergency department (ED) and must assign two staff members to cover the triage area. Which team is the most appropriate for this assignment? a. An advanced practice nurse and an experienced LPN/LVN b. An experienced LPN/LVN and an inexperienced RN c. An experienced RN and an inexperienced RN d. An experienced RN and a nursing assistant 2. You are working in the triage area of an ED, and four patients approach the triage desk at the same time. List the order in which you will assess these patients. _,_,_,_? a. An ambulatory, dazed 25-year-old male with a bandaged head wound b. An irritable infant with a fever, petechiae, and nuchal rigidity c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity d. A 50-year-old female with moderate abdominal pain and occasional vomiting 3. In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? a. Complete set of vital signs b. Palpation and auscultation of the abdomen c. Brief neurologic assessment d. Initiation of pulse oximetry 4. A 56-year-old patient presents in triage with left-sided chest pain, diaphoresis, and dizziness. This patient should be prioritized into which category? a. High urgent
b. Urgent c. Non-urgent d. Emergent 5. The physician has ordered cooling measures for a child with fever who is likely to be discharged when the temperature comes down. Which of the following would be appropriate to delegate to the nursing assistant? a. Assist the child to remove outer clothing. b. Advise the parent to use acetaminophen instead of aspirin. c. Explain the need for cool fluids. d. Prepare and administer a tepid bath. 6. It is the summer season, and patients with signs and symptoms of heat-related illness present in the ED. Which patient needs attention first? a. An elderly person complains of dizziness and syncope after standing in the sun for several hours to view a parade b. A marathon runner complains of severe leg cramps and nausea. Tachycardia, diaphoresis, pallor, and weakness are observed. c. A previously healthy homemaker reports broken air conditioner for days. Tachypnea, hypotension, fatigue, and profuse diaphoresis are observed. d. A homeless person, poor historian, presents with altered mental status, poor muscle coordination, and hot, dry, ashen skin. Duration of exposure is unknown. 7. You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform. _,_,_,_? a. Perform the chin lift or jaw thrust maneuver. b. Establish unresponsiveness. c. Initiate cardiopulmonary resuscitation (CPR). d. Call for help and activate the code team. e. Instruct a nursing assistant to get the crash cart.
8. The emergency medical service (EMS) has transported a patient with severe chest pain. As the patient is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and no palpable pulse. Which task is appropriate to delegate to the nursing assistant? a. Chest compressions b. Bag-valve mask ventilation c. Assisting with oral intubation d. Placing the defibrillator pads 9. An anxious 24-year-old college student complains of tingling sensations, palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are noted. What priority nursing action should you take? a. Notify the physician immediately. b. Administer supplemental oxygen. c. Have the student breathe into a paper bag. d. Obtain an order for an anxiolytic medication. 10.An experienced traveling nurse has been assigned to work in the ED; however, this is the nurse’s first week on the job. Which area of the ED is the most appropriate assignment for the nurse? a. Trauma team b. Triage c. Ambulatory or fats track clinic d. Pediatric medicine team 1. Answer: C – Triage requires at least one experienced RN. Pairing an experienced RN with inexperienced RN provides opportunities for mentoring. Advanced practice nurses are qualified to perform triage; however, their services are usually required in other areas of the ED. An LPN/LVN is not qualified to perform the initial patient assessment or decision making. Pairing an experienced RN with a nursing assistant is the second best option, because the assistant can obtain vital signs and assist in transporting. 2. Answer: B, A, D, C – An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable,
but not unstable at this point. For the ankle injury, medical evaluation can be delayed 24 – 48 hours if necessary. 3. Answer: C – A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Vital signs, assessment of the abdomen, and initiation of pulse oximetry are considered part of the secondary survey. 4. Answer: D – Chest pain is considered an emergent priority, which is defined as potentially life-threatening. Patients with urgent priority need treatment within 2 hours of triage (e.g. kidney stones). Non-urgent conditions can wait for hours or even days. (High urgent is not commonly used; however, in 5-tier triage systems, High urgent patients fall between emergent and urgent in terms of the time lapsing prior to treatment). 5. Answer: A – The nursing assistant can assist with the removal of the outer clothing, which allows the heat to dissipate from the child’s skin. Advising and explaining are teaching functions that are the responsibility of the RN. Tepid baths are not usually performed because of potential for rebound and shivering. 6. Answer: D – The homeless person has symptoms of heat stroke, a medical emergency, which increases risk for brain damage. Elderly patients are at risk for heat syncope and should be educated to rest in cool area and avoid future similar situations. The runner is having heat crams, which can be managed with rest and fluids. The housewife is experiencing heat exhaustion, and management includes fluids (IV or parenteral) and cooling measures. The prognosis for recovery is good. 7. Answer: B, D, A, C, E – Establish unresponsiveness first. (The patient may have fallen and sustained a minor injury.) If the patient is unresponsive, get help and have someone initiate the code. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. CPR should not be interrupted until the patient recovers or it is determined that heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the team arrives. 8. Answer: A – Nursing assistants are trained in basic cardiac life support and can perform chest compressions. The use of the bag-valve mask requires practice and usually a respiratory therapist will perform this function. The nurse or the respiratory therapist should provide PRN assistance during intubation. The defibrillator pads are clearly marked; however, placement should be done by the RN or physician because of the potential for skin damage and electrical arcing. 9. Answer: C – The patient is hyperventilating secondary to anxiety, and breathing into a paper bag will allow rebreathing of carbon dioxide. Also, encouraging slow breathing will help. Other treatments such as oxygen and medication may be needed if other causes are identified. 10. Answer: C – The fast track clinic will deal with relatively stable patients. Triage, trauma, and pediatric medicine should be staffed with experienced nurses who know the hospital routines and policies and can rapidly locate equipment.
Questions 1. The nurse is teaching a class on biological warfare. Which information should the nurse include in the presentation? a. Contaminated water is the only source of transmission of biological agents. b. Vaccines are available and being prepared to counteract biological agents. c. Biological weapons are less of a threat than chemical agents. d. Biological weapons are easily obtained and result in significant mortality. 2. Which signs/symptoms would the nurse assess in the client who has been exposed to the anthrax bacillus via the skin? a. A scabby, clear fluid–filled vesicle. b. Edema, pruritus, and a 2mm ulcerated vesicle. c. Irregular brownish-pink spots around the hairline. d. Tiny purple spots flush with the surface of the skin. 3. The client has expired secondary to smallpox. Which information about funeral arrangements is most important for the nurse to provide to the client’s family? a. The client must be cremated. b. Suggest an open casket funeral. c. Bury the client within 24 hours. d. Notify the public health department. 4. A chemical exposure has just occurred at an airport. An off-duty nurse, knowledgeable about biochemical agents, is giving directions to the travelers. Which direction should the nurse provide to the travelers? a. Hold their breath as much as possible. b. Stand up to avoid heavy exposure. c. Lie down to stay under the exposure. d. Attempt to breathe through their clothing. 5. The nurse is caring for a client in the prodromal phase of radiation exposure. Which signs/symptoms would the nurse assess in the client? a. Anemia, leukopenia, and thrombocytopenia. b. Sudden fever, chills, and enlarged lymph nodes. c. Nausea, vomiting, and diarrhea. d. Flaccid paralysis, diplopia, and dysphagia. 6. The off-duty nurse hears on the television of a bioterrorism act in the community. Which action should the nurse take first? a. Immediately report to the hospital emergency room. b. Call the American Red Cross to find out where to go. c. Pack a bag and prepare to stay at the hospital. d. Follow the nurse’s hospital policy for responding. 7. Which situation would warrant the nurse obtaining information from a material safety data sheet (MSDS)? a. The custodian spilled a chemical solvent in the hallway. b. A visitor slipped and fell on the floor that had just been mopped. c. A bottle of antineoplastic agent broke on the client’s floor. d. The nurse was stuck with a contaminated needle in the client’s room. 8. The triage nurse is working in the emergency department. Which client should be assessed first? a. The 10-year-old child whose dad thinks the child’s leg is broken. b. The 45-year-old male who is diaphoretic and clutching his chest. c. The 58-year-old female complaining of a headache and seeing spots. d. The 25-year-old male who cut his hand with a hunting knife.
9. According to the North Atlantic Treaty Organization (NATO) triage system, which situation would be considered a level red (Priority 1)? a. Injuries are extensive and chances of survival are unlikely. b. Injuries are minor and treatment can be delayed hours to days. c. Injuries are significant but can wait hours without threat to life or limb. d. Injuries are life threatening but survivable with minimal interventions. 10. Which statement best describes the role of the medical-surgical nurse during a disaster? a. The nurse may be assigned to ride in the ambulance. b. The nurse may be assigned as a first assistant in the operating room. c. The nurse may be assigned to crowd control. d. The nurse may be assigned to the emergency department. ANSWERS with RATIONALE: 1. Answer: D Rationale: Because of the variety of agents, the means of transmission, and lethality of the agents, biological weapons, including anthrax, smallpox, and plague, is especially dangerous. 2. Answer: B Rationale: Exposure to anthrax bacilli via the skin results in skin lesions, which cause edema with pruritus and the formation of macules or papules that ulcerate, forming a 1-3 mm vesicle. Then a painless eschar develops, which falls off in one (1) to 2 weeks. 3. Answer: A Rationale: Cremation is recommended because the virus can stay alive in the scabs of the body for 13 years. 4. Answer: B Rationale: Standing up will avoid heavy exposure the chemical will sink toward the floor or ground. 5. Answer: C Rationale: The prodromal phase (presenting symptoms) of radiation exposure occurs 48–72 hours after exposure and the signs/symptoms are nausea, vomiting, diarrhea, anorexia, and fatigue. Higher exposures of radiation signs/symptoms include fever, respiratory distress, and excitability. 6. Answer: D Rationale: The nurse should follow the hospital’s policy. Many times nurses will stay at home until decisions are made as to where the employees should report. 7. Answer: A Rationale: The MSDS provides chemical information regarding specific agents, health information, and spill information for a variety of chemicals. It is required for every chemical that is found in the hospital. 8. Answer: B Rationale: The triage nurse should see this client first because these are symptoms of a myocar- dial infarction, which potentially life is threatening. 9. Answer: D Rationale: This is called the immediate category. Individuals in this group can progress rapidly to expectant if treatment is delayed.
10. Answer: D Rationale: New settings and atypical roles for nurses may be required during disasters; medical-surgical nurses can provide first aid and be required to work in unfamiliar settings. NURSING COMPETENCY APPRAISAL EMERGENCY NURSING 1. The emergency medical service (EMS) has transported a patient with severe chest pain. As the patient is being transferred to the emergency stretcher, you note unresponsiveness, cessation of breathing, and no palpable pulse. Which task is appropriate to delegate to the nursing assistant? a. Chest compressions b. Bag-valve mask ventilation c. Assisting with oral intubation d. Placing the defibrillator pads Rationale: Nursing assistants are trained in basic cardiac life support and can perform chest compressions. The use of the bag-valve mask requires practice and usually a respiratory therapist will perform this function. The nurse or the respiratory therapist should provide PRN assistance during intubation. The defibrillator pads are clearly marked; however, placement should be done by the RN or physician because of the potential for skin damage and electrical arcing. 2. An anxious 24-year-old college student complains of tingling sensations, palpitations, and chest tightness. Deep, rapid breathing and carpal spasms are noted. What priority nursing action should you take? a. Notify the physician immediately. b. Administer supplemental oxygen. c. Have the student breathe into a paper bag. d. Obtain an order for an anxiolytic medication. Rationale: The patient is hyperventilating secondary to anxiety, and breathing into a paper bag will allow rebreathing of carbon dioxide. Also, encouraging slow breathing will help. Other treatments such as oxygen and medication may be needed if other causes are identified. 3. An experienced traveling nurse has been assigned to work in the ED; however, this is the nurse’s first week on the job. Which area of the ED is the most appropriate assignment for the nurse?
a. Trauma team b. Triage c. Ambulatory or fast track clinic d. Pediatric medicine team Rationale: The fast track clinic will deal with relatively stable patients. Triage, trauma, and pediatric medicine should be staffed with experienced nurses who know the hospital routines and policies and can rapidly locate equipment. 4. A patient sustains an amputation of the first and second digits in a chainsaw accident. Which task should be delegated to the LPN/LVN? a. Gently cleanse the amputated digits with Betadine solution. b. Place the amputated digits directly into ice slurry. c. Wrap the amputated digits in sterile gauze moistened with saline. d. Store the amputated digits in a solution of sterile normal saline. Rationale: The only correct intervention is C. the digits should be gently cleansed with normal saline, wrapped in sterile gauze moistened with saline, and placed in a plastic bag or container. The container is then placed on ice. 5. A 36-year-old patient with a history of seizures and medication compliance of phenytoin (Dilantin) and carbamazepine (Tegretol) is brought to the ED by the MS personnel for repetitive seizure activity that started 45 minutes prior to arrival. You anticipate that the physician will order which drug for status epilepticus? a. PO phenytoin and carbamazepine b. IV lorazepam (Ativan) c. IV carbamazepam d. IV magnesium sulfate Rationale: IV Lorazepam (Ativan) is the drug of choice for status epilepticus. Tegretol is used in the management of generalized tonic-clonic, absence or mixed type seizures, but it does not come in an IV form. PO (per os) medications are inappropriate for this emergency situation. Magnesium sulfate is given to control seizures in toxemia of pregnancy. 6. You are preparing a child for IV conscious sedation prior to repair of a facial laceration. What information should you immediately report to the physician?
a. The parent is unsure about the child’s tetanus immunization status. b. The child is upset and pulls out the IV. c. The parent declines the IV conscious sedation. d. The parent wants information about the IV conscious sedation. Rationale: Parent refusal is an absolute contraindication; therefore, the physician must be notified. Tetanus status can be addressed later. The RN can restart the IV and provide information about conscious sedation; if the parent still notsatisfied, the physician can give more information. 7. An intoxicated patient presents with slurred speech, mild confusion, and uncooperative behavior. The patient is a poor historian but admits to “drinking a few on the weekend.” What is the priority nursing action for this patient? a. Obtain an order for a blood alcohol level. b. Contact the family to obtain additional history and baseline information. c. Administer naloxone (Narcan) 2 – 4 mg as ordered. d. Administer IV fluid support with supplemental thiamine as ordered. Rationale: The patient presents with symptoms of alcohol abuse and there is a risk for Wernicke’s syndrome, which is caused by a thiamine deficiency. Multiples drug abuse is not uncommon; however, there is nothing in the question that suggests an opiate overdose that requires naloxone. Additional information or the results of the blood alcohol level are part of the total treatment plan but should not delay the immediate treatment 8. When an unexpected death occurs in the ED, which of the following tasks is most appropriate to delegate to the nursing assistant? a. Escort the family to a place of privacy. b. Go with the organ donor specialist to talk to the family. c. Assist with postmortem care. d. Assist the family to collect belongings. Rationale: Postmortem care requires some turning, cleaning, lifting, etc., and the nursing assistant is able to assist with these duties. The RN should take responsibility for the other tasks to help the family begin the grieving process. In cases of questionable death, belongings may be retained for evidence, so the chain of custody would have to be maintained.
9. 29.In the work setting, what is your primary responsibility in preparing for disaster management that includes natural disasters or bioterrorism incidents? a. Knowledge of the agency’s emergency response plan b. Awareness of the signs and symptoms for potential agnets of bioterrorism c. Knowledge of how and what to report to the CDC d. Ethical decision-making about exposing self to potentially lethal substances Rationale: In preparing for disasters, the RN should be aware of the emergency response plan. The plan gives guidance that includes roles of team members, responsibilities, and mechanisms of reporting. Signs and symptoms of many agents will mimic common complaints, such as flulike symptoms. Discussions with colleagues and supervisors may help the individual nurse to sort through ethical dilemmas related to potential danger to self. 10. You are giving discharge instructions to a woman who has been treated for contusions and bruises sustained during an episode of domestic violence. What is your priority intervention for this patient? a. Transportation arrangements to a safe house b. Referral to a counselor c. Advise about contacting the police d. Follow-up appointment for injuries Rationale: Safety is a priority for this patient, and she should not return to a place where violence could reoccur. The other options are important for the long term management of this care. 1. Nurse Cecilia is caring for a client who has undergone a vaginal hysterectomy. The nurse avoids which of the following in the care of this client? a. Elevating the knee gatch on the bed b. Assisting with range-of-motion leg exercises c. Removal of antiembolism stockings twice daily d. Checking placement of pneumatic compression boots 2. Mina, who is suspected of an ovarian tumor is scheduled for a pelvic ultrasound. The nurse provides which preprocedure instruction to the client?
a. Eat a light breakfast only b. Maintain an NPO status before the procedure c. Wear comfortable clothing and shoes for the procedure d. Drink six to eight glasses of water without voiding before the test 3. A male client is diagnosed as having a bowel tumor and several diagnostic tests are prescribed. The nurse understands that which test will confirm the diagnosis of malignancy? a. Biopsy of the tumor b. Abdominal ultrasound c. Magnetic resonance imaging d. Computerized tomography scan 4. A female client diagnosed with multiple myeloma and the client asks the nurse about the diagnosis. The nurse bases the response on which description of this disorder? a. Altered red blood cell production b. Altered production of lymph nodes c. Malignant exacerbation in the number of leukocytes d. Malignant proliferation of plasma cells within the bone 5. Nurse Bea is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which of the following would the nurse expect to note specifically in this disorder? a. Increased calcium b. Increased white blood cells c. Decreased blood urea nitrogen level d. Decreased number of plasma cells in the bone marrow 6. Vanessa, a community health nurse conducts a health promotion program regarding testicular cancer to community members. The nurse determines that further information needs to be provided if a community member states that which of the following is a sign of testicular cancer? a. Alopecia b. Back pain c. Painless testicular swelling d. Heavy sensation in the scrotum 7. The male client is receiving external radiation to the neck for cancer of the larynx. The most likely side effect to be expected is: a. Dyspnea b. Diarrhea c. Sore throat d. Constipation 8. Nurse Joy is caring for a client with an internal radiation implant. When caring for the client, the nurse should observe which of the following principles? a. Limit the time with the client to 1 hour per shift b. Do not allow pregnant women into the client’s room c. Remove the dosimeter badge when entering the client’s room d. Individuals younger than 16 years old may be allowed to go in the room as long as they are 6 feet away from the client 9. A cervical radiation implant is placed in the client for treatment of cervical cancer. The nurse initiates what most appropriate activity order for this client?
a. Bed rest b. Out of bed ad lib c. Out of bed in a chair only d. Ambulation to the bathroom only 10. A female client is hospitalized for insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. The initial action by the nurse is to: a. Call the physician b. Reinsert the implant into the vagina immediately c. Pick up the implant with gloved hands and flush it down the toilet d. Pick up the implant with long-handled forceps and place it in a lead container. ONCOLOGY NURSING EXAM ANSWERS AND RATIONALES 1. Answer A. The client is at risk of deep vein thrombosis or thrombophlebitis after this surgery, as for any other major surgery. For this reason, the nurse implements measures that will prevent this complication. Range-of-motion exercises, antiembolism stockings, and pneumatic compression boots are helpful. The nurse should avoid using the knee gatch in the bed, which inhibits venous return, thus placing the client more at risk for deep vein thrombosis or thrombophlebitis. 2. Answer D. A pelvic ultrasound requires the ingestion of large volumes of water just before the procedure. A full bladder is necessary so that it will be visualized as such and not mistaken for a possible pelvic growth. An abdominal ultrasound may require that the client abstain from food or fluid for several hours before the procedure. Option C is unrelated to this specific procedure. 3. Answer A. A biopsy is done to determine whether a tumor is malignant or benign. Magnetic resonance imaging, computed tomography scan, and ultrasound will visualize the presence of a mass but will not confirm a diagnosis of malignancy. 4. Answer D. Multiple myeloma is a B-cell neoplastic condition characterized by abnormal malignant proliferation of plasma cells and the accumulation of mature plasma cells in the bone marrow. Options A and B are not characteristics of multiple myeloma. Option C describes the leukemic process. 5. Answer A. Findings indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue, and an elevated blood urea nitrogen level. An increased white blood cell count may or may not be present and is not related specifically to multiple myeloma. 6. Answer A. Alopecia is not an assessment finding in testicular cancer. Alopecia may occur, however, as a result of radiation or chemotherapy. Options B, C, and D are assessment findings in testicular cancer. Back pain may indicate metastasis to the retroperitoneal lymph nodes. 7. Answer C. In general, only the area in the treatment field is affected by the radiation. Skin reactions, fatigue, nausea, and anorexia may occur with radiation to any site, whereas other side effects occur only when specific areas are involved in treatment. A client receiving radiation to the larynx is most likely to experience a sore throat. Options B and D may occur with radiation to the gastrointestinal tract. Dyspnea may occur with lung involvement.
8. Answer B. The time that the nurse spends in a room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The dosimeter badge must be worn when in the client’s room. Children younger than 16 years of age and pregnant women are not allowed in the client’s room. 9. Answer A. The client with a cervical radiation implant should be maintained on bed rest in the dorsal position to prevent movement of the radiation source. The head of the bed is elevated to a maximum of 10 to 15 degrees for comfort. The nurse avoids turning the client on the side. If turning is absolutely necessary, a pillow is placed between the knees and, with the body in straight alignment, the client is logrolled. 10. Answer D. A lead container and long-handled forceps should be kept in the client’s room at all times during internal radiation therapy. If the implant becomes dislodged, the nurse should pick up the implant with long-handled forceps and place it in the lead container. Options A, B, and C are inaccurate interventions. 1. The nurse is triaging four clients injured in a train derailment. Which client should receive priority treatment? A. A 42-year-old with dyspnea and chest asymmetry B. A 17-year-old with a fractured arm C. A 4-year-old with facial lacerations D. A 30-year-old with blunt abdominal trauma Answer A is correct. Following the ABCDs of basic emergency care, the client with dyspnea and asymmetrical chest should be cared for first because these symptoms are associated with flail chest. Answer D is incorrect because he should be cared for second because of the likelihood of organ damage and bleeding. Answer B is incorrect because he should be cared for after the client with abdominal trauma. Answer C is incorrect because he should receive care last because his injuries are less severe. 2. Direct pressure to a deep laceration on the client’s lower leg has failed to stop the bleeding. The nurse’s next action should be to: A. Place a tourniquet proximal to the laceration. B. Elevate the leg above the level of the heart. C. Cover the laceration and apply an ice compress. D. Apply pressure to the femoral artery. Answer B is correct. If bleeding does not subside with direct pressure, the nurse should elevate the extremity above the level of the heart. Answers A and D are done only if other measures are ineffective, so they are incorrect. Answer C would slow the bleeding but will not stop it, so it’s incorrect.
3.A pediatric client is admitted after ingesting a bottle of vitamins with iron. Emergency care would include treatment with: A. Acetylcysteine B. Deferoxamine C. Calcium disodium acetate D. British antilewisite Answer B is correct. Deferoxamine is the antidote for iron poisoning. Answer A is the antidote for acetaminophen overdose, making it wrong. Answers C and D are antidotes for lead poisoning, so they are wrong. 4.The nurse is preparing to administer Ringer’s Lactate to a client with hypovolemic shock. Which intervention is important in helping to stabilize the client’s condition? A. Warming the intravenous fluids B. Determining whether the client can take oral fluids C. Checking for the strength of pedal pulses D. Obtaining the specific gravity of the urine Answer A is correct. Warming the intravenous fluid helps to prevent further stress on the vascular system. Thirst is a sign of hypovolemia; however, oral fluids alone will not meet the fluid needs of the client in hypovolemic shock, so answer B is incorrect. Answers C and D are wrong because they can be used for baseline information but will not help stabilize the client. 5.The emergency room staff is practicing for its annual disaster drill. According to disaster triage, which of the following four clients would be cared for last? A. A client with a pneumothorax B. A client with 70% TBSA full thickness burns C. A client with fractures of the tibia and fibula D. A client with smoke inhalation injuries Answer B is correct. The client with 70% TBSA burns would be classified as an emergent client. In disaster triage, emergent clients, code black, are cared for last because they require the greatest expenditure of resources. Answers A and D are examples of immediate clients and are assigned as code red, so they are wrong. These clients are cared for first because they can survive with limited interventions. Answer C is wrong because it is an example of a delayed client, code yellow. These clients have significant injuries that require medical care.
6.An unresponsive client is admitted to the emergency room with a history of diabetes mellitus. The client’s skin is cold and clammy, and the blood pressure reading is 82/56. The first step in emergency treatment of the client’s symptoms would be: A. Checking the client’s blood sugar B. Administering intravenous dextrose C. Intubation and ventilator support D. Administering regular insulin Answer A is correct. The client has symptoms of insulin shock and the first step is to check the client’s blood sugar. If indicated, the client should be treated with intravenous dextrose. Answer B is wrong because it is not the first step the nurse should take. Answer C is wrong because it does not apply to the client’s symptoms. Answer D is wrong because it would be used for diabetic ketoacidosis, not insulin shock. 7.A client with a history of severe depression has been brought to the emergency room with an overdose of barbiturates. The nurse should pay careful attention to the client’s: A.Urinary output B.Respirations C.Temperature D.Verbal responsiveness Answer B is correct. Barbiturate overdose results in central nervous system depression, which leads to respiratory failure. Answers A and C are important to the client’s overall condition but are not specific to the question, so they are incorrect. The use of barbiturates results in slow, slurred speech, so answer D is expected, and therefore incorrect. 8.A client is to receive antivenin following a snake bite. Before administering the antivenin, the nurse should give priority to: A. Administering a local anesthetic B. Checking for an allergic response C. Administering an anxiolytic D. Withholding fluids for 6–8 hours Answer B is correct. The nurse should perform the skin or eye test before administering antivenin. Answers A and D are unnecessary and therefore incorrect. Answer C would help
calm the client but is not a priority before giving the antivenin, making it incorrect. 9.The nurse is caring for a client following a radiation accident. The client is determined to have incorporation. The nurse knows that the client will: A. Not need any medical treatment for radiation exposure B. Have damage to the bones, kidneys, liver, and thyroid C. Experience only erythema and desquamation D. Not be radioactive because the radiation passes through the body Answer B is correct. The client with incorporation radiation injuries requires immediate medical treatment. Most of the damage occurs to the bones, kidneys, liver, and thyroid. Answers A, C, and D refer to external irradiation, so they are wrong. 10.The emergency staff has undergone intensive training in the care of clients with suspected anthrax. The staff understands that the suggested drug for treating anthrax is: A. Ancef (cefazolin sodium) B. Cipro (ciprofloxacin) C. Kantrex (kanamycin) D. Garamycin (gentamicin) Answer B is correct. Cipro (ciprofloxacin) is the drug of choice for treating anthrax. Answers A, C, and D are not used to treat anthrax, so they are incorrect.
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