MS LEC: PART 1

PERIODICAL 3 LONG
QUIZ (11/3/21)
Total points 44/50

The respondent's email

(coll.intao.coc@phinmaed.com) was recorded on
submission of this form.

0 of 0 points

SURNAME, FULLNAME *

INTAO, CONRADO III. L.

TIME *

Time

07 : 58 AM

SECTION *

MULTIPLE CHOICE 44 of 50 points

50 ITEM. CHOOSE THE BEST ANSWER

The mother of a 13-year-old female tells *0/1

a clinic nurse, “I hope that no one tries to
get me to agree to have my daughter get
that new vaccine that is supposed to
prevent some STDs. My daughter is not
and will not be having sex until she is
married. What is the nurse’s best
response?

“How do you know that your daughter will

not be sexually active prior to marriage?”

“It seems that you have some questions

about the vaccine Gardasil®. I will make a
note for the health-care provider (HCP).”

“I believe that you are talking about

Gardasil®.Tell me what you have heard
about the vaccine.”

“Here is a pamphlet that talks about the

vaccine Gardasil® that is used to prevent
some STDs.”

Feedback

Rationale:
Prior to beginning teaching, the nurse should
determine what the parent knows about
Gardasil®, which is the quadrivalent human
papillomavirus (HPV) (types 6, 11, 16, 18)
recombinant vaccine. HPV causes genital
warts, abnormal Pap tests, and cervical
cancer. Because Gardasil® prevents these, it
is recommended for females before they
become sexually active and routinely given
between ages 11 or 12 years

Which is the priority nursing diagnosis *0/1

for a client taking doxorubicin (Doxil®)
for recurrent ovarian cancer?

Risk for Xuid volume deYcit

Risk for imbalanced nutrition: Less than

body requirements

Risk for alteration in cardiac output

Risk for self-care deYcit

Feedback

Doxorubicin is a chemotherapeutic agent and

can cause dysrhythmias and chest pain within
minutes of administration. Cardiomyopathy
can develop months to years after therapy.
Chemotherapy-related side effects of nausea,
vomiting, and fatigue are addressed by the
nursing diagnoses Risk for Muid volume
deNcit, Risk for imbalanced nutrition, and Risk
for self-care deNcit. These are important, but
not the priority.

The client diagnosed with lung cancer is *1/1

in an investigational program and
receiving a vaccine to treat the cancer.
Which information regarding
investigational regimens should the
nurse teach?

Investigational regimens provide a better

chance of survival for the client

Investigational treatments have not been

proven to be helpful to clients.

Clients will be paid to participate in an

investigational program.

Only clients who are dying qualify for

investigational treatments.

Feedback

Rationale: Investigational treatments are just

that—treatments being investigated to
determine if they are effective in the care of
clients diagnosed with cancer. There is no
guarantee the treatments will help the client

A patient has undergone the creation of *1/1

an Indiana pouch for the treatment of
bladder cancer. The nurse identified the
nursing diagnosis of disturbed body
image. How can the nurse best address
the effects of this urinary diversion on
the patients body image?

Emphasize that the diversion is an integral

part of successful cancer treatment.

Encourage the patient to speak openly and

frankly about the diversion.

Allow the patient to initiate the process of

providing care for the diversion.

Provide the patient with detailed written

materials about the diversion at the time
of discharge.

Feedback

Ans: B
Feedback:
Allowing the patient to express concerns and
anxious feelings can help with body image,
especially in adjusting to the changes in
toileting habits. The nurse may have to initiate
dialogue about the management of the
diversion, especially if the patient is hesitant.
Provision of educational materials is rarely
suUcient to address a sudden change and
profound change in body image. Emphasizing
the role of the diversion in cancer treatment
does not directly address the patients body
image.

The nurse is teaching an 80-year-old *1/1

client with a urinary tract infection about
the importance of increasing fluids in
the diet. Which of the following puts this
client at a risk for not obtaining sufficient
fluids?

Diminished liver function.

Increased production of antidiuretic

hormone.

Decreased production of aldosterone.

Decreased ability to detect thirst.

Feedback

Answer: D
Rationale: The sensation of thirst diminishes
in those greater than 60 years of age; hence, M
uid intake is decreased and dissolved
particles in the extracellular Muid
compartment become more concentrated

To provide free water and intracellular *1/1

fluid hydration for a patient with acute
gastroenteritis who is NPO, the nurse
would expect administration of which
infusion?

Dextrose 5% in water

Dextrose 10% in water

Lactated Ringer’s solution

Dextrose 5% in normal saline (0.9%)

Feedback

Answer: a. Fluids such as 5% dextrose in

water (D5W) allow water to move from the
extracellular Muid to the intracellular Muid.
Although D5W is physiologically isotonic, the
dextrose is rapidly metabolized, leaving free
water to shift into cells.

Resection of a patients bladder tumor *1/1

has been incomplete and the patient is
preparing for the administration of the
first ordered instillation of topical
chemotherapy. When preparing the
patient, the nurse should emphasize the
need to do which of the following?

Remain NPO for 12 hours prior to the

treatment.

Hold the solution in the bladder for 2

hours before voiding.

Drink the intravesical solution quickly and

on an empty stomach.

Avoid acidic foods and beverages until the

full cycle of treatment is complete.

Feedback

Ans: B
Feedback: The patient is allowed to eat and
drink before the instillation procedure. Once
the bladder is full, the patient must retain the
intravesical solution for 2 hours before
voiding. The solution is instilled through the
meatus; it is not consumed orally. There is no
need to avoid acidic foods and beverages
during treatment.

After a client who has had a *1/1

laparoscopic cholecystectomy receives
discharge instructions, which of the
following client statements would
indicate that the teaching has been
successful? Select all that apply

“I can resume my normal diet when I

want.”

“I need to avoid driving for about 4 weeks.”

“I may experience some pain in my right

shoulder.”

“I should spend 2 to 3 days in bed before

resuming activity.”

“I can wash the puncture site with mild

soap and water.

Feedback

Answer: A,C,E
Rationale: Following a laparoscopic
cholecystectomy, the client can resume a
normal diet as tolerated. The client may
experience right shoulder pain from the gas
that was used to inMate the abdomen during
surgery. The puncture site should be cleansed
daily with mild soap and water. Driving can
usually be resumed in 3 to 4 days following
surgery and there is no need for the client to
maintain bed rest in the days following
surgery. Light exercise such as walking can be
resumed immediately.

The nurse is assessing a patient who *1/1

has a 35 pack-year history of cigarette
smoking. In light of this known risk
factor for lung cancer, what statement
should prompt the nurse to refer the
patient for further assessment?

Lately, I have this cough that just never

seems to go away.

I Ynd that I don't have nearly the stamina

that I used to.

I seem to get nearly every cold and Xu that

goes around my workplace.

I never used to have any allergies, but now

I think I'm developing allergies to dust and
pet hair.

Feedback

Rationale:
The most frequent symptom of lung cancer is
cough or change in a chronic cough. People
frequently ignore this symptom and attribute it
to smoking or a respiratory infection. A new
onset of allergies, frequent respiratory
infections and fatigue are not characteristic
early signs of lung cancer.

An adult patient has been hospitalized *1/1

with pyelonephritis. The nurses review of
the patients intake and output records
reveals that the patient has been
consuming between 3 L and 3.5 L of oral
fluid each day since admission. How
should the nurse best respond to this
finding?

Supplement the patients Xuid intake with

a high-calorie diet.

Emphasize the need to limit intake to 2 L

of Xuid daily.

Obtain an order for a high-sodium diet to

prevent dilutional hyponatremia.

Encourage the patient to continue this

pattern of Xuid intake.

Feedback

Ans: D
Feedback: Unless contraindicated, 3 to 4 L of
Muids per day is encouraged to dilute the
urine, decrease burning on urination, and
prevent dehydration. No need to supplement
this Muid intake with additional calories or
sodium.

A 24-year-old female client comes to an *1/1

ambulatory care clinic in moderate
distress with a probable diagnosis of
acute cystitis. When obtaining the
client’s history, the nurse should ask the
client if she has had which of the
following signs and symptoms:

Fever and chills.

Frequency and burning on urination.

Flank pain and nausea.

Hematuria.

Feedback

Answer: B
Rationale: The classic symptoms of cystitis
are severe burning on urination, urgency, and
frequent urination. Systemic symptoms, such
as fever and nausea and vomiting, are more
likely to accompany pyelonephritis than
cystitis. Hematuria may occur, but it is not as
common as frequency and burning.

A client is admitted to the hospital with a *1/1

diagnosis of renal calculi. The client is
experiencing severe flank pain and
nausea; the temperature is 100.6° F
(38.1° C). Which of the following would
be a priority outcome for this client?

Prevention of urinary tract complications.

Alleviation of nausea.

Alleviation of pain.

Maintenance of Xuid and electrolyte

balance.

Feedback

Answer: C
Rationale: The priority nursing goal for this
client is to alleviate the pain, which can be
excruciating. Prevention of urinary tract
complications and alleviation of nausea are
appropriate throughout the client’s
hospitalization, but relief of the severe pain is
a priority.

Which of the following nursing *1/1

interventions prevents hyperextension of
the neck and protects integrity of suture
line in a postoperative thyroidectomy
patient?

Place in semi-Fowler’s position and

support head and neck with sandbags or
small pillows.

Keep call bell and frequently needed items

within easy reach.

Provide ice collar if indicated.

Assess verbal and nonverbal reports of

pain, noting location, intensity (0–10
scale), and duration.

A client post chemotherapy experiences *1/1

severe vomiting and loss of appetite.
What nursing diagnosis will you
incorporate into your nursing care plan?

Altered Nutrition: More than Body

Requirements.

Anorexia related to disease condition

Altered Nutrition :Less than Body

requirements related to treatment as
evidenced by severe vomiting.

Risk for Xuid excess related to

extravasation of Xuids.

An older adult patient with type 2 *1/1

diabetes is brought to the emergency
department by his daughter. The patient
is found to have a blood glucose level of
623 mg/dL. The patients daughter
reports that the patient recently had a
gastrointestinal virus and has been
confused for the last 3 hours. The
diagnosis of hyperglycemic
hyperosmolar syndrome (HHS) is made.
What nursing action would be a priority?

Administration of antihypertensive
medications

Administering sodium bicarbonate

intravenously

Reversing acidosis by administering

insulin

Fluid and electrolyte replacement

Feedback

Ans: D
Feedback: The overall approach to HHS
includes Muid replacement, correction of
electrolyte imbalances, and insulin
administration. Antihypertensive medications
are not indicated, as hypotension generally
accompanies HHS due to dehydration.
Sodium bicarbonate is not administered to
patients with HHS, as their plasma
bicarbonate level is usually normal. Insulin
administration plays a less important role in
the treatment of HHS because it is not needed
for reversal of acidosis, as in diabetic
ketoacidosis (DKA).

A patient newly diagnosed having *0/1

stomach cancer and is in preoperative
preparation. What nursing diagnosis is
most likely for a patient with this
condition?

Anxiety related to plan surgery

Impaired urinary elimination

Impaired verbal communication

Bowel incontinence

You are conducting a health teaching *1/1

session ,which of the following vaccines
should you recommend for prevention of
liver cancer?

Varicella vaccine

Hepatitis A vaccine

Meningococcal vaccine

Hepatitis B vaccine

Feedback

Rationale:
Hepatitis B vaccine dramatically reduces the
incidence of hepatitis B virus and, in turn,
prevents liver cancer. The evidence does not
support that the other vaccines have an effect
on the incidence of liver cancer.

The nurse has identified the nursing *1/1

diagnosis of risk for infection in a patient
who undergoes peritoneal dialysis. What
nursing action best addresses this risk?

Maintain aseptic technique when

administering dialysate.

Wash the skin surrounding the catheter

site with soap and water prior to each
exchange.

Add antibiotics to the dialysate as

ordered.

Administer prophylactic antibiotics by

mouth or IV as ordered

Feedback

Ans: A
Feedback: Aseptic technique is used to
prevent peritonitis and other infectious
complications of peritoneal dialysis. It is not
necessary to cleanse the skin with soap and
water prior to each exchange. Antibiotics may
be added to dialysate to treat infection, but
they are not used to prevent infection.

A patient with a longstanding diagnosis *1/1

of type 1 diabetes has a history of poor
glycemic control. The nurse recognizes
the need to assess the patient for signs
and symptoms of peripheral neuropathy.
Peripheral neuropathy constitutes a risk
for what nursing diagnosis?

Infection

Acute pain

Acute confusion

Impaired urinary elimination

Feedback

Ans: A
Feedback: Decreased sensations of pain and
temperature place patients with neuropathy at
increased risk for injury and undetected foot
infections. The neurologic changes
associated with peripheral neuropathy do not
normally result in pain, confusion, or
impairments in urinary function.

A newly diagnosed patient with *1/1

adenocarcinoma in the lungs expresses
apprehension and uncertainties. What
nursing diagnosis is applicable in this
condition?

Ineffective Individual Coping related to

poor prognosis as evidenced by inability
to meet basic care needs.

Anxiety related to poor prognosis as

evidenced by restlessness

Anticipatory Grieving related to loss of

health and income as evidenced by
expression of sadness

Altered Nutrition: Less than Body

Requirements