NCLEX Practice Questions — Set 35
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instructions?
Show answer and rationale
Correct answer: A. "I can apply lotion or powder to the incision if it is itchy."
The mother should be instructed that lotions and powders should not be applied to the incision site after cardiac surgery. Lotions and powders can irritate the surrounding skin, which could lead to skin breakdown and subsequent infection of the incision site. Options 1, 3, and 4 are accurate instructions regarding home care after cardiac surgery.
A health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant?
Show answer and rationale
Correct answer: D. When drawing blood for electrolyte level testing
Heart failure (HF) is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. Crying exhausts the limited energy supply, increases the workload of the heart, and increases the oxygen demands. Oxygen administration may be prescribed for stressful periods, especially during bouts of crying or invasive procedures. Options 1, 2, and 3 are not likely to produce crying in the infant.
The nurse reviews the record of a child who is suspected to have glomerulonephritis and expects to note which finding that is associated with this diagnosis?
Show answer and rationale
Correct answer: C. Brown-colored urine
Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Gross hematuria, resulting in dark, smoky, cola-colored or brown-colored urine, is a classic symptom of glomerulonephritis. Hypertension is also common. Blood urea nitrogen levels may be elevated. A moderately elevated to high urinary specific gravity is associated with glomerulonephritis
The nurse performing an admission assessment on a 2-year-old child who hasbeen diagnosed with nephrotic syndrome notes that which most common characteristic is associated with this syndrome?
Show answer and rationale
Correct answer: D. Generalized edema
Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, hyperlipemia, and edema. Other manifestations include weight gain; periorbital and facial edema that is most prominent in the morning; leg, ankle, labial, or scrotal edema; decreased urine output and urine that is dark and frothy; abdominal swelling; and blood pressure that is normal or slightly decreased
The nurse is planning care for a child with hemolytic-uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to implement which measure?
Show answer and rationale
Correct answer: A. Restrict fluids as prescribed.
Hemolytic-uremic syndrome is thought to be associated with bacterial toxins, chemicals, and viruses that result in acute kidney injury in children. Clinical manifestations of the disease include acquired hemolytic anemia, thrombocytopenia, renal injury, and central nervous system symptoms. A child with hemolytic-uremic syndrome undergoing peritoneal dialysis because of anuria would be on fluid restriction. Pain is not associated with hemolyticuremic syndrome, and potassium would be restricted, not encouraged, if the child is anuric. Peritoneal dialysis does not require an arteriovenous fistula (only hemodialysis).
A 7-year-old child is seen in a clinic, and the primary health care provider documents a diagnosis of primary nocturnal enuresis. The nurse should provide which information to the parents?
Show answer and rationale
Correct answer: A. Most children outgrow the bed-wetting problem without therapeutic intervention.
Primary nocturnal enuresis occurs in a child who has never been dry at night for extended periods. The condition is common in children, and most children eventually outgrow bed-wetting without therapeutic intervention. The child is unable to sense a full bladder and does not awaken to void. The child may have delayed maturation of the central nervous system. The condition is not caused by a psychiatric problem
The nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of theplan?
Show answer and rationale
Correct answer: C. "Circumcision has been delayed to save tissue for surgical repair."
Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. The infant should not be circumcised because the dorsal foreskin tissue will be used for surgical repair of the hypospadias. Options 1, 2, and 3 are unrelated to this disorder.
The nurse is caring for an infant with a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, the nurse should plan which intervention?
Show answer and rationale
Correct answer: A. Cover the bladder with a nonadhering plastic wrap.
In bladder exstrophy, the bladder is exposed and external to the body. In this disorder, one must take care to protect the exposed bladder tissue from drying, while allowing the drainage of urine. This is accomplished best by covering the bladder with a nonadhering plastic wrap. The use of petroleum jelly gauze should be avoided because this type of dressing can dry out, adhere to the mucosa, and damage the delicate tissue when removed. Dry sterile dressings and dressings soaked in solutions (that can dry out) also damage the mucosa when removed.
The nurse understands that which information collected during the assessment of a child recently diagnosed with glomerulonephritis is most often associated with the diagnosis?
Show answer and rationale
Correct answer: C. Streptococcal throat infection 2 weeks before diagnosis
Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Group A ?-hemolytic streptococcal infection is a cause of glomerulonephritis. Often, a child becomes ill with streptococcal infection of the upper respiratory tract and then develops symptoms of acute poststreptococcal glomerulonephritis after an interval of 1 to 2 weeks. The assessment data in options 1, 2, and 3 are unrelated to a diagnosis of glomerulonephritis
The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. When analyzing the results of the urinalysis, which should the nurse most likely expect to note?
Show answer and rationale
Correct answer: B. Bacteriuria
Epispadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. The urethral opening is located anywhere on the dorsum of the penis. This anatomical characteristic facilitates entry of bacteria into the urine. Options 1, 2, and 4 are not characteristically noted in this condition
The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment findings should the nurse expect to observe? Select all that apply.
Show answer and rationale
Correct answer: B. all the above
Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, and pallor. The child gains weight
A mother arrives at an emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected, and the nursechecks the child’s airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP?
Show answer and rationale
Correct answer: A. Bradycardia
Head injury is the pathological result of any mechanical force to the skull, scalp, meninges, or brain. A head injury can cause bleeding in the brain and result in increased intracranial pressure (ICP). In a child, early signs include a slight change in level of consciousness, headache, nausea, vomiting, visual disturbances (diplopia), seizures. Late signs of increased ICP include a significant decrease in level of consciousness, bradycardia, decreased motor and sensory responses, alterations in pupil size and reactivity, posturing, Cheyne-Stokes respirations, and coma
The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the health care provider’s (HCPs) prescriptions and should contact the HCP to question which prescription?
Show answer and rationale
Correct answer: B. Suction as needed.
A basilar skull fracture is a type of head injury. Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture: Because of the nature of the injury, there is a possibility that the catheter will enter the brain through the fracture, creating a high risk of secondary infection. Fluid balance is monitored closely by daily weight determination, intake and output measurement, and serum osmolality determination to detect early signs of water retention, excessive dehydration, and states of hypertonicity or hypotonicity. The child is maintained on NPO status or restricted to clear liquids until it is determined that vomiting will not occur. An intravenous line is maintained to administer fluids or medications if necessary.
The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing?
Show answer and rationale
Correct answer: D. Rigid extension and pronation of the arms and legs
Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe decorticate (flexion) posturing
The nurse develops a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child’s bedside?
Show answer and rationale
Correct answer: D. Suctioning equipment and oxygen
A seizure results from the excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. A type of generalized seizure is a tonic-clonic seizure. This type of seizure causes rigidity of all body muscles, followed by intense jerking movements. Because increased oral secretions and apnea can occur during and after the seizure, oxygen and suctioning equipment are placed at the bedside. A tracheotomy is not performed during a seizure. No object, including a padded tongue blade, is placed into the child’s mouth during a seizure. An emergency cart would not be left at the bedside, but would be available in the treatment room or nearby on the nursing unit.
An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period?
Show answer and rationale
Correct answer: A. Reposition the infant frequently.
Hydrocephalus occurs as a result of an imbalance of cerebrospinal fluid absorption or production that is caused by malformations, tumors, hemorrhage, infections, or trauma. It results in head enlargement and increased intracranial pressure. In infants with hydrocephalus, the head grows at an abnormal rate, and if the infant is not repositioned frequently, pressure ulcers can occur on the back and side of the head. An egg crate mattress under the head is also a nursing intervention that can help prevent skin breakdown. Proteinuria is not specific to hydrocephalus. Stimulus should be kept at a minimum because of the increase in intracranial pressure. It is not necessary to check the blood pressure every 15 minutes.
A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take?
Show answer and rationale
Correct answer: C. Notify the health care provider (HCP).
An absent pulse to an extremity of the affected limb after a bone fracture could mean that the child is developing or experiencing compartment syndrome. This is an emergency situation, and the HCP should be notified immediately. Administering analgesics would not improve circulation. The skin traction should not be released without an HCP’s prescription. Applying ice to an extremity with absent perfusion is incorrect. Ice may be prescribed when perfusion is adequate to decrease swelling
A child is placed in skeletal traction for treatment of a fractured femur. The nurse develops a plan of care and includes which intervention?
Show answer and rationale
Correct answer: C. Check the health care provider’s (HCP’s) prescriptions for the amount of weight to be applied.
When a child is in traction, the nurse would check the HCP’s prescription to verify the prescribed amount of traction weight. The nurse would maintain the correct amount of weight as prescribed, ensure that the weights hang freely, check the ropes for fraying and ensure that they are on the pulleys appropriately, monitor the neurovascular status of the involved extremity, and monitor for signs and symptoms of immobilization. The nurse would provide therapeutic and diversional play activities for the child
The parents of a child with juvenile idiopathic arthritis call the clinic nurse because the child is experiencing a painful exacerbation of the disease. The parents ask the nurse if the child can perform range-of-motion exercises at this time. The nurse should make which response?
Show answer and rationale
Correct answer: B. "Have the child perform simple isometric exercises during this time."
Juvenile idiopathic arthritis is an autoimmune inflammatory disease affecting the joints and other tissues, such as articular cartilage. During painful episodes of juvenile idiopathic arthritis, hot or cold packs and splinting and positioning the affected joint in a neutral position help reduce the pain. Although resting the extremity is appropriate, beginning simple isometric or tensing exercises as soon as the child is able is important. These exercises do not involve joint movement
The nurse is assisting a health care provider (HCP) examining an infant with developmental dysplasia of the hip perform an Ortolani maneuver. The nurse understands that this maneuver is performed for which purpose?
Show answer and rationale
Correct answer: D. To assess for hip instability
In developmental dysplasia of the hip, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Ortolani’s maneuver is a test to assess for hip instability. The examiner abducts the thigh and applies gentle pressure forward over the greater trochanter. A "clicking" sensation indicates a dislocated femoral head moving into the acetabulum. This maneuver does not assess for hip movement or ensure that hyperextension and full range of motion exist. Pushing the femoral head out of the acetabulum is not the purpose of Ortolani’s maneuver
A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip. On assessment, the nurse understands that which finding should be noted in this condition?
Show answer and rationale
Correct answer: A. Limited range of motion in the affected hip
In developmental dysplasia of the hip, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Asymmetrical and restricted abduction of the affected hip, when the child is placed supine with the knees and hips flexed, would be an assessment finding in developmental dysplasia of the hip in infants beyond the newborn period. Other findings include an apparent short femur on the affected side, asymmetry of the gluteal skinfolds, and limited range of motion in the affected extremity
The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply.
Show answer and rationale
Correct answer: A. all the above
While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside the cast because of the risk of altered skin integrity. The extremity is elevated to prevent swelling, and the HCP is notified immediately if any signs of neurovascular impairment develop. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the HCP should be notified.
The clinic nurse is instructing the parent of a child with human immunodeficiency virus (HIV) infection regarding immunizations. The nurse should provide which instruction to the parent?
Show answer and rationale
Correct answer: D. The inactivated influenza vaccine will be given yearly.
Immunizations against common childhood illnesses are recommended for all children exposed to or infected with HIV. The inactivated influenza vaccine that is given intramuscularly will be administered (influenza vaccine should be given yearly). The hepatitis B vaccine is administered according to the recommended immunization schedule. Varicella-zoster virus vaccine should not be given because it is a live virus vaccine; varicella-zoster immunoglobulin may be prescribed after chickenpox exposure. Option 4 is unnecessary and is inaccurate.
A health care provider prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV) to determine the presence of HIV antigen in the infant. The nurse anticipates that which laboratory study will be prescribed for the infant?
Show answer and rationale
Correct answer: A. p24 antigen assay
The detection of HIV in infants is confirmed by a p24 antigen assay, virus culture of HIV, or polymerase chain reaction. A Western blot test confirms the presence of HIV antibodies. The CD4+ cell count indicates how well the immune system is working. A chest x-ray evaluates the presence of other manifestations of HIV infection, such as pneumonia
A 6-year-old child with human immunodeficiency virus (HIV) has been admitted to the hospital for pain management. The child asks the nurse if the pain will ever go away. The nurse should make which best response to the child?
Show answer and rationale
Correct answer: A. "I know it must hurt, but if you tell me when it does, I will try and make it hurt a little less."
The multiple complications associated with HIV are accompanied by a high level of pain. Aggressive pain management is essential for the child to have an acceptable quality of life. The nurse must acknowledge the child’s pain and let the child know that everything will be done to decrease the pain. Telling the child that movement or lack thereof would eliminate the pain is inaccurate. Allowing a child to think that he or she can control the pain simply by thinking or not thinking about it oversimplifies the pain cycle associated with HIV. Giving false hope by telling the child that the pain will be taken "all away" is neither truthful nor realistic.
The nurse is caring for a 4-year-old child with human immunodeficiency virus (HIV) infection. The nurse should plan care with the understanding that which childhood psychosocial need occurs at this age?
Show answer and rationale
Correct answer: C. Beginning to conceptualize the death process as involving physical harm
A preschool child begins to conceptualize the death process as involving physical harm. A child from birth to 2 years of age is unable to grasp the concept of illness and death. A school-age child begins to understand that something is wrong. An adolescent expresses fear, withdrawal, and denial
The home care nurse provides instructions regarding basic infection control to the parent of an infant with human immunodeficiency virus (HIV) infection. Which statement, if made by the parent, indicates the need for further instruction?
Show answer and rationale
Correct answer: B. "I will clean up any spills from the diaper with diluted alcohol."
HIV is transmitted through blood, semen, vaginal secretions, and breast milk. The mother of an infant with HIV should be instructed to use a bleach solution for disinfecting contaminated objects or cleaning up spills from the child’s diaper. Alcohol would not be effective in destroying the virus. Options 2, 3, and 4 are accurate instructions related to basic infection control.
Which home care instructions should the nurse provide to the parent of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply.
Show answer and rationale
Correct answer: B. all the above
AIDS is a disorder caused by HIV and is characterized by a generalized dysfunction of the immune system. Home care instructions include the following: frequent hand-washing; monitoring for fever, malaise, fatigue, weight loss, vomiting, and diarrhea and notifying the health care provider if these occur; monitoring for signs and symptoms of opportunistic infections; administering antiretroviral medications and other medications as prescribed; avoiding exposure to other illnesses; keeping immunizations up to date; monitoring weight and providing a highcalorie, high-protein diet; washing eating utensils in the dishwasher; and avoiding sharing eating utensils. Gloves are worn for care, specially when in contact with body fluids and changing diapers; diapers are changed frequently and away from food areas, and soiled disposable diapers are folded inward, closed with the tabs, and disposed of in a tightly covered plastic-lined container. Any body fluid spills are cleaned with a bleach solution (10:1 ratio of water to bleach).
An infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at a well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention should the nurse suggest to the parent?
Show answer and rationale
Correct answer: B. Apply a cold pack to the injection site.
On occasion, tenderness, redness, or swelling may occur at the site of the DTaP injection. This can be relieved with cold packs for the first 24 hours, followed by warm or cold compresses if the inflammation persists. Bringing the infant back to the clinic is unnecessary. Option 1 may be an appropriate intervention, but is not specific to the subject of the question, a localized reaction at the injection site. Hot packs are not applied and can be harmful by causing burning of the skin.
A child is scheduled to receive inactivated polio vaccine (IPV), and the nurse preparing to administer the vaccine reviews the child’s record. The nurse questions the administration of IPV if which is documented in the child’s record?
Show answer and rationale
Correct answer: C. A history of an anaphylactic reaction to neomycin
Inactivated poliovirus vaccine (IPV) contains neomycin. A history of an anaphylactic reaction to neomycin is considered a contraindication to IPV. The presence of a minor illness such as the common cold is not a contraindication. In addition, a history of frequent respiratory infections is not a contraindication to receiving a vaccine. A local reaction to an immunization is not a contraindication to receiving a vaccine.
A child is receiving a series of the hepatitis B vaccine and arrives at the clinic with his parent for the second dose. Before administering the vaccine, the nurse should ask the child and parent about a history of a severe allergy to which substance?
Show answer and rationale
Correct answer: D. A previous dose of hepatitis B vaccine or component
A contraindication to receiving the hepatitis B vaccine is a previous anaphylactic reaction to a previous dose of hepatitis B vaccine or to a component (aluminum hydroxide or yeast protein) of the vaccine. An allergy to eggs, penicillin, and sulfonamides is unrelated to the contraindication to receiving this vaccine.
The home health nurse visits a child with infectious mononucleosis and provides home care instructions to the parents about the care of the child. Which instruction should the nurse give to the parents?
Show answer and rationale
Correct answer: A. Notify the HCP if the child develops abdominal pain or left shoulder pain.
Infectious mononucleosis is caused by Epstein-Barr virus. The parents need to be instructed to notify the HCP if abdominal pain, especially in the left upper quadrant, or left shoulder pain occurs because this may indicate splenic rupture. Children with enlarged spleens also are instructed to avoid contact sports until splenomegaly resolves. Bed rest is unnecessary, and children usually self-limit their activity. Respiratory precautions are not required, although transmission can occur via direct intimate contact or contact with infected blood. Fever is treated with acetaminophen (Tylenol) or ibuprofen (Motrin IB) per health care provider preference.
The clinic nurse prepares to administer a measles, mumps, rubella (MMR) vaccine to a 5-year-old child. The nurse should administer this vaccine by which best route and in which best site?
Show answer and rationale
Correct answer: B. Subcutaneously in the outer aspect of the upper arm
Measles, mumps, rubella (MMR) vaccine is administered subcutaneously in the outer aspect of the upper arm. The gluteal muscle is not recommended for injections. MMR vaccine is not administered by the intramuscular route.
A child with rubeola (measles) is being admitted to the hospital. In preparing for the admission of the child, the nurse should plan to place the child on which precautions?
Show answer and rationale
Correct answer: A. Airborne
Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Airborne droplet precautions are required, and persons in contact with the child should wear masks. The child is placed in a private room if hospitalized, and the hospital room door remains closed. Gowns and gloves are unnecessary, but standard precautions are used. Articles that are contaminated should be bagged and labeled. Special enteric precautions and protective (neutropenic) isolation are not indicated in rubeola.
The clinic nurse is assessing a child who is scheduled to receive a live virus vaccine (immunization). What are the general contraindications associated with receiving a live virus vaccine? Select all that apply.
Show answer and rationale
Correct answer: A. The child had a previous anaphylactic reaction to the vaccine.
The general contraindications for receiving live virus vaccines include a previous anaphylactic reaction to a vaccine or a component of a vaccine. In addition, live virus vaccines generally are not administered to individuals with a severely deficient immune system, individuals with a severe sensitivity to gelatin, or pregnant women.
The nurse is providing medication instructions to a parent. Which statement by the parent indicates a need for further instruction?
Show answer and rationale
Correct answer: D. "I should mix the medication in the baby food and give it when I feed my child."
The nurse would teach the parent to avoid putting medications in foods because it may give an unpleasant taste to the food, and the child may refuse to accept the same food in the future. In addition, the child may not consume the entire serving and would not receive the required medication dosage. The mother should provide comfort measures immediately after medication administration, such as touching, holding, cuddling, and providing a favorite toy. The mother should offer juice, a soft drink, or a frozen juice bar to the child after the child swallows the medication. If the taste of the medication is unpleasant, the child should pinch the nose and drink the medication through a straw.
A pediatric client with ventricular septal defect repair is placed on a maintenance dosage of digoxin (Lanoxin). The dosage is 0.07 mg/kg/day, and the client’s weight is 7.2 kg. The health care provider (HCP) prescribes the digoxin to be given twice daily. The nurse prepares how much digoxin to administer to the client at each dose?
Show answer and rationale
Correct answer: C. 0.25 mg
Calculate the daily dosage by weight first: 0.07 mg/day � 7.2 kg = 0.5 mg/day
Sulfisoxazole (Gantrisin), 1 g orally four times daily, is prescribed for an adolescent with a urinary tract infection. The medication label reads "500-mg tablets." The nurse has determined that the dosage prescribed is safe. The nurse administers how many tablets per dose to the adolescent?
Show answer and rationale
Correct answer: A. 2 tablets
Change 1 g to milligrams, knowing that 1000 mg = 1g. Also, when converting from grams to milligrams (larger to smaller), move the decimal point three places to the right: 1 g = 1000 mg
The nurse prepares to administer an intramuscular injection to a 4-month-old infant. The nurse selects which best site to administer the injection?
Show answer and rationale
Correct answer: B. Vastus lateralis
Intramuscular injection sites are selected on the basis of the child’s age and muscle development of the child. The vastus lateralis is the only safe muscle group to use for intramuscular injection in a 4-month-old infant.
The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first priority intervention in the event of this occurrence is which action?
Show answer and rationale
Correct answer: B. Move the victim to a safe area away from the snake and encourage the victim to rest.
In the event of a snakebite, the first priority is to move the victim to a safe area away from the snake and encourage the victim to rest to decrease venom circulation. Next, jewelry and constricting clothing are removed before swelling occurs. Immobilizing the extremity and maintaining the extremity below heart level would be done next; these actions limit the spread of the venom. The victim is kept warm and calm. Stimulants such as alcohol or caffeinated beverages are not given to the victim because these products may speed the absorption of the venom. The victim should be transported to an emergency facility as soon as is possible.
A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response?
Show answer and rationale
Correct answer: D. "Take a shower immediately, lathering and rinsing several times."
When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the human skin. The client should be instructed to cleanse the area by showering immediately and to lather the skin several times and rinse each time in running water. Calamine lotion may be one product recommended for use if dermatitis develops. The client does not need to be seen in the emergency department at this time.
A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg and asks the admitting nurse to explain what cellulitis means. The nurse bases the response on the understanding that cellulitis has which characteristic?
Show answer and rationale
Correct answer: C. A skin infection of the dermis and underlying hypodermis
Cellulitis is an infection of the dermis and underlying hypodermis that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute, superficial, rapidly spreading inflammation of the dermis and lymphatics.
The clinic nurse assesses the skin of a client with a diagnosis of psoriasis. The nurse understands that which characteristic is associated with this skin disorder?
Show answer and rationale
Correct answer: D. Silvery-white scaly patches
Psoriatic patches are covered with silvery white scales. Affected areas include the scalp, elbows, knees, shins, sacral area, and trunk. Thickening, pitting, and discoloration of the nails occur. Pruritus may occur. The lesions in psoriasis are not red-purplish scaly lesions and the skin is dry.
The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the client’s chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test?
Show answer and rationale
Correct answer: A. Culture of the lesion
With the classic presentation of herpes zoster, the clinical examination is diagnostic. However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide a cytological examination of tissue. In a Wood’s light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.
A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristic?
Show answer and rationale
Correct answer: A. It is highly metastatic.
Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. This skin cancer is highly metastatic, and a person’s survival depends on early diagnosis and treatment.
When assessing a lesion diagnosed as malignant melanoma, the nurse most likely expects to note which finding?
Show answer and rationale
Correct answer: C. An irregularly shaped lesion
A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration. Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border.
A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client’s hand?
Show answer and rationale
Correct answer: B. A white color to the skin, which is insensitive to touch
Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs, flushing of the skin, the development of blisters or blebs, or tissue edema appears.
The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy?
Show answer and rationale
Correct answer: B. Return of distal pulses
Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation control the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy.
A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the health care provider (HCP) and anticipates which prescription?
Show answer and rationale
Correct answer: D. Increasing the amount of intravenous (IV) lactated Ringer’s solution administered per hour
Fluid management during the first 24 hours following a burn injury generally includes the infusion of (usually) lactated Ringer’s solution. Fluid resuscitation is determined by urine output and hourly urine output should be at least 30 mL/hour. The client’s urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore the HCP would prescribe an increase in the amount of IV lactated Ringer’s solution administered per hour. Blood replacement is not used for fluid therapy for burn injuries. Administering a diuretic would not correct the problem because it would not replace needed fluid. Diuretics promote the removal of the circulating volume, thereby further compromising the inadequate tissue perfusion. Dextrose in water is an isotonic solution, and an isotonic solution maintains fluid balance. This type of solution may be administered after the first 24 hours following the burn injury, depending on the client’s physiological needs.
A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply.
Show answer and rationale
Correct answer: D. Administer oxygen as prescribed.
The primary goal for a burn injury is to maintain a patent airway, administer IV fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated to assist in preventing shock. The client is kept warm and placed on NPO status because of the altered gastrointestinal function that occurs as a result of a burn injury.
The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury?
Show answer and rationale
Correct answer: C. Elevated hematocrit levels
The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys, and renal perfusion and glomerular filtration are decreased, resulting in low urine output. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts.
The nurse manager is planning the clinical assignments for the day. Which staff members can be assigned to care for a client with herpes zoster? Select all that apply.
Show answer and rationale
Correct answer: C. The nurse who never had roseola
Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the causative virus of chickenpox. Individuals who have not been exposed to the varicella-zoster virus or who did not receive the varicella-zoster vaccine are susceptible to chickenpox. Health care workers who are unsure of their immune status should have varicella titers done before exposure to a person with herpes zoster.
A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client?
Show answer and rationale
Correct answer: C. 100% oxygen via a tight-fitting, nonrebreather face mask
If an inhalation injury is suspected, administration of 100% oxygen via a tight-fitting nonrebreather face mask is prescribed until carboxyhemoglobin levels fall (usually below 15%). In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation also is assessed.
The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy?
Show answer and rationale
Correct answer: B. Urine output
Successful or adequate fluid resuscitation in the client is signaled by stable vitalsigns, adequate urine output, palpable peripheral pulses, and clear sensorium. However, the most reliable indicator for determining adequacy of fluid resuscitation is the urine output. For an adult, the hourly urine volume should be 30 to 50 mL.
The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique?
Show answer and rationale
Correct answer: B. Wearing gloves and a gown only when giving direct care to the client
Thorough hand washing should be done before and after each contact with the burn-injured client. Sterile sheets and linens are used because of the client’s high risk for infection. Protective garb, including gloves, cap, masks, shoe covers, gowns, and plastic apron, need to be worn when in the client’s room and when directly caring for the client.
The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client?
Show answer and rationale
Correct answer: A. Immobilization of the affected leg
Autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3 to 7 days. This period of immobilization allows the autograft time to adhere to the wound bed.
The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client?
Show answer and rationale
Correct answer: B. Flushing
Carbon monoxide levels between 11% and 20% result in flushing, headache, decreased visual activity, decreased cerebral functioning, and slight breathlessness; levels of 21% to 40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, tachycardia; levels of 41% to 60% result in seizure and coma; and levels higher than 60% result in death.
Mafenide acetate (Sulfamylon) is prescribed for a client with a burn injury. When applying the medication, the client complains of local discomfort and burning. The nurse should take which most appropriate action?
Show answer and rationale
Correct answer: D. Inform the client that this is expected.
Mafenide acetate is bacteriostatic for gram-negative and gram-positive organisms and is used to treat burns to reduce bacteria present in avascular tissues. The client should be informed that the medication will cause local discomfort and burning and that this is a normal reaction.
Isotretinoin (Amnesteem or Claravis) is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed?
Show answer and rationale
Correct answer: B. Triglyceride level
Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on the triglycerides has been evaluated.
A client with severe acne is seen in the clinic and the health care provider (HCP) prescribes isotretinoin (Amnesteem or Claravis). The nurse reviews the client’s medication record and would contact the HCP if the client is taking which medication?
Show answer and rationale
Correct answer: D. Vitamin A
Isotretinoin is a metabolite of vitamin A and can produce generalized intensification of isotretinoin toxicity. Because of the potential for increased toxicity, vitamin A supplements should be discontinued before isotretinoin therapy.
The nurse is applying a topical corticosteroid to a client with eczema. The nurse should monitor for the potential for increased systemic absorption of the medication if the medication were being applied to which body area?
Show answer and rationale
Correct answer: D. Axilla
Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where permeability is poor (back, palms, soles).
The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid (Azelex). Because of the medication prescription, the nurse would suspect that the client is being treated for which condition?
Show answer and rationale
Correct answer: C. Acne
Azelaic acid is a topical medication used to treat mild to moderate acne. The acid appears to work by suppressing the growth of Propionibacterium acnes and by decreasing the proliferation of keratinocytes.
Silver sulfadiazine (Silvadene, Thermazene, SSD cream) is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments?
Show answer and rationale
Correct answer: A. "The medication will permanently stain my skin."
Silver sulfadiazine (Silvadene, Thermazene, SSD cream) is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not stain the skin.
The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times?
Show answer and rationale
Correct answer: B. At least 30 minutes before exposure to the sun
Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. Allsunscreens should be reapplied after swimming or sweating.
The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder?
Show answer and rationale
Correct answer: A. Increased calcium level
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.
The nurse is developing a plan of care for the client with multiple myeloma and includes which priority intervention in the plan?
Show answer and rationale
Correct answer: D. Encouraging fluids
Hypercalcemia caused by bone destruction is a priority concern in the client with multiple myeloma. The nurse should administer fluids in adequate amounts to maintain a urine output of 1.5 to 2 L/day; this requires about 3 L of fluid intake per day. The fluid is needed not only to dilute the calcium overload but also to prevent protein from precipitating in the renal tubules.
When caring for a client with an internal radiation implant, the nurse should observe which principles? Select all that apply.
Show answer and rationale
Correct answer: A. Placing the client in a private room with a private bath.
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 client must be placed in a private room with a private bath. The nurse should wear a lead shield to reduce the transmission of radiation. The dosimeter film 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.
The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy?
Show answer and rationale
Correct answer: B. Teach the client and family about the need for hand hygiene.
In the neutropenic client, meticulous hand hygiene education is implemented for the client, family, visitors, and staff. Not all visitors are restricted, but the client is protected from persons with known infections. Fluids should be encouraged. Invasive measures such as an indwelling urinary catheter should be avoided to prevent infections.
The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client’s pain should include which assessment?
Show answer and rationale
Correct answer: A. The client’s pain rating
The client’s self-report is a critical component of pain assessment. The nurse should ask the client to describe the pain and listen carefully to the words the client uses to describe the pain. Nonverbal cues from the client are important but are not the most appropriate pain assessment measure. The nurse’s impression of the client’s pain is not appropriate in determining the client’s level of pain. Assessing pain relief is an important measure, but this option is not related to the subject of the question.
During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which symptom as typical of the disease?
Show answer and rationale
Correct answer: C. Abdominal distention
Clinical manifestations of ovarian cancer include abdominal distention, urinary frequency and urgency, pleural effusion, malnutrition, pain from pressure caused by the growing tumor and the effects of urinary or bowel obstruction, constipation, ascites with dyspnea, and ultimately generalsevere pain. Abnormal bleeding, often resulting in hypermenorrhea, is associated with uterine cancer.
The nurse is caring for a client with bladder cancer and bone metastasis. What signs/symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply.
Show answer and rationale
Correct answer: C. Serum calcium level of 12 mg/dL
Oncological emergencies include sepsis, disseminated intravascular coagulation, syndrome of inappropriate antidiuretic hormone, spinal cord compression, hypercalcemia, superior vena cava syndrome, and tumor lysis syndrome. Blockage of blood flow to the venous system of the head resulting in facial edema is a sign of superior vena cava syndrome. A serum calcium level of 12 mg/dL indicates hypercalcemia. Numbness and tingling of the lower extremities could be a sign of spinal cord compression. Mild hypokalemia and weight loss are not oncological emergencies. A sodium level of 136 mg/dL is a normal level.
A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which condition?
Show answer and rationale
Correct answer: C. The development of a vesicovaginal fistula
A vesicovaginal fistula is a genital fistula that occurs between the bladder and vagina. The fistula is an abnormal opening between these two body parts and, if this occurs, the client may experience drainage of urine through the vagina
The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure?
Show answer and rationale
Correct answer: C. That the best time for the examination is after a shower
The testicular-self examination is recommended monthly after a warm bath or shower when the scrotal skin is relaxed. The client should stand to examine the testicles. Using both hands, with fingers under the scrotum and thumbs on top, the client should gently roll the testicles, feeling for any lumps.
A client is diagnosed with multiple myeloma and the client asks the nurse about the diagnosis. The nurse bases the response on which description of this disorder?
Show answer and rationale
Correct answer: C. Malignant proliferation of plasma cells within the bone
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.
A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action?
Show answer and rationale
Correct answer: C. Continue to monitor the drainage.
Following gastrectomy, drainage from the nasogastric tube is normally bloody for 24 hours postoperatively, changes to brown-tinged, and is then yellow or clear. Because bloody drainage is expected in the immediate postoperative period, the nurse should continue to monitor the drainage. The nurse does not need to notify the HCP at this time. Measuring abdominal girth is performed to detect the development of distention. Following gastrectomy, a nasogastric tube should not be irrigated unless there are specific HCP prescriptions to do so.
The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor?
Show answer and rationale
Correct answer: B. Age younger than 50 years
Colorectal cancer risk factors include age older than 50 years, a family history of the disease, colorectal polyps, and chronic inflammatory bowel disease.
The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate?
Show answer and rationale
Correct answer: A. Change the dressing as prescribed.
Immediately after surgery, profuse serosanguineous drainage from the perineal wound is expected. Therefore the nurse should change the dressing as prescribed. A Penrose drain should not be clamped because this action will cause the accumulation of drainage within the tissue. The nurse does not need to notify the HCP at this time. Penrose drains and packing are removed gradually over a period of 5 to 7 days as prescribed. The nurse should not remove the perineal packing.
The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?
Show answer and rationale
Correct answer: C. The passage of flatus
Following abdominal perineal resection, the nurse would expect the colostomy to begin to function within 72 hours after surgery, although it may take up to 5 days. The nurse should assess for a return of peristalsis, listen for bowelsounds, and check for the passage of flatus. Absent bowelsounds would not indicate the return of peristalsis. The client would remain NPO until bowelsounds return and the colostomy is functioning. Bloody drainage is not expected from a colostomy.
The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common symptom of this type of cancer?
Show answer and rationale
Correct answer: D. Hematuria
The most common symptom in clients with cancer of the bladder is hematuria. The client also may experience irritative voiding symptoms such as frequency, urgency, and dysuria, and these symptoms often are associated with carcinoma in situ. Dysuria, urgency, and frequency of urination are also signs of a bladder infection.
The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care?
Show answer and rationale
Correct answer: C. "I empty the urinary collection bag when it is two-thirds full."
The urinary collection bag should be changed when it is one-third full to prevent pulling of the appliance and leakage. The remaining options identify correct statements about the care of a urinary stoma.
A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the health care provider will request which prescriptions? Select all that apply.
Show answer and rationale
Correct answer: A. Medication that is antagonistic to antidiuretic hormone
Cancer is a common cause of syndrome of inappropriate antidiuretic hormone (SIADH). In SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. The syndrome is managed by treating the condition and cause and usually includes fluid restriction, increased sodium intake, and medication with a mechanism of action that is antagonistic to antidiuretic hormone. Sodium levels are monitored closely because hypernatremia can develop suddenly as a result of treatment. The immediate institution of appropriate cancer therapy, usually radiation or chemotherapy, can cause tumor regression so that antidiuretic hormone synthesis and release processes return to normal.
The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency?
Show answer and rationale
Correct answer: A. Periorbital edema
Superior vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens, the client experiences edema of the hands and arms. Cyanosis and mentalstatus changes are late signs.
The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which is a late sign of this oncological emergency?
Show answer and rationale
Correct answer: A. Electrocardiographic changes
Hypercalcemia is a manifestation of bone metastasis in late-stage cancer. Headache and dysphagia are not associated with hypercalcemia. Constipation may occur early in the process. Electrocardiogram changes include shortened ST segment and a widened T wave.
The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time?
Show answer and rationale
Correct answer: A. 1 week after menstruation begins
The breast self-examination should be performed monthly, 7 days after the onset of the menstrual period. Performing the examination weekly is not recommended. At the onset of menstruation and during ovulation, hormonal changes occur that may alter breast tissue.
A client is diagnosed as having a bowel tumor. The nurse should monitor the client for which complications of this type of tumor? Select all that apply.
Show answer and rationale
Correct answer: D. Lactose intolerance
Complications of bowel tumors include bowel perforation, which can result in hemorrhage and peritonitis. Other complications include bowel obstruction, and fistula formation. Flatulence can occur but is not a complication; lactose intolerance also is not a complication of intestinal tumor.
The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm?
Show answer and rationale
Correct answer: C. Elevating the affected arm on a pillow above heart level
Following mastectomy, the arm should be elevated above the level of the heart. Simple arm exercises should be encouraged. No blood pressure readings, injections, intravenous lines, or blood draws should be performed on the affected arm. Cool compresses are not a suggested measure to prevent lymphedema from occurring.
Chemotherapy dosage is frequently based on total body surface area (BSA), so it is important for the nurse to perform which assessment before administering chemotherapy?
Show answer and rationale
Correct answer: B. Measure the client’s current weight and height.
To ensure that the client receives optimal doses of chemotherapy, dosing is usually based on the total body surface area (BSA), which requires a current accurate height and weight for BSA calculation (before each medication administration). Asking the client about his or her height and weight may lead to inaccuracies in determining a true BSA and dosage. Calculating body mass index and measuring abdominal girth will not provide the data needed.
A client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed?
Show answer and rationale
Correct answer: C. Pulmonary function studies
Bleomycin is an antineoplastic medication that can cause interstitial pneumonitis, which can progress to pulmonary fibrosis. Pulmonary function studies along with hematological, hepatic, and renal function tests need to be monitored. The nurse needs to monitor lung sounds for dyspnea and crackles, which indicate pulmonary toxicity. The medication needs to be discontinued immediately if pulmonary toxicity occurs.
A client with acute myelocytic leukemia is being treated with busulfan (Myleran, Busulfex). Which laboratory value would the nurse specifically monitor during treatment with this medication?
Show answer and rationale
Correct answer: C. Uric acid level
Busulfan (Myleran, Busulfex) can cause an increase in the uric acid level. Hyperuricemia can produce uric acid nephropathy, renalstones, and acute kidney injury.
A client with small cell lung cancer is being treated with etoposide (Toposar). The nurse monitors the client during administration, knowing that which adverse effect is specifically associated with this medication?
Show answer and rationale
Correct answer: C. Orthostatic hypotension
An adverse effect specific to etoposide is orthostatic hypotension. Etoposide should be administered slowly over 30 to 60 minutes to avoid hypotension. The client’s blood pressure is monitored during the infusion. Hair loss occurs with nearly all the antineoplastic medications. Chest pain and pulmonary fibrosis are unrelated to this medication.
A clinic nurse prepares a teaching plan for a client receiving an antineoplastic medication. When implementing the plan, the nurse should make which statement to the client?
Show answer and rationale
Correct answer: C. "You need to consult with the health care provider (HCP) before receiving immunizations."
Because antineoplastic medications lower the resistance of the body, clients must be informed not to receive immunizations without an HCP’s approval. Clients also need to avoid contact with individuals who have recently received a live virus vaccine. Clients need to avoid aspirin and aspirin-containing products to minimize the risk of bleeding, and they need to avoid alcohol to minimize the risk of toxicity and side/adverse effects.
A client with ovarian cancer is being treated with vincristine (Vincasar). The nurse monitors the client, knowing that which manifestation indicates an adverse effect specific to this medication?
Show answer and rationale
Correct answer: C. Peripheral neuropathy
An adverse effect specific to vincristine is peripheral neuropathy, which occurs in almost every client. Peripheral neuropathy can be manifested as numbness and tingling in the fingers and toes. Depression of the Achilles tendon reflex may be the first clinicalsign indicating peripheral neuropathy. Constipation rather than diarrhea is most likely to occur with this medication, although diarrhea may occur occasionally. Hair loss occurs with nearly all the antineoplastic medications. Chest pain is unrelated to this medication.
The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase (Elspar), an antineoplastic agent. The nurse contacts the health care provider before administering the medication if which disorder is documented in the client’s history?
Show answer and rationale
Correct answer: D. Pancreatitis
Asparaginase (Elspar) is contraindicated if hypersensitivity exists, in pancreatitis, or if the client has a history of pancreatitis. The medication impairs pancreatic function and pancreatic function tests should be performed before therapy begins and when a week or more has elapsed between dose administrations. The client needs to be monitored for signs of pancreatitis, which include nausea, vomiting, and abdominal pain.
Tamoxifen citrate is prescribed for a client with metastatic breast carcinoma. The nurse administering the medication understands that which is the primary action of this medication?
Show answer and rationale
Correct answer: B. It competitively binds to estrogen receptors on tumors and other tissue targets.
Tamoxifen is an antineoplastic medication that competes with estradiol for binding to estrogen in tissues containing high concentrations of receptors. Tamoxifen is used to treat metastatic breast carcinoma in women and men. Tamoxifen is also effective in delaying the recurrence of cancer following mastectomy. Tamoxifen reduces DNA synthesis and estrogen response.
A client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which laboratory value while the client is taking this medication?
Show answer and rationale
Correct answer: A. Calcium level
Tamoxifen may increase calcium, cholesterol, and triglyceride levels. Before the initiation of therapy, a complete blood count, platelet count, and serum calcium levelshould be assessed. These blood levels, along with cholesterol and triglyceride levels, should be monitored periodically during therapy. The nurse should assess for hypercalcemia while the client is taking this medication. Signs of hypercalcemia include increased urine volume, excessive thirst, nausea, vomiting, constipation, hypotonicity of muscles, and deep bone and flank pain.
Megestrol acetate (Megace), an antineoplastic medication, is prescribed for a client with metastatic endometrial carcinoma. The nurse reviews the client’s history and should contact the health care provider if which diagnosis is documented in the client’s history?
Show answer and rationale
Correct answer: B. Thrombophlebitis
Megestrol acetate (Megace) suppresses the release of luteinizing hormone from the anterior pituitary by inhibiting pituitary function and regressing tumor size. Megestrol is used with caution if the client has a history of thrombophlebitis.
The nurse is monitoring the intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. On inspection of the site, the nurse notes redness and swelling and that the infusion of the medication has slowed in rate. The nurse suspects extravasation and should take which actions? Select all that apply.
Show answer and rationale
Correct answer: B. Prepare to administer a prescribed antidote into the site.
Redness and swelling and a slowed infusion indicate signs of extravasation. If the nurse suspects extravasation during the intravenous administration of an antineoplastic medication, the infusion is stopped and the HCP is notified. Ice or heat may be prescribed for application to the site and an antidote may be prescribed to be administered into the site. Increasing the flow rate can increase damage to the tissues. Restarting an IV in the same vein can increase damage to the site and vein.
The nurse is analyzing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory value would the nurse specifically note as a result of the massive cell destruction that occurred from the chemotherapy?
Show answer and rationale
Correct answer: C. Increased uric acid level
Hyperuricemia is especially common following treatment for leukemias and lymphomas because chemotherapy results in massive cell kill.
The nurse is providing medication instructions to a client with breast cancer who is receiving cyclophosphamide. The nurse should tell the client to take which action?
Show answer and rationale
Correct answer: A. Increase fluid intake to 2000 to 3000 mL daily.
Hemorrhagic cystitis is an adverse effect that can occur with the use of cyclophosphamide. The client needs to be instructed to drink copious amounts of fluid during the administration of this medication. Clients also should monitor urine output for hematuria. The medication should be taken on an empty stomach, unless gastrointestinal upset occurs. Hyperkalemia can result from the use of the medication; therefore, the client would not be told to increase potassium intake. The client would not be instructed to alter sodium intake.
The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?
Show answer and rationale
Correct answer: D. A platelet count of 50,000 cells/mm3
Bleeding precautions need to be initiated when the platelet count decreases. The normal platelet count is 150,000 to 450,000 cells/mm 3 . When the platelet count decreases, the client is at risk for bleeding. The normal white blood cell count is 4500 to 11,000 cells/mm 3 . When the white blood cell count drops, neutropenic precautions need to be implemented. The normal clotting time is 8 to 15 minutes. The normal ammonia value is 10 to 80 mcg/dL.
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
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