Title: ASN 210 UNIT EXAM# 2: VERSION B (Remotely Proctored)
Course: 16SP-ASN-210-GH1A1-ADV NUR THROUGH LIFESPAN I > Section: Week 4

This exam will cover the following lessons from Week 3 & 4:

Inflammation & Immunity
Cancer Development
Patients with Cancer
Arthritis & CT Disorders
HIV & Immune Deficiencies & Infections
Allergies & Autoimmunity

This examination is TIMED and you are allotted 2 hours to complete it.
Be sure you are taking this exam on a reliable computer with reliable internet source, if you lose connection you will NOT be allowed to log into the exam again.
Once you start the exam you will need to complete the exam in one setting.
The exam will shut off automatically after the allotted time has elapsed.
This is NOT an open book exam.  This exam contains 75 NCLEX-RN Style Questions and is worth 150 POINTS (15% of your ASN 210 Grade)
No collaboration allowed during this exam or it will be noted as a breach of academic integrity.
You must send a message to the instructor immediately (within 10 minutes) with any technical issues or irregularities related to the exam.

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Q: The nursing student learning about cancer development remembers characteristics of normal cells. Which characteristics does this include? <b>(Select all that apply.)</b>
- Differentiated function
- Large nucleus-to-cytoplasm ratio
- Loose adherence
- Nonmigratory
- Specific morphology
A: Differentiated function; Nonmigratory; Specific morphology
If right: Normal cells have the characteristics of differentiated function, nonmigratory, specific morphology, a smaller nucleus-to-cytoplasm ratio, tight adherence, and orderly and well-regulated growth.
If wrong: Normal cells have the characteristics of differentiated function, nonmigratory, specific morphology, a smaller nucleus-to-cytoplasm ratio, tight adherence, and orderly and well-regulated growth.

Q: The nursing instructor explains the difference between normal cells and benign tumor cells. What information does the instructor provide about these cells?
- Benign tumors grow through invasion of other tissue.
- Benign tumors have lost their cellular regulation from contact inhibition.
- Growing in the wrong place or time is typical of benign tumors.
- The loss of characteristics of the parent cells is called anaplasia.
A: Growing in the wrong place or time is typical of benign tumors.
If right: Benign tumors are basically normal cells growing in the wrong place or at the wrong time. Benign cells grow through hyperplasia, not invasion. Benign tumor cells retain contact inhibition. Anaplasia is a characteristic of cancer cells.
If wrong: Benign tumors are basically normal cells growing in the wrong place or at the wrong time. Benign cells grow through hyperplasia, not invasion. Benign tumor cells retain contact inhibition. Anaplasia is a characteristic of cancer cells.

Q: The nurse working with oncology clients understands that interacting factors affect cancer development. Which factors does this include? <b>(Select all that apply.)</b>
- Exposure to carcinogens
- Genetic predisposition
- Immune function
- Normal doubling time
- State of euploidy
A: Exposure to carcinogens; Genetic predisposition; Immune function
If right: The three interacting factors needed for cancer development are exposure to carcinogens, genetic predisposition, and immune function.
If wrong: The three interacting factors needed for cancer development are exposure to carcinogens, genetic predisposition, and immune function.

Q: The nurse caring for oncology clients knows that which form of metastasis is the most common?
- Bloodborne
- Direct invasion
- Lymphatic spread
- Via bone marrow
A: Bloodborne
If right: Bloodborne metastasis is the most common way for cancer to metastasize. Direct invasion and lymphatic spread are other methods. Bone marrow is not a medium in which cancer spreads, although cancer can occur in the bone marrow.
If wrong: Bloodborne metastasis is the most common way for cancer to metastasize. Direct invasion and lymphatic spread are other methods. Bone marrow is not a medium in which cancer spreads, although cancer can occur in the bone marrow.

Q: A student nurse asks the nursing instructor what “apoptosis” means. What response by the instructor is best?
- Growth by cells enlarging
- Having the normal number of chromosomes
- Inhibition of cell growth
- Programmed cell death
A: Programmed cell death
If right: Apoptosis is programmed cell death. With this characteristic, organs and tissues function with cells that are at their peak of performance. Growth by cells enlarging is hyperplasia. Having the normal number of chromosomes is euploidy. Inhibition of cell growth is contact inhibition.
If wrong: Apoptosis is programmed cell death. With this characteristic, organs and tissues function with cells that are at their peak of performance. Growth by cells enlarging is hyperplasia. Having the normal number of chromosomes is euploidy. Inhibition of cell growth is contact inhibition.

Q: A nurse is providing community education on the seven warning signs of cancer. Which signs are included? <b>(Select all that apply.)</b>
- A sore that does not heal
- Changes in menstrual patterns
- Indigestion or trouble swallowing
- Near-daily abdominal pain
- Obvious change in a mole
A: A sore that does not heal; Changes in menstrual patterns; Indigestion or trouble swallowing; Obvious change in a mole
If right: The seven warning signs for cancer can be remembered with the acronym CAUTION: <u>c</u>hanges in bowel or bladder habits, <u>a</u> sore that does not heal, <u>u</u>nusual bleeding or discharge, <u>t</u>hickening or lump in the breast or elsewhere, <u>i</u>ndigestion or difficulty swallowing, <u>o</u>bvious change in a wart or mole, and <u>n</u>agging cough or hoarseness. Abdominal pain is not a warning sign.
If wrong: The seven warning signs for cancer can be remembered with the acronym CAUTION: <u>c</u>hanges in bowel or bladder habits, <u>a</u> sore that does not heal, <u>u</u>nusual bleeding or discharge, <u>t</u>hickening or lump in the breast or elsewhere, <u>i</u>ndigestion or difficulty swallowing, <u>o</u>bvious change in a wart or mole, and <u>n</u>agging cough or hoarseness. Abdominal pain is not a warning sign.

Q: A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse most likely to engage? <b>(Select all that apply.)</b>
- Demonstrating breast self-examination methods to women
- Instructing people on the use of chemoprevention
- Providing vaccinations against certain cancers
- Screening teenage girls for cervical cancer
- Teaching teens the dangers of tanning booths
A: Instructing people on the use of chemoprevention; Providing vaccinations against certain cancers; Teaching teens the dangers of tanning booths
If right: Primary prevention aims to prevent the occurrence of a disease or disorder, in this case cancer. Secondary prevention includes screening and early diagnosis. Primary prevention activities include teaching people about chemoprevention, providing approved vaccinations to prevent cancer, and teaching teens the dangers of tanning beds. Breast examinations and screening for cervical cancer are secondary prevention methods.
If wrong: Primary prevention aims to prevent the occurrence of a disease or disorder, in this case cancer. Secondary prevention includes screening and early diagnosis. Primary prevention activities include teaching people about chemoprevention, providing approved vaccinations to prevent cancer, and teaching teens the dangers of tanning beds. Breast examinations and screening for cervical cancer are secondary prevention methods.

Q: A nurse is assessing a client with glioblastoma. What assessment is most important?
- Abdominal palpation
- Abdominal percussion
- Lung auscultation
- Neurologic examination
A: Neurologic examination
If right: A glioblastoma arises in the brain. The most important assessment for this client is the neurologic examination.
If wrong: A glioblastoma arises in the brain. The most important assessment for this client is the neurologic examination.

Q: A nurse has taught a client about dietary changes that can reduce the chances of developing cancer. What statement by the client indicates the nurse needs to provide additional teaching?
- “Foods high in vitamin A and vitamin C are important.”
- “I’ll have to cut down on the amount of bacon I eat.”
- “I’m so glad I don’t have to give up my juicy steaks.”
- “Vegetables, fruit, and high-fiber grains are important.”
A: “I’m so glad I don’t have to give up my juicy steaks.”
If right: To decrease the risk of developing cancer, one should cut down on the consumption of red meats and animal fat. The other statements are correct.
If wrong: To decrease the risk of developing cancer, one should cut down on the consumption of red meats and animal fat. The other statements are correct.

Q: A group of nursing students has entered a futuristic science contest in which they have “developed” a cure for cancer. Which treatment would most likely be the winning entry?
- Artificial fibronectin infusion to maintain tight adhesion of cells
- Chromosome repair kit to halt rapid division of cancer cells
- Synthetic enzyme transfusion to allow rapid cellular migration
- Telomerase therapy to maintain chromosomal immortality
A: Artificial fibronectin infusion to maintain tight adhesion of cells
If right: Cancer cells do not have sufficient fibronectin and so do not maintain tight adhesion with other cells. This is part of the mechanism of metastasis. Chromosome alterations in cancer cells (aneuploidy) consist of having too many, too few, or altered chromosome pairs. This does not necessarily lead to rapid cellular division. Rapid cellular migration is part of metastasis. Immortality is a characteristic of cancer cells due to too much telomerase.
If wrong: Cancer cells do not have sufficient fibronectin and so do not maintain tight adhesion with other cells. This is part of the mechanism of metastasis. Chromosome alterations in cancer cells (aneuploidy) consist of having too many, too few, or altered chromosome pairs. This does not necessarily lead to rapid cellular division. Rapid cellular migration is part of metastasis. Immortality is a characteristic of cancer cells due to too much telomerase.

Q: The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem?
- CD4+ cells
- Cytotoxic T cells
- Natural killer cells
- Suppressor T cells
A: Suppressor T cells
If right: Suppressor T cells help prevent hypersensitivity to one’s own cells, which is the basis for autoimmune disease. CD4+ cells are also known as helper/inducer cells, which secrete cytokines. Natural killer cells have direct cytotoxic effects on some non-self cells without first being sensitized. Suppressor T cells have an inhibitory action on the immune system. Cytotoxic T cells are effective against self cells infected by parasites such as viruses or protozoa.
If wrong: Suppressor T cells help prevent hypersensitivity to one’s own cells, which is the basis for autoimmune disease. CD4+ cells are also known as helper/inducer cells, which secrete cytokines. Natural killer cells have direct cytotoxic effects on some non-self cells without first being sensitized. Suppressor T cells have an inhibitory action on the immune system. Cytotoxic T cells are effective against self cells infected by parasites such as viruses or protozoa.

Q: The nurse working in an organ transplantation program knows that which individual is typically the best donor of an organ?
- Child
- Identical twin
- Parent
- Same-sex sibling
A: Identical twin
If right: The recipient’s immune system recognizes donated tissues as non-self except in the case of an identical twin, whose genetic makeup is identical to the recipient.
If wrong: The recipient’s immune system recognizes donated tissues as non-self except in the case of an identical twin, whose genetic makeup is identical to the recipient.

Q: The nurse understands that which type of immunity is the longest acting?
- Artificial active
- Inflammatory
- Natural active
- Natural passive
A: Natural active
If right: Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural passive do not last as long. “Inflammatory” is not a type of immunity.
If wrong: Natural active immunity is the most effective and longest acting type of immunity. Artificial and natural passive do not last as long. “Inflammatory” is not a type of immunity.

Q: The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? <b>(Select all that apply.)</b>
- Edema
- Pulselessness
- Pallor
- Redness
- Warmth
A: Edema; Redness; Warmth
If right: The five cardinal signs of inflammation include redness, warmth, pain, swelling, and decreased function.
If wrong: The five cardinal signs of inflammation include redness, warmth, pain, swelling, and decreased function.

Q: For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? <b>(Select all that apply.)</b>
- Antibody-mediated immunity
- Cell-mediated immunity
- Inflammation
- Red blood cells
- White blood cells
A: Antibody-mediated immunity; Cell-mediated immunity; Inflammation
If right: The three processes that need to be functional and interact with each other for a person to be immunocompetent are antibody-mediated immunity, cell-mediated immunity, and inflammation. Red and white blood cells are not processes.
If wrong: The three processes that need to be functional and interact with each other for a person to be immunocompetent are antibody-mediated immunity, cell-mediated immunity, and inflammation. Red and white blood cells are not processes.

Q: An older adult has a mild temperature, night sweats, and productive cough. The client’s tuberculin test comes back negative. What action by the nurse is best?
- Recommend a pneumonia vaccination.
- Teach the client about viral infections.
- Tell the client to rest and drink plenty of fluids.
- Treat the client as if he or she has tuberculosis (TB).
A: Treat the client as if he or she has tuberculosis (TB).
If right: Due to an age-related decrease in circulating T lymphocytes, the older adult may have a falsely negative TB test. With signs and symptoms of TB, the nurse treats the client as if he or she does have TB. A pneumonia vaccination is not warranted at this time. TB is not a viral infection. The client should rest and drink plenty of fluids, but this is not the best answer as it does not address the possibility that the client’s TB test could be a false negative.
If wrong: Due to an age-related decrease in circulating T lymphocytes, the older adult may have a falsely negative TB test. With signs and symptoms of TB, the nurse treats the client as if he or she does have TB. A pneumonia vaccination is not warranted at this time. TB is not a viral infection. The client should rest and drink plenty of fluids, but this is not the best answer as it does not address the possibility that the client’s TB test could be a false negative.

Q: A student nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the student learn? <b>(Select all that apply.)</b>
- Basophils are only involved in the general inflammatory process.
- Eosinophils increase during allergic reactions and parasitic invasion.
- Macrophages can participate in many episodes of phagocytosis.
- Monocytes turn into macrophages after they enter body tissues.
- Neutrophils can only take part in one episode of phagocytosis.
A: Eosinophils increase during allergic reactions and parasitic invasion.; Macrophages can participate in many episodes of phagocytosis.; Monocytes turn into macrophages after they enter body tissues.; Neutrophils can only take part in one episode of phagocytosis.
If right: Eosinophils do increase during allergic and parasitic invasion. Macrophages participate in many episodes of phagocytosis. Monocytes turn into macrophages after they enter body tissues. Neutrophils only take part in one episode of phagocytosis. Basophils are involved in <i>both</i> the general inflammatory response and allergic or hypersensitivity responses.
If wrong: Eosinophils do increase during allergic and parasitic invasion. Macrophages participate in many episodes of phagocytosis. Monocytes turn into macrophages after they enter body tissues. Neutrophils only take part in one episode of phagocytosis. Basophils are involved in <i>both</i> the general inflammatory response and allergic or hypersensitivity responses.

Q: A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ?
- Bone marrow
- Spleen
- Thymus
- Tonsils
A: Bone marrow
If right: The B cell is the primary cell in antibody-mediated immunity and is released from the bone marrow. These cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B cells.
If wrong: The B cell is the primary cell in antibody-mediated immunity and is released from the bone marrow. These cells then travel to other organs and tissues, known as the secondary lymphoid tissues for B cells.

Q: A nurse is assessing an older client for the presence of infection. The client’s temperature is 97.6° F (36.4° C). What response by the nurse is best?
- Assess the client for more specific signs.
- Conclude that an infection is not present.
- Document findings and continue to monitor.
- Request that the provider order blood cultures.
A: Assess the client for more specific signs.
If right: Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse should assess the client for specific signs of infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures may or may not be needed depending on the results of further assessment.
If wrong: Because older adults have decreased immune function, including reduced neutrophil function, fever may not be present during an episode of infection. The nurse should assess the client for specific signs of infection. Documentation needs to occur, but a more thorough assessment comes first. Blood cultures may or may not be needed depending on the results of further assessment.

Q: A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider?
- Blood urea nitrogen (BUN) of 18 mg/dL
- Cloudy, foul-smelling urine
- Creatinine of 3.9 mg/dL
- Urine output of 340 mL/8 hr
A: Creatinine of 3.9 mg/dL
If right: A creatinine of 3.9 mg/dL is high, indicating possible dysfunction of the kidney. This is a possible sign of rejection. The BUN is normal, as is the urine output. Cloudy, foul-smelling urine would probably indicate a urinary tract infection.
If wrong: A creatinine of 3.9 mg/dL is high, indicating possible dysfunction of the kidney. This is a possible sign of rejection. The BUN is normal, as is the urine output. Cloudy, foul-smelling urine would probably indicate a urinary tract infection.

Q: The student nurse caring for clients who have cancer understands that the general consequences of cancer include which client problems? <b>(Select all that apply.)</b>
- Clotting abnormalities from thrombocythemia
- Increased risk of infection from white blood cell deficits
- Nutritional deficits such as early satiety and cachexia
- Potential for reduced gas exchange
- Various motor and sensory deficits
A: Increased risk of infection from white blood cell deficits; Nutritional deficits such as early satiety and cachexia; Potential for reduced gas exchange; Various motor and sensory deficits
If right: The general consequences of cancer include reduced immunity and blood-producing functions, altered GI structure and function, decreased respiratory function, and motor and sensory deficits. Clotting problems often occur due to thrombocytopenia (not enough platelets), not thrombocythemia (too many platelets).
If wrong: The general consequences of cancer include reduced immunity and blood-producing functions, altered GI structure and function, decreased respiratory function, and motor and sensory deficits. Clotting problems often occur due to thrombocytopenia (not enough platelets), not thrombocythemia (too many platelets).

Q: The nurse working with oncology clients understands that which age-related change increases the older client’s susceptibility to infection during chemotherapy?
- Decreased immune function
- Diminished nutritional stores
- Existing cognitive deficits
- Poor physical reserves
A: Decreased immune function
If right: As people age, there is an age-related decrease in immune function, causing the older adult to be more susceptible to infection than other clients. Not all older adults have diminished nutritional stores, cognitive dysfunction, or poor physical reserves.
If wrong: As people age, there is an age-related decrease in immune function, causing the older adult to be more susceptible to infection than other clients. Not all older adults have diminished nutritional stores, cognitive dysfunction, or poor physical reserves.

Q: The nurse has taught a client with cancer ways to prevent infection. What statement by the client indicates that more teaching is needed?
- “I should take my temperature daily and when I don’t feel well.”
- “I will wash my toothbrush in the dishwasher once a week.”
- “I won’t let anyone share any of my personal items or dishes.”
- “It’s alright for me to keep my pets and change the litter box.”
A: “It’s alright for me to keep my pets and change the litter box.”
If right: Clients should wash their hands after touching their pets and should not empty or scoop the cat litter box. The other statements are appropriate for self-management.
If wrong: Clients should wash their hands after touching their pets and should not empty or scoop the cat litter box. The other statements are appropriate for self-management.

Q: Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients should the nurse assess first?
- Client with dry, itchy, peeling skin
- Client with a serum calcium of 9.2 mg/dL
- Client with a serum potassium of 2.8 mEq/L
- Client with a weight gain of 0.5 pound (1.1 kg) in 1 day
A: Client with a serum potassium of 2.8 mEq/L
If right: TKIs can cause electrolyte imbalances. This potassium level is very low, so the nurse should assess this client first. Dry, itchy, peeling skin can be a problem in clients receiving biologic response modifiers, and the nurse should assess that client next because of the potential for discomfort and infection. This calcium level is normal. TKIs can also cause weight gain, but the client with the low potassium level is more critical.
If wrong: TKIs can cause electrolyte imbalances. This potassium level is very low, so the nurse should assess this client first. Dry, itchy, peeling skin can be a problem in clients receiving biologic response modifiers, and the nurse should assess that client next because of the potential for discomfort and infection. This calcium level is normal. TKIs can also cause weight gain, but the client with the low potassium level is more critical.

Q: After receiving the hand-off report, which client should the oncology nurse see first?
- Client who is afebrile with a heart rate of 108 beats/min
- Older client on chemotherapy with mental status changes
- Client who is neutropenic and in protective isolation
- Client scheduled for radiation therapy today
A: Older client on chemotherapy with mental status changes
If right: Older clients often do not exhibit classic signs of infection, and often mental status changes are the first observation. Clients on chemotherapy who become neutropenic also often do not exhibit classic signs of infection. The nurse should assess the older client first. The other clients can be seen afterward.
If wrong: Older clients often do not exhibit classic signs of infection, and often mental status changes are the first observation. Clients on chemotherapy who become neutropenic also often do not exhibit classic signs of infection. The nurse should assess the older client first. The other clients can be seen afterward.

Q: A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority?
- Helping clients adjust to their appearance
- Reassuring clients that this change is temporary
- Referring clients to a reputable wig shop
- Teaching measures to prevent scalp injury
A: Teaching measures to prevent scalp injury
If right: All of the actions are appropriate for clients with alopecia. However, the priority is client safety, so the nurse should first teach ways to prevent scalp injury.
If wrong: All of the actions are appropriate for clients with alopecia. However, the priority is client safety, so the nurse should first teach ways to prevent scalp injury.

Q: A nurse works on an oncology unit and delegates personal hygiene to an unlicensed assistive personnel (UAP). What action by the UAP requires intervention from the nurse?
- Allowing a very tired client to skip oral hygiene and sleep
- Assisting clients with washing the perianal area every 12 hours
- Helping the client use a soft-bristled toothbrush for oral care
- Reminding the client to rinse the mouth with water or saline
A: Allowing a very tired client to skip oral hygiene and sleep
If right: Even though clients may be tired, they still need to participate in hygiene to help prevent infection. The other options are all appropriate.
If wrong: Even though clients may be tired, they still need to participate in hygiene to help prevent infection. The other options are all appropriate.

Q: A nurse working with clients who experience alopecia knows that which is the best method of helping clients manage the psychosocial impact of this problem?
- Assisting the client to pre-plan for this event
- Reassuring the client that alopecia is temporary
- Teaching the client ways to protect the scalp
- Telling the client that there are worse side effects
A: Assisting the client to pre-plan for this event
If right: Alopecia does not occur for all clients who have cancer, but when it does, it can be devastating. The best action by the nurse is to teach the client about the possibility and to give the client multiple choices for preparing for this event. Not all clients will have the same reaction, but some possible actions the client can take are buying a wig ahead of time, buying attractive hats and scarves, and having a hairdresser modify a wig to look like the client’s own hair. Teaching about scalp protection is important but does not address the psychosocial impact. Reassuring the client that hair loss is temporary and telling him or her that there are worse side effects are both patronizing and do not give the client tools to manage this condition.
If wrong: Alopecia does not occur for all clients who have cancer, but when it does, it can be devastating. The best action by the nurse is to teach the client about the possibility and to give the client multiple choices for preparing for this event. Not all clients will have the same reaction, but some possible actions the client can take are buying a wig ahead of time, buying attractive hats and scarves, and having a hairdresser modify a wig to look like the client’s own hair. Teaching about scalp protection is important but does not address the psychosocial impact. Reassuring the client that hair loss is temporary and telling him or her that there are worse side effects are both patronizing and do not give the client tools to manage this condition.

Q: A nurse reads on a hospitalized client’s chart that the client is receiving teletherapy. What action by the nurse is best?
- Coordinate continuation of the therapy.
- Place the client on radiation precautions.
- No action by the nurse is needed at this time.
- Restrict visitors to only adults over age 18.
A: Coordinate continuation of the therapy.
If right: The client needs to continue with radiation therapy, and the nurse can coordinate this with the appropriate department. The client is not radioactive, so radiation precautions and limiting visitors are not necessary.
If wrong: The client needs to continue with radiation therapy, and the nurse can coordinate this with the appropriate department. The client is not radioactive, so radiation precautions and limiting visitors are not necessary.

Q: A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? <b>(Select all that apply.)</b>
- “Chemo” gloves
- Facemask
- Isolation gown
- N95 respirator
- Shoe covers
A: “Chemo” gloves; Facemask; Isolation gown
If right: The Occupational Safety and Health Administration (OSHA) and the Oncology Nurses Society have developed safety guidelines for those preparing or administering IV chemotherapy. These include double gloves (or “chemo” gloves), a facemask, and a gown. An N95 respirator and shoe covers are not required.
If wrong: The Occupational Safety and Health Administration (OSHA) and the Oncology Nurses Society have developed safety guidelines for those preparing or administering IV chemotherapy. These include double gloves (or “chemo” gloves), a facemask, and a gown. An N95 respirator and shoe covers are not required.

Q: A nurse is assessing a female client who is taking progestins. What assessment finding requires the nurse to notify the provider immediately?
- Irregular menses
- Edema in the lower extremities
- Ongoing breast tenderness
- Red, warm, swollen calf
A: Red, warm, swollen calf
If right: All clients receiving progestin therapy are at risk for thromboembolism. A red, warm, swollen calf is a manifestation of deep vein thrombosis and should be reported to the provider. Irregular menses, edema in the lower extremities, and breast tenderness are common side effects of the therapy.
If wrong: All clients receiving progestin therapy are at risk for thromboembolism. A red, warm, swollen calf is a manifestation of deep vein thrombosis and should be reported to the provider. Irregular menses, edema in the lower extremities, and breast tenderness are common side effects of the therapy.

Q: A nurse in the oncology clinic is providing preoperative education to a client just diagnosed with cancer. The client has been scheduled for surgery in 3 days. What action by the nurse is best?
- Call the client at home the next day to review teaching.
- Give the client information about a cancer support group.
- Provide all the preoperative instructions in writing.
- Reassure the client that surgery will be over soon.
A: Call the client at home the next day to review teaching.
If right: Clients are often overwhelmed at a sudden diagnosis of cancer and may be more overwhelmed at the idea of a major operation so soon. This stress significantly impacts the client’s ability to understand, retain, and recall information. The nurse should call the client at home the next day to review the teaching and to answer questions. The client may or may not be ready to investigate a support group, but this does not help with teaching. Giving information in writing is important (if the client can read it), but in itself will not be enough. Telling the client that surgery will be over soon is giving false reassurance and does nothing for teaching.
If wrong: Clients are often overwhelmed at a sudden diagnosis of cancer and may be more overwhelmed at the idea of a major operation so soon. This stress significantly impacts the client’s ability to understand, retain, and recall information. The nurse should call the client at home the next day to review the teaching and to answer questions. The client may or may not be ready to investigate a support group, but this does not help with teaching. Giving information in writing is important (if the client can read it), but in itself will not be enough. Telling the client that surgery will be over soon is giving false reassurance and does nothing for teaching.

Q: A new nurse has been assigned a client who is in the hospital to receive iodine-131 treatment. Which action by the nurse is best?
- Ensure the client is placed in protective isolation.
- Hand off a pregnant client to another nurse.
- No special action is necessary to care for this client.
- Read the policy on handling radioactive excreta.
A: Read the policy on handling radioactive excreta.
If right: This type of radioisotope is excreted in body fluids and excreta (urine and feces) and should not be handled directly. The nurse should read the facility’s policy for handling and disposing of this type of waste. The other actions are not warranted.
If wrong: This type of radioisotope is excreted in body fluids and excreta (urine and feces) and should not be handled directly. The nurse should read the facility’s policy for handling and disposing of this type of waste. The other actions are not warranted.

Q: A client’s family members are concerned that telling the client about a new finding of cancer will cause extreme emotional distress. They approach the nurse and ask if this can be kept from the client. What actions by the nurse are most appropriate?<i> </i><b>(Select all that apply.)</b>
- Ask the family to describe their concerns more fully.
- Consult with a social worker, chaplain, or ethics committee.
- Explain the client’s right to know and ask for their assistance.
- Have the unit manager take over the care of this client and family.
- Tell the family that this secret will not be kept from the client.
A: Ask the family to describe their concerns more fully.; Consult with a social worker, chaplain, or ethics committee.; Explain the client’s right to know and ask for their assistance.
If right: The client’s right of autonomy means that the client must be fully informed as to his or her diagnosis and treatment options. The nurse cannot ethically keep this information from the client. The nurse can ask the family to explain their concerns more fully so everyone understands the concerns. A social worker, chaplain, or ethics committee can become involved to assist the nurse, client, and family. The nurse should explain the client’s right to know and ask the family how best to proceed. The nurse should not abdicate responsibility for this difficult situation by transferring care to another nurse. Simply telling the family that he or she will not keep this secret sets up an adversarial relationship. Explaining this fact along with the concept of autonomy would be acceptable, but this by itself is not.
If wrong: The client’s right of autonomy means that the client must be fully informed as to his or her diagnosis and treatment options. The nurse cannot ethically keep this information from the client. The nurse can ask the family to explain their concerns more fully so everyone understands the concerns. A social worker, chaplain, or ethics committee can become involved to assist the nurse, client, and family. The nurse should explain the client’s right to know and ask the family how best to proceed. The nurse should not abdicate responsibility for this difficult situation by transferring care to another nurse. Simply telling the family that he or she will not keep this secret sets up an adversarial relationship. Explaining this fact along with the concept of autonomy would be acceptable, but this by itself is not.

Q: A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the client’s oral chemotherapy medications. What action by the nurse is most appropriate?
- Crush the medications if the client cannot swallow them.
- Give one medication at a time with a full glass of water.
- No special precautions are needed for these medications.
- Wear personal protective equipment when handling the medications.
A: Wear personal protective equipment when handling the medications.
If right: During the administration of oral chemotherapy agents, nurses must take the same precautions that are used when administering IV chemotherapy. This includes using personal protective equipment. These medications cannot be crushed, split, or chewed. Giving one at a time is not needed.
If wrong: During the administration of oral chemotherapy agents, nurses must take the same precautions that are used when administering IV chemotherapy. This includes using personal protective equipment. These medications cannot be crushed, split, or chewed. Giving one at a time is not needed.

Q: A client with cancer has anorexia and mucositis, and is losing weight. The client’s family members continually bring favorite foods to the client and are distressed when the client won’t eat them. What action by the nurse is best?
- Explain the pathophysiologic reasons behind the client not eating.
- Help the family show other ways to demonstrate love and caring.
- Suggest foods and liquids the client might be willing to try to eat.
- Tell the family the client isn’t able to eat now no matter what they bring.
A: Help the family show other ways to demonstrate love and caring.
If right: Families often become distressed when their loved ones won’t eat. Providing food is a universal sign of caring, and to some people the refusal to eat signifies worsening of the condition. The best option for the nurse is to help the family find other ways to demonstrate caring and love, because with treatment-related anorexia and mucositis, the client is not likely to eat anything right now. Explaining the rationale for the problem is a good idea but does not suggest to the family anything that they can do for the client. Simply telling the family the client is not able to eat does not give them useful information and is dismissive of their concerns.
If wrong: Families often become distressed when their loved ones won’t eat. Providing food is a universal sign of caring, and to some people the refusal to eat signifies worsening of the condition. The best option for the nurse is to help the family find other ways to demonstrate caring and love, because with treatment-related anorexia and mucositis, the client is not likely to eat anything right now. Explaining the rationale for the problem is a good idea but does not suggest to the family anything that they can do for the client. Simply telling the family the client is not able to eat does not give them useful information and is dismissive of their concerns.

Q: A client with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important?
- Assess the client’s gait and balance.
- Ask the client about the ease of urine flow.
- Document the report completely.
- Inquire about the client’s job risks.
A: Assess the client’s gait and balance.
If right: This client has manifestations of spinal cord compression, which can be seen with prostate cancer. This may affect both gait and balance and urinary function. For client safety, assessing gait and balance is the priority. Documentation should be complete. The client may or may not have occupational risks for low back pain, but with his history of prostate cancer, this should not be where the nurse starts investigating.
If wrong: This client has manifestations of spinal cord compression, which can be seen with prostate cancer. This may affect both gait and balance and urinary function. For client safety, assessing gait and balance is the priority. Documentation should be complete. The client may or may not have occupational risks for low back pain, but with his history of prostate cancer, this should not be where the nurse starts investigating.

Q: A client tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate?
- “Avoid getting salt water on the radiation site.”
- “Do not expose the radiation area to direct sunlight.”
- “Have a wonderful time and enjoy your vacation!”
- “Remember you should not drink alcohol for a year.”
A: “Do not expose the radiation area to direct sunlight.”
If right: The skin overlying the radiation site is extremely sensitive to sunlight after radiation therapy has been completed. The nurse should inform the client to avoid sun exposure to this area. This advice continues for 1 year after treatment has been completed. The other statements are not appropriate.
If wrong: The skin overlying the radiation site is extremely sensitive to sunlight after radiation therapy has been completed. The nurse should inform the client to avoid sun exposure to this area. This advice continues for 1 year after treatment has been completed. The other statements are not appropriate.

Q: A client receiving chemotherapy has a white blood cell count of 1000/mm<sup>3</sup>. What actions by the nurse are most appropriate?<i> </i><b>(Select all that apply.)</b>
- Assess all mucous membranes every 4 to 8 hours.
- Do not allow the client to eat meat or poultry.
- Listen to lung sounds and monitor for cough.
- Monitor the venous access device appearance with vital signs.
- Take and record vital signs every 4 to 8 hours.
A: Assess all mucous membranes every 4 to 8 hours.; Listen to lung sounds and monitor for cough.; Monitor the venous access device appearance with vital signs.; Take and record vital signs every 4 to 8 hours.
If right: Depending on facility protocol, the nurse should assess this client for infection every 4 to 8 hours by assessing all mucous membranes, listening to lung sounds, monitoring for cough, monitoring the appearance of the venous access device, and recording vital signs. Eating meat and poultry is allowed.
If wrong: Depending on facility protocol, the nurse should assess this client for infection every 4 to 8 hours by assessing all mucous membranes, listening to lung sounds, monitoring for cough, monitoring the appearance of the venous access device, and recording vital signs. Eating meat and poultry is allowed.

Q: A nurse is discharging a client after a total hip replacement. What statement by the client indicates good potential for self-management?
- “I can bend down to pick something up.”
- “I no longer need to do my exercises.”
- “I will not sit with my legs crossed.”
- “I won’t wash my incision to keep it dry.”
A: “I will not sit with my legs crossed.”
If right: There are many precautions clients need to take after hip replacement surgery, including not bending more than 90 degrees at the hips, continuing prescribed exercises, not crossing the legs, and washing the incision daily and patting it dry.
If wrong: There are many precautions clients need to take after hip replacement surgery, including not bending more than 90 degrees at the hips, continuing prescribed exercises, not crossing the legs, and washing the incision daily and patting it dry.

Q: A nurse is caring for a client with systemic sclerosis. The client’s facial skin is very taut, limiting the client’s ability to open the mouth. After consulting with a registered dietitian for appropriate nutrition, what other consultation should the nurse facilitate?
- Dentist
- Massage therapist
- Occupational therapy
- Physical therapy
A: Dentist
If right: With limited ability to open the mouth, dental hygiene may be lacking. The nurse should encourage the client to see a dentist. The other referrals are not related to the mouth.
If wrong: With limited ability to open the mouth, dental hygiene may be lacking. The nurse should encourage the client to see a dentist. The other referrals are not related to the mouth.

Q: A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection?
- Assess the client’s white blood cell count.
- Culture any drainage from the wound.
- Monitor the client’s temperature every 4 hours.
- Use aseptic technique for dressing changes.
A: Use aseptic technique for dressing changes.
If right: Preventing surgical wound infection is a primary responsibility of the nurse, who must use aseptic technique to change dressings or empty drains. The other actions do not prevent infection but can lead to early detection of an infection that is already present.
If wrong: Preventing surgical wound infection is a primary responsibility of the nurse, who must use aseptic technique to change dressings or empty drains. The other actions do not prevent infection but can lead to early detection of an infection that is already present.

Q: A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching?
- Acetaminophen (Tylenol)
- Cyclobenzaprine hydrochloride (Flexeril)
- Hyaluronate (Hyalgan)
- Ibuprofen (Motrin)
A: Acetaminophen (Tylenol)
If right: All of the drugs are appropriate to treat OA. However, the first-line drug is acetaminophen. Cyclobenzaprine is a muscle relaxant given to treat muscle spasms. Hyaluronate is a synthetic joint fluid implant. Ibuprofen is a nonsteroidal anti-inflammatory drug.
If wrong: All of the drugs are appropriate to treat OA. However, the first-line drug is acetaminophen. Cyclobenzaprine is a muscle relaxant given to treat muscle spasms. Hyaluronate is a synthetic joint fluid implant. Ibuprofen is a nonsteroidal anti-inflammatory drug.

Q: A home health care nurse is visiting a client discharged home after a hip replacement. The client is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client? <b>(Select all that apply.)</b>
- Buy and install an elevated toilet seat.
- Install grab bars in the shower and by the toilet.
- Step into the bathtub with the affected leg first.
- Remove all throw rugs throughout the house.
- Use a shower chair while taking a shower.
A: Buy and install an elevated toilet seat.; Install grab bars in the shower and by the toilet.; Remove all throw rugs throughout the house.; Use a shower chair while taking a shower.
If right: Buying and installing an elevated toilet seat, installing grab bars, removing throw rugs, and using a shower chair will all promote safety for this client. The client is still on partial weight bearing, so he or she cannot step into the bathtub leading with the operative side. Stepping into a bathtub may also require the client to bend the hip more than the allowed 90 degrees.
If wrong: Buying and installing an elevated toilet seat, installing grab bars, removing throw rugs, and using a shower chair will all promote safety for this client. The client is still on partial weight bearing, so he or she cannot step into the bathtub leading with the operative side. Stepping into a bathtub may also require the client to bend the hip more than the allowed 90 degrees.

Q: A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acute exacerbation. The client is in the clinic for a follow-up visit and is distraught about the possibility of another hospitalization disrupting the family. What action by the nurse is best?
- Explain to the client that SLE is an unpredictable disease.
- Help the client create backup plans to minimize disruption.
- Offer to talk to the family and educate them about SLE.
- Tell the client to remain compliant with treatment plans.
A: Help the client create backup plans to minimize disruption.
If right: SLE is an unpredictable disease and acute exacerbations can occur without warning, creating chaos in the family. Helping the client make backup plans for this event not only will decrease the disruption but will give the client a sense of having more control. Explaining facts about the disease is helpful as well but does not engage the client in problem solving. The family may need education, but again this does not help the client to problem-solve. Remaining compliant may help decrease exacerbations, but is not as powerful an intervention as helping the client plan for such events.
If wrong: SLE is an unpredictable disease and acute exacerbations can occur without warning, creating chaos in the family. Helping the client make backup plans for this event not only will decrease the disruption but will give the client a sense of having more control. Explaining facts about the disease is helpful as well but does not engage the client in problem solving. The family may need education, but again this does not help the client to problem-solve. Remaining compliant may help decrease exacerbations, but is not as powerful an intervention as helping the client plan for such events.

Q: A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like “pins and needles” and that the neck is very painful since returning from surgery. What action by the nurse is best?
- Assist the client to change positions.
- Document the findings in the client’s chart.
- Encourage range of motion of the neck.
- Notify the provider immediately.
A: Notify the provider immediately.
If right: Clients with RA can have cervical joint involvement. This can lead to an emergent situation in which the phrenic nerve is compressed, causing respiratory insufficiency. The client can also suffer a permanent spinal cord injury. The nurse needs to notify the provider immediately. Changing positions and doing range of motion may actually worsen the situation. The nurse should document findings after notifying the provider.
If wrong: Clients with RA can have cervical joint involvement. This can lead to an emergent situation in which the phrenic nerve is compressed, causing respiratory insufficiency. The client can also suffer a permanent spinal cord injury. The nurse needs to notify the provider immediately. Changing positions and doing range of motion may actually worsen the situation. The nurse should document findings after notifying the provider.

Q: A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply?
- Heating pad
- Ice packs
- Splints
- Wax dip
A: Ice packs
If right: Ice is best for acute inflammation. Heat often helps with joint stiffness. Splinting helps preserve joint function. A wax dip is used to provide warmth to the joint which is more appropriate for chronic pain and stiffness.
If wrong: Ice is best for acute inflammation. Heat often helps with joint stiffness. Splinting helps preserve joint function. A wax dip is used to provide warmth to the joint which is more appropriate for chronic pain and stiffness.

Q: A client with fibromyalgia is in the hospital for an unrelated issue. The client reports that sleep, which is always difficult, is even harder now. What actions by the nurse are most appropriate? <b>(Select all that apply.)</b>
- Allow the client uninterrupted rest time.
- Assess the client’s usual bedtime routine.
- Limit environmental noise as much as possible.
- Offer a massage or warm shower at night.
- Request an order for a strong sleeping pill.
A: Allow the client uninterrupted rest time.; Assess the client’s usual bedtime routine.; Limit environmental noise as much as possible.; Offer a massage or warm shower at night.
If right: Clients with fibromyalgia often have sleep disturbances, which can be exacerbated by the stress, noise, and unfamiliar environment of the hospital. Allowing uninterrupted rest time, adhering to the client’s usual bedtime routine as much as possible, limiting noise and light, and offering massages or warm showers can help. The client does not need a strong sleeping pill unless all other options fail and the client requests something for sleep. At that point a mild sleeping agent can be tried.
If wrong: Clients with fibromyalgia often have sleep disturbances, which can be exacerbated by the stress, noise, and unfamiliar environment of the hospital. Allowing uninterrupted rest time, adhering to the client’s usual bedtime routine as much as possible, limiting noise and light, and offering massages or warm showers can help. The client does not need a strong sleeping pill unless all other options fail and the client requests something for sleep. At that point a mild sleeping agent can be tried.

Q: A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best?
- Assess medication records for steroid use.
- Facilitate a consultation with physical therapy.
- Measure the range of motion in both hips.
- Notify the health care provider immediately.
A: Assess medication records for steroid use.
If right: Chronic steroid use is seen in clients with SLE and can lead to osteonecrosis (bone necrosis). The nurse should determine if the client has been taking a steroid. Physical therapy may be beneficial, but there is not enough information about the client yet. Measuring range of motion is best done by the physical therapist. Notifying the provider immediately is not warranted.
If wrong: Chronic steroid use is seen in clients with SLE and can lead to osteonecrosis (bone necrosis). The nurse should determine if the client has been taking a steroid. Physical therapy may be beneficial, but there is not enough information about the client yet. Measuring range of motion is best done by the physical therapist. Notifying the provider immediately is not warranted.

Q: A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief. The client also requests the celecoxib in addition to the morphine. What action by the nurse is best?
- Consult with the health care provider about administering both drugs to the client.
- Inform the client that the celecoxib will be started when he or she goes home.
- Teach the client that, since morphine is stronger, celecoxib is not needed.
- Tell the client he or she should not take both drugs at the same time.
A: Consult with the health care provider about administering both drugs to the client.
If right: Despite getting an opioid analgesic for postoperative pain, the nurse should be aware that the client may be on other medications for arthritis in other joints. The nonsteroidal anti-inflammatory drug celecoxib will also help with the postoperative pain. The nurse should consult the provider about continuing the celecoxib while the client is in the hospital. The other responses are not warranted, as the client should be restarted on this medication postoperatively.
If wrong: Despite getting an opioid analgesic for postoperative pain, the nurse should be aware that the client may be on other medications for arthritis in other joints. The nonsteroidal anti-inflammatory drug celecoxib will also help with the postoperative pain. The nurse should consult the provider about continuing the celecoxib while the client is in the hospital. The other responses are not warranted, as the client should be restarted on this medication postoperatively.

Q: A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement?
- “I always wear long sleeves, pants, and a hat when outdoors.”
- “I try not to use cosmetics that contain any type of sunblock.”
- “Since I tend to sweat a lot, I use a lot of baby powder.”
- “Since I can’t be exposed to the sun, I have been using a tanning bed.”
A: “I always wear long sleeves, pants, and a hat when outdoors.”
If right: Good self-management of the skin in SLE includes protecting the skin from sun exposure, using sunblock, avoiding drying agents such as powder, and avoiding tanning beds.
If wrong: Good self-management of the skin in SLE includes protecting the skin from sun exposure, using sunblock, avoiding drying agents such as powder, and avoiding tanning beds.

Q: A client is started on etanercept (Enbrel). What teaching by the nurse is most appropriate?
- Giving subcutaneous injections
- Having a chest x-ray once a year
- Taking the medication with food
- Using heat on the injection site
A: Giving subcutaneous injections
If right: Etanercept is given as a subcutaneous injection twice a week. The nurse should teach the client how to self-administer the medication. The other options are not appropriate for etanercept.
If wrong: Etanercept is given as a subcutaneous injection twice a week. The nurse should teach the client how to self-administer the medication. The other options are not appropriate for etanercept.

Q: A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly anemic and the surgeon states the client may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important?
- Administer preoperative medications as prescribed.
- Ensure that a consent for transfusion is on the chart.
- Explain to the client how anemia affects healing.
- Teach the client about foods high in protein and iron.
A: Ensure that a consent for transfusion is on the chart.
If right: The preoperative nurse should ensure that all valid consents are on the chart, including one for blood transfusions if this may be needed. Administering preoperative medications is important for all preoperative clients and is not specific to this client. Teaching in the preoperative area should focus on immediate concerns.
If wrong: The preoperative nurse should ensure that all valid consents are on the chart, including one for blood transfusions if this may be needed. Administering preoperative medications is important for all preoperative clients and is not specific to this client. Teaching in the preoperative area should focus on immediate concerns.

Q: A client is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important?
- Have adequate help to transfer the client.
- Provide socks so the client can slide easier.
- Tell the client full weight bearing is allowed.
- Use a footstool to elevate the client’s leg.
A: Have adequate help to transfer the client.
If right: The client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure there is adequate help to transfer the client while preventing falls. Slippery socks will encourage a fall. Elevating the leg greater than 90 degrees is not allowed.
If wrong: The client with an uncemented hip will be on toe-touch only right after surgery. The nurse should ensure there is adequate help to transfer the client while preventing falls. Slippery socks will encourage a fall. Elevating the leg greater than 90 degrees is not allowed.

Q: A client in the orthopedic clinic has a self-reported history of osteoarthritis. The client reports a low-grade fever that started when the weather changed and several joints started “acting up,” especially both hips and knees. What action by the nurse is best?
- Assess the client for the presence of subcutaneous nodules or Baker’s cysts.
- Inspect the client’s feet and hands for podagra and tophi on fingers and toes.
- Prepare to teach the client about an acetaminophen (Tylenol) regimen.
- Reassure the client that the problems will fade as the weather changes again.
A: Assess the client for the presence of subcutaneous nodules or Baker’s cysts.
If right: Osteoarthritis is not a systemic disease, nor does it present bilaterally. These are manifestations of rheumatoid arthritis. The nurse should assess for other manifestations of this disorder, including subcutaneous nodules and Baker’s cysts. Podagra and tophi are seen in gout. Acetaminophen is not used for rheumatoid arthritis. Telling the client that the symptoms will fade with weather changes is not accurate.
If wrong: Osteoarthritis is not a systemic disease, nor does it present bilaterally. These are manifestations of rheumatoid arthritis. The nurse should assess for other manifestations of this disorder, including subcutaneous nodules and Baker’s cysts. Podagra and tophi are seen in gout. Acetaminophen is not used for rheumatoid arthritis. Telling the client that the symptoms will fade with weather changes is not accurate.

Q: A client has rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best?
- “Let’s ask the provider about increasing your pain pills.”
- “Hold ice bags against your hands before quilting.”
- “Try a paraffin wax dip 20 minutes before you quilt.”
- “You need to stop quilting before it destroys your fingers.”
A: “Try a paraffin wax dip 20 minutes before you quilt.”
If right: Paraffin wax dips are beneficial for decreasing pain in arthritic hands and lead to increased mobility. The nurse can suggest this comfort measure. Increasing pain pills will not help with movement. Ice has limited use unless the client has a “hot” or exacerbated joint. The client wants to finish her project, so the nurse should not negate its importance by telling the client it is destroying her joints.
If wrong: Paraffin wax dips are beneficial for decreasing pain in arthritic hands and lead to increased mobility. The nurse can suggest this comfort measure. Increasing pain pills will not help with movement. Ice has limited use unless the client has a “hot” or exacerbated joint. The client wants to finish her project, so the nurse should not negate its importance by telling the client it is destroying her joints.

Q: A nurse suspects a client has serum sickness. What laboratory result would the nurse correlate with this condition?
- Blood urea nitrogen: 12 mg/dL
- Creatinine: 3.2 mg/dL
- Hemoglobin: 8.2 mg/dL
- White blood cell count: 12,000/mm<sup>3</sup>
A: Creatinine: 3.2 mg/dL
If right: The creatinine is high, possibly indicating the client has serum sickness nephritis. Blood urea nitrogen and white blood cell count are both normal. Hemoglobin is not related.
If wrong: The creatinine is high, possibly indicating the client has serum sickness nephritis. Blood urea nitrogen and white blood cell count are both normal. Hemoglobin is not related.

Q: A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed?
- “I don’t need to go to the hospital after using it.”
- “I must carry two EpiPens with me at all times.”
- “I will write the expiration date on my calendar.”
- “This can be injected right through my clothes.”
A: “I don’t need to go to the hospital after using it.”
If right: Clients should be instructed to call 911 and go to the hospital for monitoring after using the EpiPen. The other statements show good understanding of this treatment.
If wrong: Clients should be instructed to call 911 and go to the hospital for monitoring after using the EpiPen. The other statements show good understanding of this treatment.

Q: A client with Sjögren’s syndrome reports dry skin, eyes, mouth, and vagina. What nonpharmacologic comfort measure does the nurse suggest?
- Frequent eyedrops
- Home humidifier
- Strong moisturizer
- Tear duct plugs
A: Home humidifier
If right: A humidifier will help relieve many of the client’s Sjögren’s syndrome symptoms. Eyedrops and tear duct plugs only affect the eyes, and moisturizer will only help the skin.
If wrong: A humidifier will help relieve many of the client’s Sjögren’s syndrome symptoms. Eyedrops and tear duct plugs only affect the eyes, and moisturizer will only help the skin.

Q: A client suffered an episode of anaphylaxis and has been stabilized in the intensive care unit. When assessing the client’s lungs, the nurse hears the following sounds. What medication does the nurse prepare to administer?<br><i><span style="font-size:11pt">(Click the media button to hear the audio clip.)</span></i>
- Albuterol (Proventil) via nebulizer
- Diphenhydramine (Benadryl) IM
- Epinephrine 1:10,000 5 mg IV push
- Methylprednisolone (Solu-Medrol) IV push
A: Albuterol (Proventil) via nebulizer
If right: The nurse has auscultated wheezing in the client’s lungs and prepares to administer albuterol, which is a bronchodilator, or assists respiratory therapy with administration. Diphenhydramine is an antihistamine. Epinephrine is given during an acute crisis in a concentration of 1:1000. Methylprednisolone is a corticosteroid.
If wrong: The nurse has auscultated wheezing in the client’s lungs and prepares to administer albuterol, which is a bronchodilator, or assists respiratory therapy with administration. Diphenhydramine is an antihistamine. Epinephrine is given during an acute crisis in a concentration of 1:1000. Methylprednisolone is a corticosteroid.

Q: A client is receiving plasmapheresis as treatment for Goodpasture’s syndrome. When planning care, the nurse places highest priority on interventions for which client problem?
- Reduced physical activity related to the disease’s effects on the lungs
- Inadequate family coping related to the client’s hospitalization
- Inadequate knowledge related to the plasmapheresis process
- Potential for infection related to the site for organism invasion
A: Potential for infection related to the site for organism invasion
If right: Physical diagnoses take priority over psychosocial diagnoses, so inadequate family coping and inadequate knowledge are not the priority. The client has a potential for infection because plasmapheresis is an invasive procedure. Reduced activity is manifested by changes in vital signs, oxygenation, or electrocardiogram, and/or reports of chest pain or shortness of breath. There is no information in the question to indicate that the client is experiencing reduced physical activity.
If wrong: Physical diagnoses take priority over psychosocial diagnoses, so inadequate family coping and inadequate knowledge are not the priority. The client has a potential for infection because plasmapheresis is an invasive procedure. Reduced activity is manifested by changes in vital signs, oxygenation, or electrocardiogram, and/or reports of chest pain or shortness of breath. There is no information in the question to indicate that the client is experiencing reduced physical activity.

Q: A nurse is caring for a client who has methicillin-resistant <i>Staphylococcus aureus</i> (MRSA) infection cultured from the urine. What action by the nurse is most appropriate?
- Prepare to administer vancomycin (Vancocin).
- Strictly limit visitors to immediate family only.
- Wash hands only after taking off gloves after care.
- Wear a respirator when handling urine output.
A: Prepare to administer vancomycin (Vancocin).
If right: Vancomycin is one of a few drugs approved to treat MRSA. The others include linezolid (Zyvox) and ceftaroline fosamil (Teflaro). Visitation does not need to be limited to immediate family only. Hand hygiene is performed before and after wearing gloves. A respirator is not needed, but if splashing is anticipated, a face shield can be used.
If wrong: Vancomycin is one of a few drugs approved to treat MRSA. The others include linezolid (Zyvox) and ceftaroline fosamil (Teflaro). Visitation does not need to be limited to immediate family only. Hand hygiene is performed before and after wearing gloves. A respirator is not needed, but if splashing is anticipated, a face shield can be used.

Q: A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first?
- Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm<sup>3</sup> and a temp of 102.4° F (39.1° C)
- Client with Bruton’s agammaglobulinemia who is waiting for discharge teaching
- Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion
- Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia
A: Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm<sup>3</sup> and a temp of 102.4° F (39.1° C)
If right: A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be assessed first. The client who is post immunoglobulin infusion should have had all infusion-related vital signs and assessments completed and should be checked next. The client receiving antibiotics should be seen third, and the client waiting for discharge teaching is the lowest priority. Since discharge teaching can take time, the nurse may want to delegate this task to someone else while attending to the most seriously ill client.
If wrong: A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be assessed first. The client who is post immunoglobulin infusion should have had all infusion-related vital signs and assessments completed and should be checked next. The client receiving antibiotics should be seen third, and the client waiting for discharge teaching is the lowest priority. Since discharge teaching can take time, the nurse may want to delegate this task to someone else while attending to the most seriously ill client.

Q: A nurse is observing as an unlicensed assistive personnel (UAP) performs hygiene and changes a client’s bed linens. What action by the UAP requires intervention by the nurse?
- Not using gloves while combing the client’s hair
- Rinsing the client’s commode pan after use
- Shaking dirty linens and placing them on the floor
- Wearing gloves when providing perianal care
A: Shaking dirty linens and placing them on the floor
If right: Shaking dirty linens (or even clean linens) can spread microbes through the air. Placing linens on the floor contaminates the floor surface and can lead to infection spread via shoes. The other actions are appropriate. If the client has a scalp infection or infestation, the UAP should wear gloves; otherwise it is not required.
If wrong: Shaking dirty linens (or even clean linens) can spread microbes through the air. Placing linens on the floor contaminates the floor surface and can lead to infection spread via shoes. The other actions are appropriate. If the client has a scalp infection or infestation, the UAP should wear gloves; otherwise it is not required.

Q: A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states “Whew! I was really worried about that result.” What action by the nurse is most important?
- Assess the client’s sexual activity and patterns.
- Express happiness over the test result.
- Remind the client about safer sex practices.
- Tell the client to be retested in 3 months.
A: Assess the client’s sexual activity and patterns.
If right: The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to making antibodies to HIV. This period of time is known as the window period and can last up to 36 months. The nurse needs to assess the client’s sexual behavior further to determine the proper response. The other actions are not the most important, but discussing safer sex practices is always appropriate.
If wrong: The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to making antibodies to HIV. This period of time is known as the window period and can last up to 36 months. The nurse needs to assess the client’s sexual behavior further to determine the proper response. The other actions are not the most important, but discussing safer sex practices is always appropriate.

Q: A nurse is traveling to a third-world country with a medical volunteer group to work with people who are infected with human immune deficiency virus (HIV). The nurse should recognize that which of the following might be a barrier to the prevention of perinatal HIV transmission? <b>(Select all that apply.)</b>
- Clean drinking water
- Cultural beliefs about illness
- Lack of antiviral medication
- Social stigma
- Unknown transmission routes
A: Clean drinking water; Cultural beliefs about illness; Lack of antiviral medication; Social stigma
If right: Treatment and prevention of HIV is complex, and in third-world countries barriers exist that one might not otherwise think of. Mothers must have access to clean drinking water if they are to mix formula. Cultural beliefs about illness, lack of available medications, and social stigma are also possible barriers. Perinatal transmission is well known to occur across the placenta during birth, from exposure to blood and body fluids during birth, and through breast-feeding.
If wrong: Treatment and prevention of HIV is complex, and in third-world countries barriers exist that one might not otherwise think of. Mothers must have access to clean drinking water if they are to mix formula. Cultural beliefs about illness, lack of available medications, and social stigma are also possible barriers. Perinatal transmission is well known to occur across the placenta during birth, from exposure to blood and body fluids during birth, and through breast-feeding.

Q: A nurse receives report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has “a shift to the left” on the white blood cell count. What action by the nurse is most important?
- Document findings and continue monitoring.
- Notify the provider and request antibiotics.
- Place the client in protective isolation.
- Tell the client this signifies inflammation.
A: Notify the provider and request antibiotics.
If right: A shift to the left indicates an increase in immature neutrophils and is often seen in infections, especially those caused by bacteria. The nurse should notify the provider and request antibiotics. Documentation and teaching need to be done, but the nurse needs to do more. The client does not need protective isolation.
If wrong: A shift to the left indicates an increase in immature neutrophils and is often seen in infections, especially those caused by bacteria. The nurse should notify the provider and request antibiotics. Documentation and teaching need to be done, but the nurse needs to do more. The client does not need protective isolation.

Q: A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the “AIDS guy” and wondering how the client contracted the disease. What action by the nurse is best?
- Confront the staff members about unethical behavior.
- Ignore the behavior; they will stop on their own soon.
- Report the behavior to the unit’s nursing management.
- Tell the client that other staff members are talking about him or her.
A: Confront the staff members about unethical behavior.
If right: The professional nurse should be able to confront unethical behavior assertively. The staff should not be talking about clients unless they have a need to do so for client care. Ignoring the behavior may be more comfortable, but the nurse is abdicating responsibility. The behavior may need to be reported, but not as a first step. Telling the client that others are talking about him or her does not accomplish anything.
If wrong: The professional nurse should be able to confront unethical behavior assertively. The staff should not be talking about clients unless they have a need to do so for client care. Ignoring the behavior may be more comfortable, but the nurse is abdicating responsibility. The behavior may need to be reported, but not as a first step. Telling the client that others are talking about him or her does not accomplish anything.

Q: A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would best help prevent these infections?
- Auditing staff members’ hand hygiene practices
- Ensuring clients are placed in appropriate isolation
- Establishing a policy to remove urinary catheters quickly
- Teaching staff members about infection control methods
A: Auditing staff members’ hand hygiene practices
If right: All methods will help prevent infection; however, health care workers’ lack of hand hygiene is the biggest cause of healthcare-associated infections. The manager can start with a hand hygiene audit to see if this is a contributing cause.
If wrong: All methods will help prevent infection; however, health care workers’ lack of hand hygiene is the biggest cause of healthcare-associated infections. The manager can start with a hand hygiene audit to see if this is a contributing cause.

Q: A student nurse asks the nursing instructor why older adults are more prone to infection than other adults. What reasons does the nursing instructor give? <b>(Select all that apply.)</b>
- Age-related decrease in immune function
- Decreased cough and gag reflexes
- Diminished acidity of gastric secretions
- Increased lymphocytes and antibodies
- Thinning skin that is less protective
A: Age-related decrease in immune function; Decreased cough and gag reflexes; Diminished acidity of gastric secretions; Thinning skin that is less protective
If right: Older adults have several age-related changes making them more susceptible to infection, including decreased immune function, decreased cough and gag reflex, decreased acidity of gastric secretions, thinning skin, and fewer lymphocytes and antibodies.
If wrong: Older adults have several age-related changes making them more susceptible to infection, including decreased immune function, decreased cough and gag reflex, decreased acidity of gastric secretions, thinning skin, and fewer lymphocytes and antibodies.

Q: A student nurse asks why brushing clients’ teeth with a toothbrush in the intensive care unit is important to infection control. What response by the registered nurse is best?
- “It mechanically removes biofilm on teeth.”
- “It’s easier to clean all surfaces with a brush.”
- “Oral care is important to all our clients.”
- “Toothbrushes last longer than oral swabs.”
A: “It mechanically removes biofilm on teeth.”
If right: Biofilms are a complex group of bacteria that function within a slimy gel on surfaces such as teeth. Mechanical disruption (i.e., toothbrushing with friction) is the best way to control them. The other answers are not accurate.
If wrong: Biofilms are a complex group of bacteria that function within a slimy gel on surfaces such as teeth. Mechanical disruption (i.e., toothbrushing with friction) is the best way to control them. The other answers are not accurate.

Q: A student nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? <b>(Select all that apply.)</b>
- CD4+ cells begin to create new HIV virus particles.
- Antibodies produced are incomplete and do not function well.
- Macrophages stop functioning properly.
- Opportunistic infections and cancer are leading causes of death.
- People with stage 1 HIV disease are not infectious to others.
A: CD4+ cells begin to create new HIV virus particles.; Antibodies produced are incomplete and do not function well.; Macrophages stop functioning properly.; Opportunistic infections and cancer are leading causes of death.
If right: In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do not function well. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two leading causes of death in clients with HIV infection. People infected with HIV are infectious in all stages of the disease.
If wrong: In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do not function well. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two leading causes of death in clients with HIV infection. People infected with HIV are infectious in all stages of the disease.

Q: An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug?
- “Truvada does not reduce the need for safe sex practices.”
- “This drug has been taken off the market due to increases in cancer.”
- “Truvada reduces the number of HIV tests you will need.”
- “This drug is only used for postexposure prophylaxis.”
A: “Truvada does not reduce the need for safe sex practices.”
If right: Truvada is a new drug used for pre-exposure prophylaxis and appears to reduce transmission of human immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not reduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3 months. This drug has not been taken off the market and is not used for postexposure prophylaxis.
If wrong: Truvada is a new drug used for pre-exposure prophylaxis and appears to reduce transmission of human immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people. The drug does not reduce the need for practicing safe sex. Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3 months. This drug has not been taken off the market and is not used for postexposure prophylaxis.

Q: An HIV-positive client is admitted to the hospital with <i>Toxoplasma gondii</i> infection. Which action by the nurse is most appropriate?
- Initiate Contact Precautions.
- Place the client on Airborne Precautions.
- Place the client on Droplet Precautions.
- Use Standard Precautions consistently.
A: Use Standard Precautions consistently.
If right: <i>Toxoplasma gondii</i> infection is an opportunistic infection that poses no threat to immunocompetent health care workers. Use of Standard Precautions is sufficient to care for this client.
If wrong: <i>Toxoplasma gondii</i> infection is an opportunistic infection that poses no threat to immunocompetent health care workers. Use of Standard Precautions is sufficient to care for this client.

Q: The nurse is caring for a client diagnosed with human immune deficiency virus. The client’s CD4+ cell count is 399/mm<sup>3</sup>. What action by the nurse is best?
- Counsel the client on safer sex practices/abstinence.
- Encourage the client to abstain from alcohol.
- Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors.
- Help the client plan high-protein/iron meals.
A: Counsel the client on safer sex practices/abstinence.
If right: This client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she remains highly infectious and should be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of the disease.
If wrong: This client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she remains highly infectious and should be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of the disease.