NURSING 2392 mdc2 exam 1 study guide

NURSING 2392 mdc2 exam 1 study guide MDC 2 Exam 1 NCLEX Style Practce Questons Flashcards | Quizlet A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced ...

NURSING 2392 mdc2 exam 1 study guide MDC 2 Exam 1 NCLEX Style Practce Questons Flashcards | Quizlet A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication? Urine output of 400 ml in 8 hours Serum potassium level of 2.6 mEq/L Blood pressure of 120/64 to 130/72 mm HgSodium level of 142 mEq/L, Serum potassium level of 2.6 mEq/L A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan? Avoiding using soap on the irradiated areas Applying talcum powder to the irradiated areas daily after bathing Wearing a lead apron during direct contact with the client Removing thoracic skin markings after each radiation treatment, Avoiding using soap on the irradiated areas A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000/mm3. Which statement by the client indicates a need for additional teaching? "I floss my teeth every morning." "I use an electric razor to shave." "I take a stool softener every morning." "I removed all the throw rugs from the house.", "I floss my teeth every morning." A nurse is caring for a client receiving chemotherapy. Which assessment finding places the client at the greatest risk for an infection? White blood cell (WBC) count of 9,000 cells/mm3 Stage 3 pressure ulcer on the left heel Temperature of 98.3° F (36.8° C) Ate 75% of all meals during the day, Stage 3 pressure ulcer on the left heel A client received chemotherapy 24 hours ago. Which precautions are necessary when caring for the client? Wear sterile gloves. Place incontinence pads in the regular trash container. Wear personal protective equipment when handling blood, body fluids, and feces. Provide a urinal or bedpan to decrease the likelihood of soiling linens., Wear personal protective equipment when handling blood, body fluids, and feces. Palliation refers to The spread of cancer cells from the primary tumor to distant sites. Hair loss related to the treatment of cancer. Relief of symptoms associated with disease and promotion of comfort and quality of life.The lowest point of white blood cell depression after therapy that has toxic effects on bone marrow., Relief of symptoms associated with disease and promotion of comfort and quality of life. Which is a sign or symptom of septic shock? Hypertension Warm, moist skin Altered mental status Increased urine output, Altered mental status A client is receiving radiation therapy and asks the nurse about oral hygiene. What teaching specific to the client's situation should the nurse include? Gargle after each meal. Floss before going to bed. Treat cavities immediately. Use a soft toothbrush and allow it to air dry before storing., Use a soft toothbrush and allow it to air dry before storing. The nurse is providing client teaching for a client undergoing chemotherapy. What dietary modifications should the nurse advise? Eat wholesome meals. Avoid spicy and fatty foods. Avoid intake of fluids. Eat warm or hot foods., Avoid spicy and fatty foods. An oncology nurse is caring for a client who relates that certain tastes have changed. The client states that "meat tastes bad." What nursing intervention can be used to increase protein intake for a client with taste changes? Stay away from protein beverages. Encourage maximum fluid intake. Encourage eating cheese, eggs, and legumesSuck on hard candy during treatment., Encourage eating cheese, eggs, and legumes You are a clinic nurse. One of your clients has found she is at high risk for breast cancer. She asks you what can be done to reduce her risk. What is a means of reducing the risk for breast cancer? Palliative surgery Prophylactic surgery Curative surgery Reduction surgery, Prophylactic surgery Which oncologic emergency involves the accumulation of fluid in the pericardial space? Cardiac tamponade Disseminated intravascular coagulation (DIC) Syndrome of inappropriate antidiuretic hormone release (SIADH) Tumor lysis syndrome, Cardiac tamponadeWhat should the nurse tell a client who is about to begin chemotherapy and is anxious about hair loss? The client should consider getting a wig or cap prior to beginning treatment. Alopecia related to chemotherapy is relatively uncommon. The hair will grow back within 2 months post therapy. The client should consider getting a wig or cap prior to beginning treatment. The nurse working on a bone marrow unit knows that it is a priority to monitor which of the following in a client who has just undergone a stem cell transplant? Monitor the client's toilet patterns. Monitor the client closely to prevent infection. Monitor the client's physical condition.Monitor the client's heart rate., Monitor the client closely to prevent infection. The client is diagnosed with a benign brain tumor. Which of the following features of a benign tumor is of most concern to the nurse? Random, rapid growth of the tumor Cells colonizing to distant body parts Tumor pressure against normal tissues Emission of abnormal proteins, Tumor pressure against normal tissues A client with metastatic pancreatic cancer underwent surgery to remove a malignant tumor in the pancreas. Despite the tumor being removed, the physician informs the client that chemotherapy must be started. Why might the physician opt for chemotherapy? To prevent metastasis Angiogenesis Stomatitis Fatigue, To prevent metastasis The nurse at the clinic explains to the patient that the surgeon will be removing a mole on the patient's back that has the potential to develop into cancer. The nurse informs the patient that this is what type of procedure? Diagnostic Palliative Prophylactic Reconstructive, Prophylactic A nurse is caring for a client after a bone marrow transplant. What is the nurse's priority in caring for the client? Monitor the client's toilet patterns. Monitor the client to prevent sepsis. Monitor the client's physical condition. Monitor the client's heart rate., Monitor the client to prevent sepsis.A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: Tis, N0, M0. What does this classification mean? No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis Can't assess tumor or regional lymph nodes and no evidence of metastasis Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis, Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis A client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis/mucositis? White, cottage cheese-like patches on the tongue Yellow tooth discoloration Red, open sores on the oral mucosa Rust-colored sputum, Red, open sores on the oral mucosa For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan? Administering aspirin if the temperature exceeds 102° F (38.8° C) Inspecting the skin for petechiae once every shift Providing for frequent rest periods Placing the client in strict isolation, Inspecting the skin for petechiae once every shift Which statement by a client undergoing external radiation therapy indicates the need for further teaching? "I'll wash my skin with mild soap and water only." "I'll not use my heating pad during my treatment." "I'll wear protective clothing when outside.""I'm worried I'll expose my family members to radiation.", "I'm worried I'll expose my family members to radiation." Which is a growth-based classification of tumors? Sarcoma Carcinoma Malignancy Leukemia, Malignancy Which type of surgery is used in an attempt to relieve complications of cancer? Palliative Prophylactic Reconstructive Salvage, Palliative A young female client has received chemotherapeutic medications and asks about any effects the treatments will have related to her sexual health. The most appropriate statement by the nurse is"You will need to practice birth control measures." "You will continue having your menses every month." "You will experience menopause now." "You will be unable to have children.", "You will need to practice birth control measures." Which primary cancer treatment goal is prolonged survival and containment of cancer cell growth? Control Cure Palliation Prevention, Control Which of the following would be inconsistent as a common side effect of chemotherapy? Weight gain Alopecia Myelosuppression Fatigue, Weight gain A client diagnosed with cancer makes the following statement to the nurse: "I guess I will tell my health care provider to forego the chemotherapy. I do not want to be throwing up all the time. I would rather die." Which of the following facts supports the use of chemotherapy for this client? Nausea and vomiting are only a factor for the first 24 hours after treatment. Most clients believe the discomfort is well worth the cure for cancer. Chemotherapy treatment can be adjusted to optimize effects while limiting adverse effects. Clinical trials are opening up new cancer treatments all the time., Chemotherapy treatment can be adjusted to optimize effects while limiting adverse effects. Which does a nurse thoroughly evaluate before a hematopoietic stem cell transplant (HSCT) procedure? Family history Drug history Blood studies Allergy history, Blood studies A side-effect of chemotherapy is renal damage. To prevent this, the nurse should: Encourage fluid intake, if possible, to dilute the urine. Withhold medication when the blood urea nitrogen level exceeds 20 mg/dL. Limit fluids to 1,000 mL/day to minimize stress on the renal tubules. Modify the diet to acidify the urine, thus preventing uric acid crystallization., Encourage fluid intake, if possible, to dilute the urine. A nurse is administering daunorubicin (DaunoXome) to a patient with lung cancer. Which situation requires immediate intervention? The I.V. site is red and swollen. The client states he is nauseous.The laboratory reports a white blood cell (WBC) count of 1,000/mm3. The client begins to shiver., The I.V. site is red and swollen. A nurse is caring for a client receiving chemotherapy. Which nursing action is most appropriate for handling chemotherapeutic agents? Wear disposable gloves and protective clothing. Break needles after the infusion is discontinued. Disconnect I.V. tubing with gloved hands.Throw I.V. tubing in the trash after the infusion is stopped., Wear disposable gloves and protective clothing. During which step of cellular carcinogenesis do cellular changes exhibit increased malignant behavior? Promotion Initiation Prolongation Progression, Progression The nurse is teaching a healthy lifestyle class to a group of adolescents. The nurse recommends Eating four servings of vegetables and fruits per each day Decreasing caloric intake to maintain a body mass index lower than 24 Exercising at least 60 minutes per day doing moderate to vigorous activities at least 5 days per week Increasing proteins to more than 5 1/2 ounces per day for the male students to build muscle mass, Exercising at least 60 minutes per day doing moderate to vigorous activities at least 5 days per week A client is recovering from a craniotomy with tumor debulking. Which comment by the client indicates to the nurse a correct understanding of what the surgery entailed? "I guess the doctor could not remove the entire tumor." "I am so glad the doctor was able to remove the entire tumor." "I will be glad to finally be done with treatments for this thing." "Thank goodness the tumor is contained and curable.", "I guess the doctor could not remove the entire tumor." The nurse is caring for a client undergoing an incisional biopsy. Which statement does the nurse understand to be true about an incisional biopsy? It is used to remove cancerous cells using a needle. It removes an entire lesion and the surrounding tissue. It removes a wedge of tissue for diagnosis. It treats cancer with lymph node involvement., It removes a wedge of tissue for diagnosis. The physician is attending to a 72-year-old client with a malignant brain tumor. The physician recommends immediate radiation therapy. What is a reason for the physician's recommendation? To remove the tumor from the brain To prevent the formation of new cancer cells To analyze the lymph nodes involved To destroy marginal tissues, To prevent the formation of new cancer cellsThe nurse is conducting a screening for familial predisposition to cancer. Which element should the nurse note as a possible indication of hereditary cancer syndrome? Onset of cancer after age 50 in family member A first cousin diagnosed with cancer A second cousin diagnosed with cancer An aunt and uncle diagnosed with cancer, An aunt and uncle diagnosed with cancer A nurse is receiving a client with a radioactive implant for the treatment of cervical cancer. What is the nurse's best action? Place the client in a private room. Place a chair next to the bed to allow the spouse to sit. Have visitors wear dosimeters for safety.Allow visitors to telephone only., Place the client in a private room. A client is scheduled for a nerve-sparing prostatectomy. The emotional spouse confides in the nurse that the client will not talk about the cancer and/or upcoming surgery. Which nursing diagnosis will the nurse choose as primary diagnosis for this client? Sexual Dysfunction Fear Knowledge Deficit Grieving, Fear A client with a nagging cough makes an appointment to see the physician after reading that this symptom is one of the seven warning signs of cancer. What is another warning sign of cancer? Persistent nausea Rash Indigestion Chronic ache or pain, Indigestion After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should assign highest priority to which intervention? Serving small portions of bland food Encouraging rhythmic breathing exercises Administering metoclopramide and dexamethasone as ordered Withholding fluids for the first 4 to 6 hours after chemotherapy administration, Administering metoclopramide and dexamethasone as ordered A nurse is administering daunorubicin through a peripheral I.V. line when the client complains of burning at the insertion site. The nurse notes no blood return from the catheter and redness at the I.V. site. The client is most likely experiencing which complication? Erythema Flare Extravasation Thrombosis, Extravasation A decrease in circulating white blood cells isgranulocytopenia. thrombocytopenia. leukopenia. neutropenia., leukopenia. The nurse is evaluating the client's risk for cancer. The nurse should recommend the client change which lifestyle choice? uses the treadmill for 30 minutes on 5 days each week eats red meat such as steaks or hamburgers every day works as a secretary at a medical radiation treatment center drinks one glass of wine at dinner each night, eats red meat such as steaks or hamburgers every day The oncology nurse is giving chemotherapy to a client in a short stay area. The client confides that they are very depressed. The nurse recognizes depression as which of the following? A psychiatric diagnosis everyone has at one time or another. A side effect of the neoplastic drugs. A normal reaction to the diagnosis of cancer.An aberrant psychologic reaction to the chemotherapy., A normal reaction to the diagnosis of cancer. Which of the following would be consistent with a benign neoplasm? Usually progressive and slow Grows by invasion Gains access to the blood and lymph channels to metastasize Cells are undifferentiated, Usually progressive and slow When caring for an older client who is receiving external beam radiation, which is the key point for the nurse to incorporate into the plan of care? Time, distance, and shielding The use of disposable utensils and wash cloths Avoid showering or washing over skin markings. Inspect the skin frequently., Inspect the skin frequently. According to the tumor-node-metastasis (TNM) classification system, T0 means there is No evidence of primary tumor No regional lymph node metastasis No distant metastasis Distant metastasis, No evidence of primary tumor A nurse is assessing a 75-year-old woman who had a total hysterectomy when she was 30 years old and normal Pap test results for the past 10 years. The client asks about continuing the Pap test. What is the best response by the nurse? "You will need to continue for the rest of your life." "You need to continue obtaining a Pap test for only the next 5 years." "You could have stopped immediately after your hysterectomy." "You may choose to discontinue this test.", "You may choose to discontinue this test."A client with ovarian cancer is ordered hydroxyurea, an antimetabolite drug. Antimetabolites are a diverse group of antineoplastic agents that interfere with various metabolic actions of the cell. What mechanism of action do antimetabolites interferes with? cell division or mitosis during the M phase of the cell cycle normal cellular processes during the S phase of the cell cycle the chemical structure of deoxyribonucleic acid (DNA) and chemical binding between DNA molecules (cell cycle-nonspecific) one or more stages of ribonucleic acid (RNA) synthesis, DNA synthesis, or both (cell cyclenonspecific), normal cellular processes during the S phase of the cell cycle A client with cancer is being evaluated for possible metastasis. What is one of the most common metastasis sites for cancer cells? Liver Colon Reproductive tract White blood cells (WBCs), Liver A client diagnosed with acute myelocytic leukemia has been receiving chemotherapy. During the last 2 cycles of chemotherapy, the client developed severe thrombocytopenia requiring multiple platelet transfusions. The client is now scheduled to receive a third cycle. How can the nurse best detect early signs and symptoms of thrombocytopenia? Perform a cardiovascular assessment every 4 hours. Check the client's history for a congenital link to thrombocytopenia. Monitor daily platelet counts. Closely observe the client's skin for petechiae and bruising., Closely observe the client's skin for petechiae and bruising. The drug interleukin-2 is an example of which type of biologic response modifier? Cytokine Monoclonal antibodies Retinoids Antimetabolites, Cytokine Which type of hematopoietic stem cell transplantation (HSCT) is characterized by cells from a donor other than the patient? Allogeneic Autologous Syngeneic Homogenic, Allogeneic The root cause of cancer is damage to cellular deoxyribonucleic acid (DNA) which can be caused by many factors, or carcinogens. What factors can be carcinogenic? Select all that apply. dietary substances environmental factors virusesgender age, dietary substances environmental factors viruses The nurse performs a breast exam on a client and finds a firm, non-moveable lump in the upper outer quadrant of the right breast that the client reports was not there 3 weeks ago. What does this finding suggest? Normal finding Benign fibrocystic disease Malignant tumor Malignant tumor with metastasis to surrounding tissue, Malignant tumor The client is receiving a vesicant antineoplastic for treatment of cancer. Which assessment finding would require the nurse to take immediate action? Extravasation Stomatitis Nausea and vomiting Bone pain Extravasation A patient will be having an endoscopic procedure with a diagnostic biopsy. What type of biopsy does the nurse explain will remove an entire piece of suspicious tissue? Excisional biopsy Incisional biopsy Needle biopsy Punch biopsy, Excisional biopsy A client is diagnosed with metastatic adenocarcinoma of the stomach. The physician orders mitomycin and other chemotherapeutic agents for palliative treatment. How does mitomycin exert its cytotoxic effects? It inhibits deoxyribonucleic acid (DNA) synthesis. It inhibits ribonucleic acid (RNA) synthesis. It's cell cycle-phase specific. It inhibits protein synthesis., It inhibits deoxyribonucleic acid (DNA) synthesis. A nurse is teaching a client with bone marrow suppression about the time frame when bone suppression will be noticeable after administration of floxuridine. What is the time frame the nurse should include with client teaching? 24 hours 2 to 4 days 7 to 14 days 21 to 28 days, 7 to 14 days A serum sodium concentration lower than 115 mEq/L (115 mmol/L) is associated with anorexia. seizure. weight gain.myalgia., seizure. A male client has been unable to return to work for 10 days following chemotherapy as the result of ongoing fatigue and inability to perform usual activities. Laboratory test results are WBCs 2000/mm³, RBCs 3.2 x 10¹²/L, and platelets 85,000/mm³. The nurse notes that the client is anxious. Which of the following is the priority nursing diagnosis? Risk for infection related to inadequate defenses Fatigue related to deficient blood cells Activity intolerance related to side effects of chemotherapy Anxiety related to change in role function, Risk for infection related to inadequate defenses Which of the following is a characteristic of a malignant tumor? It gains access to the blood and lymphatic channels. It demonstrates cells that are well differentiated. It is usually slow growing. It grows by expansion., It gains access to the blood and lymphatic channels. 5-Fluorouracil (5FU) is classified as which type of antineoplastic agent? Antimetabolite Alkylating Nitrosoureas Mitotic spindle poisons, Antimetabolite Following surgery for adenocarcinoma, the client learns the tumor stage is T3,N1,M0. What treatment mode should the nurse anticipate? No further treatment is indicated. Adjuvant therapy is likely. Palliative care is likely. Repeat biopsy is needed before treatment begins., Adjuvant therapy is likely. The client has finished the first round of chemotherapy. Which statement made by the client indicates a need for further teaching by the nurse? "I will eat clear liquids for the next 24 hours." "Hair loss may not occur until after the second round of therapy." "I will use birth control measures until after all treatment is completed." "I can continue taking my vitamins and herbs because they make me feel better.", "I can continue taking my vitamins and herbs because they make me feel better." A nurse has agreed to draft a medication teaching plan for a patient who is taking the hormonal agent, Aromasin, an aromatase inhibitor for postmenopausal women with breast cancer. The nurse knows that a major teaching point is to tell the patient to: Report the unusual sign of nausea. Be alarmed if she notices fluid retention.Increase her intake of calcium-rich foods.Report the unexpected sign of increased appetite and weight gain., Increase her intake of calcium-rich foods.The nurse is caring for a client is scheduled for chemotherapy followed by autologous stem cell transplant. Which of the following statements by the client indicates a need for further teaching? "I hope they find a bone marrow donor who matches." "The doctor will remove cells from my bone marrow before beginning chemotherapy." "I will receive chemotherapy until most of the cancer is gone, and then I will get my own stem cells back." "I will need to attend follow-up visits for up to 3 months after treatment.", "I hope they find a bone marrow donor who matches." Chemotherapeutic agents have which effect associated with the renal system? Hypokalemia Increased uric acid excretion Hypophosphatemia Hypercalcemia, Increased uric acid excretion A bowel resection is scheduled for a client with the diagnosis of colon cancer with metastasis to the liver and bone. Which statement by the nurse best explains the purpose of the surgery? "Removing the tumor is a primary treatment for colon cancer." "This surgery will prevent further tumor growth." "Once the tumor is removed, cell pathology can be determined." "Tumor removal will promote comfort.", "Tumor removal will promote comfort." The nurse is completing an admission assessment for a client receiving interstitial implants for prostate cancer. The nurse documents this as brachytherapy. external beam radiation therapy. systemic radiation. a contact mold., brachytherapy. A patient is admitted for an excisional biopsy of a breast lesion. What intervention should the nurse provide for the care of this patient? Clarify information provided by the physician. Provide aseptic care to the incision postoperatively. Provide time for the patient to discuss her concerns. Counsel the patient about the possibility of losing her breast., Provide time for the patient to discuss her concerns. A patient will be receiving radiation for 6 weeks for the treatment of breast cancer and asks the nurse why it takes so long. What is the best response by the nurse? "It allows time for you to cope with the treatment." "It will allow time for the repair of healthy tissue." "It will decrease the incidence of leukopenia and thrombocytopenia." "It is not really understood why you have to go for 6 weeks of treatment.", "It will allow time for the repair of healthy tissue." A patient with uterine cancer is being treated with internal radiation therapy. What would the nurse's priority responsibility be for this patient?Explain to the patient that she will continue to emit radiation while the implant is in place. Maintain as much distance as possible from the patient while in the room. Alert family members that they should restrict their visiting to 5 minutes at any one time. Wear a lead apron when providing direct patient care., Explain to the patient that she will continue to emit radiation while the implant is in place. The nurse is teaching a client newly diagnosed with cancer about chemotherapy. The nurse tells the client he'll receive an antitumor antibiotic. The nurse knows that this type of medications is: cell-cycle nonspecific. cell-cycle specific in the S phase. cell-cycle specific in the M phase. cell-cycle specific in the P phase., cell-cycle nonspecific. A client is receiving the cell cycle-nonspecific alkylating agent thiotepa (Thioplex), 60 mg weekly for 4 weeks by bladder instillation as part of chemotherapy regimen to treat bladder cancer. The client asks the nurse how the drug works. How does thiotepa exert its therapeutic effects? It interferes with deoxyribonucleic acid (DNA) replication only. It interferes with ribonucleic acid (RNA) transcription only. It interferes with DNA replication and RNA transcription. It destroys the cell membrane, causing lysis.,It interferes with DNA replication and RNA transcription. A nurse caring for a client who has just received chemotherapy infusion is wearing a disposable gown, gloves, and goggles for protection. The nurse knows that accidental exposure to chemotherapy agents can occur through: inhalation of aerosols. absorption through the gown. absorption through the gloves. absorption through the goggles., inhalation of aerosols. A client has received several treatments of bleomycin. It is now important for the nurse to assess Skin integrity Lung sounds Urine output Hand grasp, Skin integrity The client is to receive cyclophosphamide (Cytoxan) 50 mg/kg intravenously in divided doses over 5 days. The client weighs 176 pounds. How many mg of cyclophosphamide will the client receive each day? 500 600 700 800, 800Carcinogens are factors related to the formation of various malignancies. Which factor has the greatest impact on the development of all cancers? chemical agents environmental factors viruses defective genes, chemical agents A client has just received stem cell transplantation as treatment for leukemia. What are the post procedural nursing interventions for clients receiving any form of stem cell transplantation? Closely monitor the client for at least 3 months. Closely monitor the client for at least 3 days. Closely monitor the client for at least 4 weeks. Closely monitor the client for at least 5 months., Closely monitor the client for at least 3 months. What is the best way for the nurse to assess the nutritional status of a patient with cancer? Weigh the patient daily. Monitor daily caloric intake. Observe for proper wound healing. Assess BUN and creatinine levels., Weigh the patient daily. A nurse is teaching a client about the rationale for administering allopurinol with chemotherapy. Which example would be the best teaching by the nurse? It stimulates the immune system against the tumor cells. It treats drug-related anemia. It prevents alopecia. It lowers serum and uric acid levels., It lowers serum and uric acid levels. The nurse should teach the patient who is being radiated about protecting his skin and oral mucosa. An important teaching point would be to tell the patient to: Cleanse the skin with a mild soap, using his fingertips, not a rough wash cloth. Use an ointment, after treatment, to decrease the feeling of burning, which may last for several hours. Apply a small ice compress to the treated area afterward to decrease localized redness, postradiation. Use an approved emollient 2 hours before the radiation to give the skin time to absorb the medication and provide a shield for damage., Cleanse the skin with a mild soap, using his fingertips, not a rough wash cloth. A 67-year-old client is admitted for diagnostic studies to rule out cancer. The patient is white, married, has been employed as a landscaper for 40 years, and has a 36-year history of smoking a pack of cigarettes daily. What significant risk factors does the nurse recognize this patient has? Select all that apply. Age Cigarette smoking OccupationRace Marital status, Age Cigarette smoking Occupation The lethal tumor dose is defined as the dose that will eradicate what percentage of the tumor yet preserve normal tissue? 95% 85% 75% 65%, 95% Cancer is the second leading cause of death in the United States, second only to heart disease. Half of all men and one third of all women will develop cancer during their lifetimes. Which types of cancer have the highest prevalence among both men and women? lung and colon lung and skin skin and brain colon and skin, lung and colon A client with a recent history of GI disturbance has been scheduled for a barium study. The physician ordered this particular test for this client because it will: show movement of the GI tract. remove a tissue sample from the GI tract. show tumor "hot spots" in the GI tract. provide a three-dimensional cross-sectional view., show movement of the GI tract. The nurse is caring for a thyroid cancer client following oral radioactive iodine treatment. Which teaching point is most important? Shield your throat area when near others. Flush the toilet twice after every use. Prepare food separately from family members. Use disposable utensils for the next month., Flush the toilet twice after every use. The nurse is providing education to a client with cancer radiation treatment options. The nurse determines that the client understands the teaching when the client states that which type of radiation aims to protect healthy tissue during the treatment? Proton therapy Teletherapy Brachytherapy External, Brachytherapy A nurse is caring for a recently married, 29-year-old female client, who was diagnosed with acute lymphocytic leukemia. The client is preparing for an allogeneic bone marrow transplant. Which statement by the client demonstrates she understands the informed consent she gave about the diagnosis and treatment? "I should be able to finally start a family after I'm finished with the chemo.""I always had a good appetite. Even with chemo I shouldn't have to make any changes to my diet." "I'll have to remain in the hospital for about 3 months after my transplant." "I'll only need chemotherapy treatment before receiving my bone marrow transplant.", "I'll only need chemotherapy treatment before receiving my bone marrow transplant." The nurse is to administer a vesicant chemotherapeutic drug to a client who had a right mastectomy and inserts the intravenous line In the client's left hand With a butterfly needle In the client's right forearm With a soft, plastic catheter, With a soft, plastic catheter A client diagnosed with cancer has the tumor staged and graded based on what? How the tumor tends to grow and the cell type How the tumor spreads and tends to growHow the tumor differentiates the cell typeHow the tumor spreads and differentiates, How the tumor tends to grow and the cell type A client has been receiving chemotherapy. Upon assessing the client during morning rounds, the nurse notes the client is now bleeding from intravenous and venipuncture sites. Stool is positive for occult blood. The client is requesting to sit in a chair for a meal. The nurse implements the following interventions: (Select all that apply.) Monitor vital signs once a shift. Assess level of consciousness. Assist the client to a chair. Apply pressure to the bleeding sites. Check intake and output records., Assess level of consciousness. Apply pressure to the bleeding sites. Check intake and output records. A client, 66 years old, has just been diagnosed with multiple myeloma (a cancer of the plasma) and will be initiating chemotherapy. The nurse, in an outpatient clinic, reviews the medications the client has been taking at home. The medications include pantoprazole for gastroesophageal reflux disease (GERD) and an over-the-counter calcium supplement to prevent osteoporosis. What interventions should the nurse take? Select all that apply. instructs the client to discontinue calcium asks about nausea and vomiting restricts fluids to 1500 mL per day teaches the client to report abdominal or bone pain provides information about antidiarrheal medication, instructs the client to discontinue calcium asks about nausea and vomiting teaches the client to report abdominal or bone pain A client without symptoms receives a diagnosis of prostate cancer after a routine physical. What factors contributed to this diagnosis? Select all that apply. client history risk factorstumor markers use of sunscreen, client history risk factors tumor markers During a client's examination and consultation, the physician keeps telling the client, "You have an abdominal neoplasm." Which statements accurately paraphrase the physician's statement? Select all that apply. "You have a new growth of abnormal tissue in your abdomen." "You have an abdominal tumor." "You have an abdominal malignancy." "You have abdominal cancer." "You have a new growth of abnormal tissue in your abdomen." "You have an abdominal tumor." The nurse knows that interferon agents are used in association with chemotherapy to produce which effects in the client? Suppression of the bone marrow Enhance action of the chemotherapy Decrease the need for additional adjuvant therapies Shorten the period of neutropenia, Shorten the period of neutropenia The nurse is preparing to assess a client whose chart documents that the client experienced extravasation when receiving the vesicant vincristine during the previous shift. The documentation also notes that an antidote was administered immediately. The nurse prepares to assess for which conditions? Select all that apply. Sloughing tissue Tissue necrosis Active bleeding Effectiveness of the antidote, Sloughing tissue Tissue necrosis Effectiveness of the antidote The nurse is caring for a client with cancer who is treating her cancer with deep-tissue massage in addition to radiation therapy. The nurse documents the use of which therapy on the client's chart? Alternative therapy Global medicine Integrative medicine Compliant medicine, Integrative medicine When a client receives vincristine, an antineoplastic agent that inhibits DNA and protein synthesis, the client needs to be informed to report which symptoms that would be expected side effects of motor neuropathy? Select all that apply. burning and tingling sensations in the extremities muscle weakness cramps and spasms in the legsloss of balance and coordination alopecia, burning and tingling sensations in the extremities muscle weakness cramps and spasms in the legs An oncology nurse is caring for a client who is taking antineoplastic agents. What symptoms would the nurse consider with tumor lysis syndrome when monitoring this client? symptoms of gout symptoms of hypertension symptoms of constipation symptoms of anemia, symptoms of gout The client is scheduled for a breast lump excision and sentinel node biopsy. What should the nurse know in planning care for the client with a positive biopsy? A lump excision is not necessary. A wide excision of lump will be performed. The lump and all axillary lymph nodes will be excised. The entire breast and all regional lymph nodes will be excised., A wide excision of lump will be performed. An oncology clinic nurse is reinforcing prevention measures for oropharyngeal infections to a client receiving chemotherapy. Which statement by the client indicates that teaching was successful? "I clean my teeth gently several times per day." "I replace my toothbrush every month." "I lubricate my lips with petroleum jelly." "I use an alcohol-based mouthwash every morning.", "I clean my teeth gently several times per day." You are the nurse caring for a client with cancer. The client complains of pain and nausea. When assessed, you note that the client appears fearful. What other factor must you consider when a client with cancer indicates signs of pain, nausea, and fear? Infection Fatigue Ulceration High cholesterol levels, Fatigue Which oncologic emergency involves the failure in the negative feedback mechanism that normally regulates the release of antidiuretic hormone (ADH)? Syndrome of inappropriate antidiuretic hormone release (SIADH) Cardiac tamponade Disseminated intravascular coagulation (DIC) Tumor lysis syndrome , Syndrome of inappropriate antidiuretic hormone release (SIADH) A patient is to receive Bacille Calmette-Guerin (BCG), a nonspecific biologic response modifier. Why would the patient receive this form of treatment?For cancer of the bladder For cancer of the breast For cancer of the lungs For skin cancer , For cancer of the bladder A client asks the nurse what is causing the fatigue following radiotherapy. What is the nurse's best response? The cancer is spreading to other parts of the body. The cancer cells are dying in large numbers. Fighting off infection is an exhausting venture. Substances are released when tumor cells are destroyed. , Substances are released when tumor cells are destroyed. A nurse is administering a peripheral chemotherapeutic agent. What nursing actions are used for extravasation of a chemotherapeutic agent? Select all that apply. Stop the medication infusion at the first sign of extravasation Aspirate any residual drug from the IV line Administer an antidote, if indicated Apply warm compresses to the irritated site to encourage healing Schedule the client for implanted device, Stop the medication infusion at the first sign of extravasation Aspirate any residual drug from the IV line Administer an antidote, if indicated A 72-year-old client recovering from lung cancer surgery asks the nurse to explain how she developed cancer when she has never smoked. Which factor may explain the possible cause? A diagnosis of diabetes treated with insulin and diet An exercise regimen of jogging 3 miles four times a week A history of cardiac disease Advancing age Advancing age The nurse includes which factors in teaching regarding the typical warning signs of cancer? Select all that apply. Persistent constipation Scab present for 6 months Curdlike vaginal discharge Axillary swelling Headache Persistent constipation Scab present for 6 months Axillary swelling Which information must the organ transplant nurse emphasize before a client is discharged? "Taking immunosuppressant medications increases your risk for cancer and the need for screenings." "You are at increased risk for cancer when you reach 60 years of age." "Immunosuppressant medications will decrease your risk for developing cancers.""After 6 months, you may stop immunosuppressant medications, and your risk for cancer will be the same as that of the general population." "Taking immunosuppressant medications increases your risk for cancer and the need for screenings." A nurse is counseling a 60-year-old African-American male client about risk factors for lung cancer. Teaching should focus most on what risk factor? Tobacco use Ethnicity Gender Increased age Tobacco use The nurse manager in a long-term care facility is developing a plan for primary and secondary prevention of colorectal cancer. Which tasks associated with the screening plan will be delegated to nursing assistants within the facility? Testing of stool specimens for occult blood Teaching about the importance of dietary fiber Referring clients for colonoscopy procedures Giving vitamin and mineral supplements Testing of stool specimens for occult blood Which type of cancer has been associated with Down syndrome? Breast cancer Colorectal cancer Malignant melanoma Leukemia Leukemia What are the common cancers related to tobacco use? Select all that apply. Cardiac cancer Lung cancer Cancer of the tongue Skin cancer Cancer of the larynx Lung cancer Cancer of the tongue Cancer of the larynx A client has a glioblastoma. The nurse begins to plan care for this client with which type of cancer? Liver Smooth muscle Fatty tissue Brain Brain The nurse is giving a group presentation on cancer prevention and recognition. Which statement by an older adult male client indicates understanding of the nurse's instructions? "Cigarette smoking always causes lung cancer." "Taking multivitamins will prevent me from developing cancer.""If I have only one shot of whiskey a day, I probably will not develop cancer." "I need to report the pain going down my legs to my health care provider." "I need to report the pain going down my legs to my health care provider." The home health nurse is caring for a client who has a history of a kidney transplant and takes cyclosporine (Sandimmune) and prednisone (Deltasone) to prevent rejection. Which assessment finding is most important to communicate to the transplant team? Temperature of 96.6°F (35.9°C) Reports of joint pain Pink and dry oral mucosa Palpable lump in the client's axilla Palpable lump in the client's axilla A client has a diagnosis of lung cancer. To which areas does the nurse anticipate that this client's tumor may metastasize? Select all that apply. Brain Bone Lymph nodes Kidneys Liver Brain Bone Lymph nodes Liver The nurse explains to a client that which risk factor of those listed most likely contributed to the client's primary liver carcinoma? Infection with hepatitis B virus Consuming a diet high in animal fat Exposure to radon Familial polyposis Infection with hepatitis B virus The nurse is conducting a community health education class on diet and cancer risk reduction. What should be included in the discussion? Select all that apply. Limit sodium intake. Avoid beef and processed meats. Increase consumption of whole grains. Eat "colorful fruits and vegetables," including greens. Avoid gas-producing vegetables such as cabbage. Avoid beef and processed meats. Increase consumption of whole grains. Eat "colorful fruits and vegetables," including greens. Which statement about the process of malignant transformation is correct? Mutation of genes is an irreversible event that always leads to cancer development in the initiation phase. Insulin and estrogen enhance the division of an initiated cell during the promotion phase.Tumors form when carcinogens invade the gene structure of the cell in the latency phase. Nutrition of cancer cells is provided by tumor angiogenesis factor (TAF) in the promotion stage. Nutrition of cancer cells is provided by tumor angiogenesis factor (TAF) in the promotion stage. The nurse is teaching a 47-year-old woman about recommended screening practices for breast cancer. Which statement by the client indicates understanding of the nurse's instructions? "My mother and grandmother had breast cancer, so I am at risk." "I get a mammogram every 2 years since I turned 30." "A clinical breast examination is performed every month since I turned 40." "A computed tomography (CT) scan will be done every year after I turn 50." "My mother and grandmother had breast cancer, so I am at risk." A client who is scheduled to undergo radiation for prostate cancer is admitted to the hospital by the nurse. Which statement by the client is most important to communicate to the health care provider? "I am allergic to iodine." "My urinary stream is very weak." "My legs are numb and weak." "I am incontinent when I cough." "My legs are numb and weak." The nurse reviews the chart of a client admitted with a diagnosis of glioblastoma with a T1NXM0 classification. Which explanation does the nurse offer when the client asks what the terminology means? "Two lymph nodes are involved in this tumor of the glial cells, and another tumor is present." "The brain tumor measures about 1 to 2 cm and shows no regional lymph nodes and no distant metastasis." "This type of tumor in the brain is small with some lymph node involvement; another tumor is present somewhere else in your body." "Glioma means this tumor is benign, so I will have to ask your health care provider the reason for the chemotherapy and radiation." "The brain tumor measures about 1 to 2 cm and shows no regional lymph nodes and no distant metastasis." The nurse suspects metastasis from left breast cancer to the thoracic spine when the client has which symptom? Vomiting Back pain Frequent urination Cyanosis of the toes Back pain The nurse presents a cancer prevention program to teens. Which instruction will have the greatest impact in cancer prevention? Avoid asbestos. Wear sunscreen. Get the human papilloma virus (HPV) vaccine. Do not smoke cigarettes. Do not smoke cigarettes.A 52-year-old client tells the nurse that she has never had a mammogram because she is terrified that she will have cancer. Which response by the nurse is therapeutic? "Don't worry, most lumps are discovered by women during breast self-examination." "Does anyone in your family have breast cancer?" "Finding a cancer in the early stages increases the chance for cure." "Have you noticed a lump or thickening in your breast?" "Finding a cancer in the early stages increases the chance for cure." The nurse is assessing a client with lung cancer. Which symptom does the nurse anticipate finding? Easy bruising Dyspnea Night sweats Chest wound Dyspnea Which activity performed by the community health nurse best reflects primary prevention of cancer? Assisting women to obtain free mammograms Teaching a class on cancer prevention Encouraging long-term smokers to get a chest x-ray Encouraging sexually active women to get annual Papanicolaou (Pap) smears Teaching a class on cancer prevention When caring for a client who has had a colostomy created during treatment for colon cancer, which nursing actions help support the client in accepting changes in appearance or function? Select all that apply. Explain to the client that the colostomy is only temporary. Encourage the client to participate in changing the ostomy. Obtain a psychiatric consultation. Offer to have a person who is coping with a colostomy visit with the client. Encourage the client and family members to express their feelings and concerns. Encourage the client to participate in changing the ostomy. Offer to have a person who is coping with a colostomy visit with the client. Encourage the client and family members to express their feelings and concerns. A newly graduated RN has just finished a 6-week orientation to the oncology unit. Which client is most appropriate to assign to the new graduate? A 30-year-old with acute lymphocytic leukemia who will receive combination chemotherapy today A 40-year-old with chemotherapy-induced nausea and vomiting who has had no urine output for 16 hours A 45-year-old with pancytopenia who will require IV administration of erythropoietin (Procrit) A 72-year-old with tumor lysis syndrome who is receiving normal saline IV at a rate of 250 mL/hr A 45-year-old with pancytopenia who will require IV administration of erythropoietin (Procrit)The nurse is caring for a client who is receiving rituximab (Rituxan) for treatment of lymphoma. During the infusion, it is essential for the nurse to observe for which side effect? Alopecia Allergy Fever Chills Allergy Which client problem does the nurse set as the priority for the client experiencing chemotherapyinduced peripheral neuropathy? Potential for lack of understanding related to side effects of chemotherapy Potential for injury related to sensory and motor deficits Potential for ineffective coping strategies related to loss of motor control Altered sexual function related to erectile dysfunction Potential for injury related to sensory and motor deficits The RN working on an oncology unit has just received report on these clients. Which client should be assessed first? Client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature Client with lymphoma who will need administration of an antiemetic before receiving chemotherapy Client with metastatic breast cancer who is scheduled for external beam radiation in 1 hour Client with xerostomia associated with laryngeal cancer who needs oral care before breakfast Client with chemotherapy-induced neutropenia who has just been admitted with an elevated temperature Which instruction is most appropriate for the nurse to convey to the client with chemotherapyinduced neuropathy? Bathe in cold water. Wear cotton gloves when cooking. Consume a diet high in fiber. Make sure shoes are snug. Consume a diet high in fiber. An outpatient client is receiving photodynamic therapy. Which environmental factor is a priority for the client to adjust for protection? Storing drugs in dark locations at room temperature Wearing soft clothing Wearing a hat and sunglasses when going outside Reducing all direct and indirect sources of light Reducing all direct and indirect sources of light The nurse teaches a client that intraperitoneal chemotherapy will be delivered to which part of the body? Veins of the legs LungHeart Abdominal cavity Abdominal cavity Which statement made by a client allows the nurse to recognize whether the client receiving brachytherapy for ovarian cancer understands the treatment? "I may lose my hair during this treatment." "I must be positioned in the same way during each treatment." "I will have a radioactive device in my body for a short time." "I will be placed in a semiprivate room for company." "I will have a radioactive device in my body for a short time." When caring for the client with chemotherapy-induced mucositis, which intervention will be most helpful? Administering a biological response modifier Encouraging oral care with commercial mouthwash Providing oral care with a disposable mouth swab Maintaining NPO until the lesions have resolved Providing oral care with a disposable mouth swab The nurse is caring for a client receiving chemotherapy who reports anorexia. Which measure does the nurse use to best monitor for cachexia? Monitor weight. Trend red blood cells and hemoglobin and hematocrit. Monitor platelets. Observe for motor deficits. Monitor weight. The nurse is caring for a client with end-stage ovarian cancer who needs clarification on the purpose of palliative surgery. Which outcome should the nurse teach the client is the goal of palliative surgery? Cure of the cancer Relief of symptoms or improved quality of life Allowing other therapies to be more effective Prolonging the client's survival time Relief of symptoms or improved quality of life The nurse corrects the nursing student when caring for a client with neutropenia secondary to chemotherapy in which circumstance? The student demonstrates asepsis by scrubbing the hub of IV tubing before administering an antibiotic. The nurse overhears the student explaining to the client the importance of handwashing. The student teaches the client that symptoms of neutropenia include fatigue and weakness. The nurse observes the student educating the client about hygiene and perineal care. The student teaches the client that symptoms of neutropenia include fatigue and weakness. The nurse is teaching a client who is receiving an antiestrogen drug about the side effects she may encounter. Which side effects does the nurse include in the discussion? Select all that apply.Heavy menses Smooth facial skin Hyperkalemia Breast tenderness Weight loss Deep vein thrombosis Breast tenderness Deep vein thrombosis The nurse is caring for a client with hyperuricemia associated with tumor lysis syndrome (TLS). Which medication does the nurse anticipate being ordered? Recombinant erythropoietin (Procrit) Allopurinol (Zyloprim) Potassium chloride Radioactive iodine-131 (131I) Allopurinol (Zyloprim) Which medication does the nurse plan to administer to a client before chemotherapy to decrease the incidence of nausea and vomiting? Morphine Ondansetron (Zofran) Naloxone (Narcan) Diazepam (Valium) Ondansetron (Zofran) A client who is undergoing chemotherapy for breast cancer reports problems with concentration and memory. Which nursing intervention is indicated at this time? Explain that this occurs in some clients and is usually permanent. Inform the client that a small glass of wine may help her relax. Protect the client from infection. Allow the client an opportunity to express her feelings. Allow the client an opportunity to express her feelings. Which finding alarms the nurse when caring for a client receiving chemotherapy who has a platelet count of 17,000/mm3 (17 × 109/L)? Increasing shortness of breath Diminished bilateral breath sounds Change in mental status Weight gain of 4 pounds (1.8 kg) in 1 day Change in mental status Which potential side effects does the nurse include in the teaching plan for a client undergoing radiation therapy for laryngeal cancer? Select all that apply. Fatigue Changes in color of hair Change in taste Changes in skin of the neck Difficulty swallowing Fatigue Change in tasteChanges in skin of the neck Difficulty swallowing The oncology nurse is caring for a group of clients receiving chemotherapy. The client with which sign/symptom is displaying bone marrow suppression? Hemoglobin of 7.4 g/dL (74 mmol/L) and hematocrit of 21.8% Potassium level of 2.9 mEq/L (2.9 mmol/L) and diarrhea 250,000 platelets/mm3 (250 × 109/L) 5000 white blood cells/mm3 (5 × 109/L) Hemoglobin of 7.4 g/dL (74 mmol/L) and hematocrit of 21.8% When caring for a client receiving chemotherapy, the nurse plans care during the nadir of bone marrow activity to prevent which complication? Drug toxicity Polycythemia Infection Dose-limiting side effects Infection When caring for the client receiving cancer chemotherapy, which signs or symptoms related to thrombocytopenia should the nurse report to the health care provider? Select all that apply. Bruises Fever Petechiae Epistaxis Pallor Bruises Petechiae Epistaxis The nurse has received in report that a client receiving chemotherapy has severe neutropenia. Which interventions does the nurse plan to implement? Select all that apply. Assess for fever. Observe for bleeding. Administer pegfilgrastim (Neulasta). Do not permit fresh flowers or plants in the room. Do not allow the client's 16-year-old son to visit. Teach the client to omit raw fruits and vegetables from the diet. Assess for fever. Administer pegfilgrastim (Neulasta). Do not permit fresh flowers or plants in the room. Teach the client to omit raw fruits and vegetables from the diet. When monitoring a client with suspected syndrome of inappropriate antidiuretic hormone (SIADH), the nurse reviews the client's medical record, which contains the following information. The nurse notifies the health care provider for which signs and symptoms consistent with this syndrome? Physical Assessment FindingsDiagnostic FindingsMedicationsNeuro: Episodes of confusionCardiac: Pulse 88 and regularMusculoskeletal: Weakness, tremorsNa: 115mEq/L (115 mmol/L)K: 4.2 mEq/L (4.2 mmol/L)Creatinine: 0.8 mg/dL (70.8 mcmol/L)Ondansetron (Zofran)Cyclophosphamide (Cytoxan) Select all that apply. Hyponatremia Mental status changes Azotemia Bradycardia Weakness Hyponatremia Mental status changes Weakness The oncology nurse should use which intervention to prevent disseminated intravascular coagulation (DIC)? Monitoring platelets Administering packed red blood cells Using strict aseptic technique to prevent infection Administering low-dose heparin therapy for clients on bedrest Using strict aseptic technique to prevent infection Which manifestation of an oncologic emergency requires the nurse to contact the health care provider immediately? New onset of fatigue Edema of arms and hands Dry cough Weight gain Edema of arms and hands Which is the initial stage of grief, according to Kübler-Ross? Anger Bargaining Denial Depression Denial The family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which intervention should a nurse perform in such a situation? Encourage the family members to express their feelings and listen to them in their frank communication Encourage conversations about the impending death of the client Be a silent observer and allow the client to communicate with the family members Encourage the client's family members to spend time with the client Encourage the family members to express their feelings and listen to them in their frank communication The family of a terminally ill client tells the nurse that the client has been breathing irregularly and, at times, it appears that he is not breathing at all. The client's daughter states, "He moans when he breathes. Is he in pain?" Which response by the nurse would be most appropriate? "His moaning does indicate pain, so we'll increase his pain medication." "The moaning you hear is from air moving over very relaxed vocal cords.""He has secretions that are collecting at the back of the throat." "He is getting less oxygen to the brain, so the moaning means he is dreaming." "The moaning you hear is from air moving over very relaxed vocal cords." A nurse is providing in-home hospice care to a terminally ill client. The client experiences a medical crisis requiring monitoring and medication administration. Which level of hospice care would the nurse implement? Routine home care Continuous care Inpatient respite care General inpatient care Continuous care The nurse identifies a nursing diagnosis of Imbalanced nutrition: less than body requirements for a terminally ill client who is near the end of life. Which of the following would the nurse expect to include in the client's plan of care? Suggestions that the family offer the client foods that are hot. Encouragement of the family to serve the client meat, especially beef. Advice for the family to have fruit juices readily available at the client's bedside. Arrangements for the client to eat meals while others are out of the home. Advice for the family to have fruit juices readily available at the client's bedside. Which of the following is an appropriate method of assessing the dying client? Stimulate the client every 30 minutes. Focus on the client's basic needs. Repeat assessments as necessary. Sedate the client before completing range-of-motion exercises. Focus on the client's basic needs. Immediately on cessation of vital functions, the body begins to change. The nurse would expect which physical change to occur following death? Dusky appearance Increased body temperature Flushed appearance Absence of incontinence Dusky appearance A 90-year-old home care client's son has been designated to make decisions regarding the client's medical care when the client is no longer able to do so. As the client nears the end of life, the son is consulted on an ever-increasing basis. What legal instrument activates the son's decisionmaking designation? durable power of attorney for health care power of attorney living will designated signer durable power of attorney for health care The nurse is providing home care to a dying client and has noticed over the course of several weeks that the client's daughter is usually quiet and withdrawn when in the client's room. Which intervention should the nurse perform in this situation?Sit with the client's daughter privately and encourage her to express her feelings frankly. Remind the daughter of the client's impending death and the importance of expressing herself. Remain focused on the client's needs and care because these are your main responsibilities. Insist that the daughter try her best to make the client's final days happy ones. Sit with the client's daughter privately and encourage her to express her feelings frankly. All nurses care for clients who are grieving. It is important for the nurse to understand the grieving process for which reason? Allows for the nurse to facilitate the grieving process Allows for the nurse to take the client through in the appropriate order Allows for the nurse to understand when the grieving process should be concluded Allows the nurse to express his or her feelings Allows for the nurse to facilitate the grieving process The family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which nursing interventions should a nurse perform in such a situation? Encourage the family members to express their feelings and listen to them in their frank communication. Encourage conversations about the impending death of the client. Be a silent observer and allow the client to communicate with the family members. Encourage the client's family members to spend time with the client. Encourage the family members to express their feelings and listen to them in their frank communication. Which statements made by the nurse demonstrates that the nurse is providing spiritually sensitive care? "A key component of hospice care is following your family for up to a year after your death." "Denial, sadness, anger, fear, and anxiety are normal grief reactions." "Mourning may be demonstrated by emotional feelings of sadness, anger, guilt, and numbness." "Tell me who or what gives you strength." "Tell me who or what gives you strength." A client with a brain tumor recently stopped radiation and chemotherapy for treatment of the cancer. The client recently reported dry mouth. Which intervention by the hospice nurse demonstrates that the nurse understands treatment measures for dry mouth? Begin 9% normal saline IV at 125 mL hr. Place two drops of atropine ophthalmic 1% solution sublingually. Provide gentle oral care after each meal. Gently suction the client's mouth and buccal cavity. Provide gentle oral care after each meal. Which action by the nurse demonstrates an effective method to assess the client and the client's family's ability to cope with end-of-life interventions? Filling voids in conversation with information related to death and dying to avoid awkward moments during the admission interview Providing evidenced-based advice for end-of-life care based on the nurse's experiences with previous clients in hospiceRemaining silent, allowing the client and family to respond after asking a question related to end-of-life care Offering reassurance that the nurse has had 5 years of assisting clients in hospice and their families care for loved ones at the end of lifeRemaining silent, allowing the client and family to respond after asking a question related to end-of-life care A terminally ill patient in pain asks the nurse to administer enough pain medication to end the suffering forever. What is the best response by the nurse? "I can't do that, I will go to jail." "I am surprised that you would ask me to do something like that." "I will see if the physician will order enough for that to occur." "I will notify the physician that the current dose of medication is not relieving your pain." "I will notify the physician that the current dose of medication is not relieving your pain." A patient's family member asks the nurse what the purpose of hospice is. What is the best response by the nurse? "It will hasten the death of the patient." "It will prolong life in a dignified manner." "It will use artificial means of life support if the patient requests it." "It will enable the patient to remain home if that is what is desired." "It will enable the patient to remain home if that is what is desired." The nurse practitioner has four patients with chronic illness that require consistent medical and nursing management. Select the condition that is the best example of a "chronically critical and progressively ill" condition. Type 2 diabetes mellitus Carcinoma-in-situ Coronary artery disease End-stage renal disease End-stage renal disease Based on the most common concern of a dying patient, the hospice nurse should: Administer pain medication on a schedule that prevents pain from intensifying. Position the patient to prevent difficulties with breathing. Offer supplemental fluids to prevent dehydration. Turn the patient every 2 hours to prevent decubitus ulcers. Administer pain medication on a schedule that prevents pain from intensifying. A nurse is evaluating a client with a terminal illness. What should the nurse report so that the health care team can consider alternative nutritional approaches and fluid administration routes for the client at the end of life? altered gastrointestinal function drop in blood pressure and rapid heart rate weight loss and inadequate food intake irregular eating habits weight loss and inadequate food intake Which of the following may be contained in an "emergency kit" for a hospice patient exhibiting restlessness?Benzodiazepine Oral sucrose Laxative Atropine sulfate dropsBenzodiazepine In spite of administering the prescribed pain medication, a dying client is still experiencing dyspnea due to fear and anxiety. Which nursing intervention should the nurse use to potentiate the effects of pain medication and help reduce the dyspnea? Offer small amounts of nourishment frequently Gently massage the arms and legs Use imagery, humor, and progressive relaxation Encourage the patient to sleep Use imagery, humor, and progressive relaxation A type of comprehensive care for clients whose disease is not responsive to cure is a terminal illness. palliative care. euthanasia. interdisciplinary collaboration. palliative care. A nurse is caring for a client with a terminal illness. The client asks the nurse to help him end his own life to alleviate his suffering and that of his family. When responding to the client, the nurse integrates knowledge of which of the following? Participating in assisted suicide violates the Code of Ethics for Nurses. Nurses may administer medications prescribed by physicians to hasten end of life. A client has the right to make independent decisions about the timing of his or her death. Most states have enacted laws that allow for physician-assisted suicide. Participating in assisted suicide violates the Code of Ethics for Nurses. Which of the following nursing interventions is appropriate with regard to pain control in the dying client? Explain that narcotics can cause addiction. Explain that oxygen will eventually be used. Give pain medications on a routine schedule. Explain that morphine will be avoided because of its sedative effects. Give pain medications on a routine schedule. The spouse of a terminally ill client is confused by the new terminology being used during discussions regarding the client's treatment. The nurse should explain that palliative care is: care that will reduce the client's physical discomfort and manage clinical symptoms. care that is provided at the very end of an illness to ease the dying process. an alternative therapy that uses massage and progressive relaxation for pain relief. offered to terminally ill clients who wish to remain in their homes in lieu of hospice care. care that will reduce the client's physical discomfort and manage clinical symptoms.The physician is attending to a 72-year-old client with a malignant brain tumor. Family members report that the client rarely sleeps and frequently reports seeing things that are not real. Which intervention is an appropriate request for the hospice nurse to suggest to the physician? Perform surgery to remove the tumor from the brain. Begin radiation therapy to prevent cellular growth. Obtain a biopsy to analyze the lymph nodes. Add haloperidol to the client's treatment plan. Add haloperidol to the client's treatment plan A patient with end-stage chronic obstructive pulmonary disease is admitted to a hospice facility and asks the admitting nurse, "How long will I be allowed to stay here?" What is the best response by the nurse? "You will be able to stay only for approximately 1 month and then you will be discharged." "You will be able to stay for 2 months before being discharged." "There is no time limit for your stay. You can stay until you die." "When your stay reaches 6 months, you will be recertified for a continued stay." "When your stay reaches 6 months, you will be recertified for a continued stay." A terminally ill patient is admitted to the hospital. The patient grabs the nurse's hand and asks, "Am I dying?" What response would be best for the nurse to give? "Why do you think that?" "Did someone tell you that you are dying?" "Tell me more about what's on your mind." "I am not at liberty to disclose that information." "Tell me more about what's on your mind." A nurse has been providing in-home hospice care to an older adult client with lung cancer for more than six months. The family asks the nurse how long the Medicare hospice services will continue. What is the nurse's best response? The hospice services need to end now that the client has had the services for six months. The Medicare hospice services can continue as long as the physician and hospice director agree about the client's terminal condition. Medicare hospice services end at the seventh month of care. The client must begin to pay for other home health services since six months of hospice care have been received. The Medicare hospice services can continue as long as the physician and hospice director agree about the client's terminal condition. A client is dying, and the client and loved ones are in the grieving period. The nurse wants to support them in the grieving process. Which is the best intervention the nurse could perform? Encourage loved ones to express their feelings. Spend time alone with the client. Provide palliative care to the client. Disengage to give the grieving individuals privacy. Encourage loved ones to express their feelings. When describing the term "grief" to a group of students, which of the following would the instructor include?A part of the life cycle in the form of change, growth, and transition The response experienced by anyone who has suffered a loss A feeling of connectedness with one's self and others Feelings of apprehension or worry in response to a situationThe response experienced by anyone who has suffered a loss A nurse is providing care to a terminally ill client who is experiencing dyspnea. Which of the following would be most appropriate to do to assess the severity of the client's complaint? Ask the client to rate the dyspnea on a scale of 0 to 10. Have the client state if the dyspnea is mild, moderate, or severe. Question the client about when the dyspnea eases or worsens. Auscultate the client's lung sounds for changes. Ask the client to rate the dyspnea on a scale of 0 to 10. A nurse is providing care to a client experiencing symptoms associated with terminal illness. Which of the following would be most appropriate to use as a means for managing the client's symptoms? Physician's orders Client's goals Length of required treatment Invasiveness of the treatment Client's goals Which of the following does not coincide with Kübler-Ross's stages related to a dying client? Clients don't always follow the stages in order. Some client regress, then move forward again. The dying client usually exhibits anger first. The client may be in several stages at once. The dying client usually exhibits anger first. As the moment of death approaches, which of the following does the nurse encourage the family to do? Have the family sit in front of the client so they can be seen. Rub the client's hand and arm to comfort the client. Speak to the client in a calm and soothing voice. Lie next to the client and hold the client. Speak to the client in a calm and soothing voice. The family of a client in hospice decides to place their loved one in a long-term care facility to establish an effective pain control regimen. Which aspects of hospice care is the family using? Inpatient respite care Palliative care Continuous care General inpatient care Palliative care A client diagnosed with a terminal illness appoints her oldest son as the authorized individual to make medical decisions on her behalf when she is no longer able to speak for herself. Which proxy directive is the patient using?Medical directive by proxy Living will declaration Durable power of attorney for health care End-of-life treatment directive Durable power of attorney for health care Which term is used to describe the personal feelings that accompany an anticipated or actual loss? Bereavement Grief Mourning Spirituality Grief A hospice nurse is visiting the home of a client who was recently diagnosed with a terminal illness. The nurse is developing the client's plan of care and is assessing beliefs and preferences about end-of-life care. The nurse would expect to complete this assessment at which time? Over the course of several visits During the initial visit As the client's condition begins to deteriorate When the client exhibits signs of imminent death Over the course of several visits A nurse is conducting a spiritual assessment of a terminally ill client using the four step FICA process and asks the question, "What gives your life meaning?" The nurse is assessing which of the following? Importance and influence Community Address in care Faith and belief Faith and belief A nurse is assessing a client with a terminal illness and finds that the client has cachexia. The nurse interprets this as indicating which of the following? Extreme anorexia Starvation Profound protein loss Severe asthenia Profound protein loss A client states, "My children still need me. Why did I get cancer? I am only 30." This client is exhibiting which stage according to Kübler-Ross? Denial Anger Bargaining Acceptance Anger A mother of three young children has been diagnosed with stage III breast cancer and is distraught. Which statement best communicates a spirit of hopefulness to this client? "Let's take this one day at a time; remember you have your daughter's dance recital next week." "You should seek a second medical opinion about your diagnosis.""I believe that you will fight hard to beat this and see your babies grow up." "I know another client with the same diagnosis who has been in remission for 10 years." "Let's take this one day at a time; remember you have your daughter's dance recital next week." The nurse is caring for a pediatric client who is dying. The best way to provide care and comfort to dying clients and their families is to first do which of the following? A workshop on caring for the dying client Use evidence-based practice in daily care regimen. Explore own feelings on mortality and death and dying. Participate in a support group to learn clients' feeling on care. Explore own feelings on mortality and death and dying. The nurse is caring for a client who just learned of his terminal diagnosis. After the physician leaves, the nurse remains to answer further questions so that the client can make an informed decision about further treatment. By providing all available information, the nurse is promoting which ethical principle? The principle of justice The principle of nonmaleficence The principle of fidelity The principle of autonomy The principle of autonomy A client is declared to have a terminal illness. What intervention will a nurse perform related to the final decision of a dying client? Respect the client's and family members' choices. Share emotional pain. Abide by the dying client's wishes. Ask the family members about spiritual care. Respect the client's and family members' choices. A 50-year-old client is an alcoholic. The client has been diagnosed with pancreatic cancer and underwent surgery to remove the tumor. Despite the tumor being removed, the physician informs the client that chemotherapy needs to be started immediately. Using evidence-based practice, which intervention might the nurse expect the physician to include, with the goal of improving quality of life, mood, and median survival. Palliative care Radiation Angiogenesis Respite care Palliative care Which is also known as a proxy directive? Medical directive Living will Durable power of attorney for health care Treatment directive Durable power of attorney for health careA terminally ill client is receiving morphine around-the-clock for pain control. As part of the client's plan of care focusing on pain management, which nursing diagnosis would the nurse most likely identify? Risk for constipation related to the effects of an opioid Risk for ineffective cerebral tissue perfusion related to central nervous system effects of the drug Caregiver role strain related to the need for around-the-clock pain control Impaired physical mobility related to sedative effects of the drug Risk for constipation related to the effects of an opioid A nurse is developing a teaching plan for a terminally ill client and his family about the stages of dying and emotional reactions experienced. The nurse integrates knowledge of which of the following in the teaching plan? Each client experiences each of the stages. Typically, the stages occur in succession. The stages are applicable to any loss. Most clients reach acceptance by the time of death. The stages are applicable to any loss. A nurse is providing hospice care in Portland, Oregon to a client with terminal liver cancer. The client confides to the nurse, "I'm in agony all the time. I want this to be over now—please help me." Which interventions should the nurse implement? Select all that apply. Control the client's pain with prescribed medication. Advise the client's health care provider of the client's condition. Comfort the client by saying it will all be over soon. Encourage the client to explain his or her wishes. Recommend that the client consider physician-assisted suicide. Control the client's pain with prescribed medication. Advise the client's health care provider of the client's condition. Encourage the client to explain his or her wishes. A nurse is caring for a terminally ill client inquiring about physician-assisted suicide. Which statement if made by the nurse would correctly inform the client of this practice? The health care provider administers a lethal dose of medication via IV. The health care provider provides the means for the clients to take their life. The health care provider provides the means and waits to pronounce them dead. The health care provider provides counseling and has a third party physician assist in the suicide. The health care provider provides the means for the clients to take their life. When a person authorizes another to make medical decisions on his or her behalf, the person has written which of the following? Treatment directive Living will Standard addendum to a will Proxy directive Proxy directive A dying patient wants to talk to the nurse. The patient states, "I know I'm dying, aren't I?" What would an appropriate nursing response be?"This must be very difficult for you." "Let me explain to you what is happening." "I'm so sorry. I know how you must feel." "You know you're dying?" "This must be very difficult for you." Which term refers to the period of time during which mourning of a loss takes place? Grief Mourning Hospice Bereavement Bereavement Which term best describes a living will? Proxy directive Medical directive Health care power of attorney Durable power of attorney for health care Medical directive A group of nursing students is reviewing information about palliative care. The students demonstrate a need for additional review when they identify which of the following? Palliative care is the same as hospice care. Palliative care developed after hospice care developed. Palliative care is conceptually broader than hospice care. Palliative care is often provided along with disease-lessening treatments. Palliative care is the same as hospice care. Which of the following interventions should the nurse perform while providing spiritual care for a dying client? Encourage family members in their frank communication. Provide spiritual books. Ask the family members about spiritual care. Allow a period of privacy. Ask the family members about spiritual care. A client has learned of a terminal illness and impending death. The client asks the nurse to explain the concepts and care that are provided under the definition of palliative care. Which of the following would the nurse include in the explanation for this client? Select all that apply. Provides pain relief Includes chemotherapy Integrates spirituality Hastens death Offers a team approach to care Enhances quality of life Provides pain relief Integrates spirituality Offers a team approach to care Enhances quality of life Which statement, made by the nurse, can be most helpful when caring for a client in the third stage of Kubler-Ross' emotional reactions to dying?"Let's review the laboratory results and compare them with the diagnostic tests." "I understand that it would be wonderful to see your daughter's graduation." "What makes you most angry about getting the disease?" "I like your idea of living for today and enjoying those around you." "I understand that it would be wonderful to see your daughter's graduation." Which intervention should a nurse perform during the grieving period when caring for a dying client? Allowing a period of privacy Avoiding criticizing or giving advice Spending time with the client Providing palliative care Avoiding criticizing or giving advice A 25-year-old client with cancer who is experiencing unrelieved pain rated a 9 on the pain scale requests that the hospice nurse induce a state of unconsciousness until the client dies. Which statement by the nurse demonstrates an understanding of a key difference between conscious sedation and euthanasia? "I cannot legally administer pain medications that will induce unconsciousness to relieve your pain." "Your doctor can prescribe medications necessary to relieve pain; however; this treatment will not hasten death." "Total sedation is a commonly practiced method used in this situation; I will contact your physician and begin treatment as soon as possible." "I need to perform a complete pain assessment to confirm the amount of pain you are experiencing before recommending sedation." "Your doctor can prescribe medications necessary to relieve pain; however; this treatment will not hasten death." A nurse is providing care to a terminally ill client who follows Islamic traditions and is experiencing pain. When developing a plan of care for this client, an understanding of which of the following would the nurse need to integrate into the plan? Pain is viewed as a means of cleansing by God. Pain must be controlled regardless of the client's wishes. Pain is considered a positive aspect that leads to rebirth. Pain provides the client with an opportunity for repentance. Pain is viewed as a means of cleansing by God. When assessing a terminally ill client, the nurse notices that the client has copious secretions at the back of the throat and in the mouth. The nurse is preparing a teaching plan for the family about caring for these secretions. Which of the following would be least appropriate to include? Positioning the client on the side with the head supported with a pillow Using a soft toothbrush to vigorously clean the mouth Performing gentle suctioning of the mouth Administering a prescribed anticholinergic agent Using a soft toothbrush to vigorously clean the mouthWhile providing care to a terminally ill client, the client's niece asks the nurse about the client's condition and prognosis. Which of the following would be most appropriate? Provide the niece with the information that she is requesting. Ask the client's consent before sharing any information with the niece. Check with the client's immediate family members about sharing information. Refer the niece to the client's physician for information. Ask the client's consent before sharing any information with the niece. While providing care to a client near death, the nurse is helping the family to prepare by teaching them what to expect. Which of the following would the nurse include in the teaching plan as a sign of approaching death? Select all that apply. Gurgling as the client breathes through the mouth Breathing that is very rapid Decrease in amount of urine produced Refusal to ingest food or fluids Increase in visual and auditory abilities Gurgling as the client breathes through the mouth Decrease in amount of urine produced Refusal to ingest food or fluids Which of the following is a term that refers to individual, family, group, and cultural expressions of grief and associated behaviors? Mourning Grief Bereavement Spirituality Mourning How does a nurse who has been providing home care to a terminally ill client know that the client's condition is beginning to deteriorate? apical pulse reaches 100 beats per minute skin appears red and flushed urine output increases facial muscles contract apical pulse reaches 100 beats per minute A patient near the end of life is experiencing anorexia-cachexia syndrome. What characteristics of the syndrome does the nurse recognize? (Select all that apply.) Alterations in carbohydrate, fat, and protein metabolism Endocrine dysfunction Anemia Neurologic dysfunction Bladder incontinence Alterations in carbohydrate, fat, and protein metabolism Endocrine dysfunction Anemia A nurse is caring for a client with end-stage testicular cancer who has been referred to hospice care. Which criterion indicates that the client requires more teaching about hospice care?The client doesn't want to discuss death around his girlfriend. The client entered a clinical trial through the National Cancer Institute. The physician orders weekly blood transfusions to be given at home. The client explains that he isn't ready to complete his will. The client entered a clinical trial through the National Cancer Institute. A client is experiencing anorexia and the physician is to order a medication to stimulate the client's appetite. Which of the following would the nurse least likely expect the physician to prescribe? Megestrol Dexamethasone Dronabinol Atropine Atropine Anorexia and cachexia are common problems at the end of life. The nurse plays an important role in managing symptoms and preventing complications. Which of the following are appropriate nursing interventions for these problems? Select all that apply. Advise the patient and family about the importance of a balanced diet. Encourage the patient to eat in an upright position. Suggest a daily weighing time to monitor treatment plan. Recommend that the patient eat when hungry, regardless of usual meal times. Teach the patient how to increase the nutritional value of meals (i.e., add dry milk powder to milk). Encourage the patient to eat in an upright position. Recommend that the patient eat when hungry, regardless of usual meal times. Teach the patient how to increase the nutritional value of meals (i.e., add dry milk powder to milk A hospitalized client of the Islamic (Muslim) religion is dying. What concept does the nurse share with the health care team about this client's beliefs about death? Death is seen as the beginning of a new and better life, with Islam as the vehicle. Life experiences do not affect the individual's preparation for "everlasting life." The timing of death is under the power of the person who is facing death. Plans for burial will take days, maybe even weeks, after the death. Death is seen as the beginning of a new and better life, with Islam as the vehicle. Which condition, when assessed in a dying client, requires that the nurse take action? Alternating apnea and rapid breathing Anorexia Cool extremities Moaning Moaning A client with terminal lung cancer is receiving hospice care at home. Which nursing action does the RN manager ask the LPN/LVN to do? Administer prescribed medications to relieve the client's pain, shortness of breath, and nausea. Clarify family members' feelings about the meaning of client behaviors and symptoms. Develop a plan for care after assessing the needs and feelings of both the client and the family.Teach the family to recognize signs of client discomfort such as restlessness or grimacing. Administer prescribed medications to relieve the client's pain, shortness of breath, and nausea. A dying client becomes increasingly withdrawn and begins to refuse to eat and drink. What intervention does the nurse implement? Brings in the client's favorite food Calls the family to come in right away Gives intravenous hydration Offers ice chips Offers ice chips In a dying client's hospital room, the nurse overhears family telling the client to "calm down," and observes the client being agitated and making repetitive motions. What action does the nurse take? Asks the family to speak in low tones or whispers to avoid disturbing the client Offers to call and have a hospital chaplain come to help the client calm down Recommends giving the client antianxiety medications to reduce distress Suggests that the family tell the client that things are "all right" Suggests that the family tell the client that things are "all right" The nurse is performing a spiritual assessment on a dying client. Which question provides the most accurate data on this aspect of the client's life? "Do you believe in God?" "Tell me about the history of religion in your life." "What gives you purpose and meaning in your life?" "Where have you been attending church for the past several years?" "What gives you purpose and meaning in your life?" A client admitted with a non-life-threatening illness says, "I was asked to fill out an advance directive when I was admitted, but I was too stressed. What was it all about?" How does the nurse respond? "Advance directives are only for those individuals who are severely ill." "Advance directives allow a client to convey his or her wishes about health care ahead of time." "Most Americans have an advance directive in place; you will need to see a lawyer." "You should have completed the paperwork before you were admitted." "Advance directives allow a client to convey his or her wishes about health care ahead of time." A dying client exhibits signs of agitation. The Foley catheter has drained 100 mL in the last 3 hours, and the client's last bowel movement was yesterday evening. What does the nurse do first? Administer an analgesic. Arrange for a consultation with a bereavement counselor. Assess the client for impaction. Change the Foley catheter to ensure adequate drainage. Administer an analgesic. The nurse is coordinating interdisciplinary palliative care interventions for the dying client. Which goal is the nurse seeking to meet?Avoiding symptoms of client distress Ensuring an expedited death Meeting all of the client's needs Facilitating a peaceful death for the client Facilitating a peaceful death for the client The daughter of a dying client says, "I don't want my father to be uncomfortable." How does the nurse respond? "Do you want to talk to the bereavement nurse?" "Your father will be closely monitored and cared for." "Your father will be kept sedated." "We will send him to hospice when the time comes." "Your father will be closely monitored and cared for." The nurse working on an inpatient hospice unit has received the change-of-shift report. Which client does the nurse assess first? A 26-year-old with metastatic breast cancer who is experiencing pain rated at 10 (0-to-10 scale) and anxiety A 30-year-old with AIDS-associated dementia and agitation who is asking for assistance with calling family members A 62-year-old with lung cancer who has cool, clammy, dusky skin, and blood pressure of 64/20 mm Hg A 70-year-old with cancer of the colon who has a respiratory rate of 8 with loud, wet-sounding respirations A 26-year-old with metastatic breast cancer who is experiencing pain rated at 10 (0-to-10 scale) and anxiety A hospice client has just died. Which of these postmortem nursing tasks is most appropriate to delegate to a nursing assistant? Assessing the client for cessation of respiratory effort and lack of pulse Documenting the time of death and required assessment data on the chart Notifying the spouse and other family members about the client's death Removing all IV lines or tubes according to the hospice policy Removing all IV lines or tubes according to the hospice policy The family of an unconscious dying client realizes that their mother will die soon. The client's children are having a difficult time letting go. How does the nurse respond to the needs of this family? "Don't be upset; she wouldn't want it that way." "She will soon be in a better place." "Things will be fine, try not to worry so much." "This must be difficult for you." "This must be difficult for you." The nurse manager for home health and hospice is scheduling daily client visits. Which client is appropriate for the nursing assistant to visit? Advanced cirrhosis of the liver and just called the hospice agency reporting nausea Aggressive brain tumor and needs daily assistance with ambulation and bathing Inoperable lung cancer and considering whether to have radiation and chemotherapyProstate cancer and bone metastases and has new-onset leg weakness and tingling Aggressive brain tumor and needs daily assistance with ambulation and bathing A hospice client becomes too weak to swallow. What does the nurse do initially to increase the client's comfort? Administers nutrition and fluids through a nasogastric tube Explains to the family that aspiration may be a concern Obtains a physician order to initiate an IV line Teaches the family how to provide oral care Teaches the family how to provide oral care A dying client says to the nurse, "I am afraid to die. I did a lot of wrong things in my life." How does the nurse respond? "Don't worry, God will forgive you." "I'm sure it is nothing to worry about." "Tell me more about that." "Why? What did you do wrong?" "Tell me more about that." A client diagnosed with lung cancer 6 months ago is now ventilator-dependent and unresponsive. The family wants to remove the ventilator and stop antibiotics and IV fluids. What does the nurse do next? Facilitates a meeting between the family and health care team Removes the interventions, per the family's wishes Tells the family that removing the interventions is illegal Waits to obtain information on the client's wishes Facilitates a meeting between the family and health care team A client with terminal pancreatic cancer is near death and reports increasing shortness of breath with associated anxiety. Which hospice protocol order does the nurse implement first? Albuterol (Proventil) 0.5% solution per nebulizer Morphine sulfate (Roxanol) 5 to 10 mg sublingually as needed Oxygen 2 to 6 L/min per nasal cannula Prednisone (Deltasone) elixir 10 mg orally Morphine sulfate (Roxanol) 5 to 10 mg sublingually as needed In which newly admitted client situations does the nurse initiate a conversation about advance directives? Select all that apply. A client with a non-life-threatening illness A person who currently has advance directives The client with end-stage kidney disease The comatose client who was injured in an automobile crash The laboring mother expecting her first childA client with a non-life-threatening illness A person who currently has advance directives The client with end-stage kidney disease The laboring mother expecting her first childA Christian client is struggling with a diagnosis of cancer and says, "Why is life so unfair?" What health care team member does the nurse ask to provide support? Client's family Physician Hospital chaplain Psychiatrist Hospital chaplain A dying client is having difficulty swallowing oral medications. Which intervention does the nurse implement for this client? Asks the pharmacy to substitute intramuscular (IM) equivalents for the medications Asks the provider if the medications can be discontinued or substituted Crushes the pills, opens the sustained-release capsules, and mixes them with a spoonful of applesauce Does not give the medications and documents: "Unable to swallow" Asks the provider if the medications can be discontinued or substituted A client has died after a long hospital stay. The family was present at the time of the client's death. Which postmortem action does the nurse implement? Asks the family if they wish to help wash the client Asks the family to leave during post-death care Raises the head of the bed and opens the client's eyes Removes dentures and any prosthetics Asks the family if they wish to help wash the client A dying client cannot swallow and is accumulating audible mucus in the upper airway (death rattles). The nursing assistant reports that these noises are upsetting to family members. What does the nurse tell the assistant to do? Assist the family in leaving the room so that they can compose themselves. Place the client in a side-lying position so secretions can drain. Position the client in a high-Fowler's position to minimize secretions. Use a Yankauer suction tip to remove secretions from the client's upper airway. Place the client in a side-lying position so secretions can drain. The nurse recognizes signs and symptoms of delirium in an 80-year-old client who is dying from metastatic breast cancer. What does the nurse do initially for this client? Requests an order for an antipsychotic medication to control these symptoms Collaborates with the end-of-life (EOL) care team to evaluate possible medication-induced causes Discontinues all medications that have central nervous system adverse effects Assures the client's family that this terminal delirium indicates that death is imminent Collaborates with the end-of-life (EOL) care team to evaluate possible medicationinduced causes A nurse who is skilled in complementary and alternative medicine (CAM) therapies works on a cancer unit with clients who are terminally ill. For which client symptom does the nurse use these therapies? Constipation Cool extremities Increased pain Memory loss Increased painA client dying of cancer is receiving high doses of opioids. In addition, which intervention is the most effective for this client? Classical music Deep muscle massage More pain medication Short, light massage Short, light massage The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse? Client behavior that changes from anxious to lethargic Deep furrows on the surface of the tongue Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched Urine output of 950 mL for the past 24 hoursClient behavior that changes from anxious to lethargic A client with diarrhea for 3 days and inability to eat or drink well is brought to the emergency department (ED) by her family. She states she has been taking her diuretics for congestive heart failure (CHF). What nursing actions are indicated at this time? Select all that apply. Place the client on bed rest. Evaluate the electrolyte levels. Administer the ordered diuretic. assess for orthostatic hypotension. initiate cardiac monitoring A client with hypokalemia has a prescription for parenteral potassium chloride (KCl). Which of these interventions does the nurse use to safely administer KCl? Select all that apply. Use a potassium infusion prepared by a registered pharmacist. Assess for burning or redness during infusion. Infuse at a rate of no more than 10 mEq per hour. Administer only through a central venous catheter. Administer by IV push only during cardiac arrest. The nurse is caring for a client who is receiving a loop diuretic for treatment of heart failure. Which of these actions will be included in the plan of care? Select all that apply. Assess daily weights. Encourage consumption of citrus fruits. Weigh the client weekly. Monitor serum potassium. Discourage intake of spinach. Monitor for bradycardia. Assess daily weights. Encourage consumption of citrus fruits. Monitor serum potassium. The nurse is caring for a client who takes furosemide (Lasix) and digoxin (Lanoxin). The client's potassium (K+) level is 2.5 mEq/L (2.5 mmol/L). Which additional assessment will the nurse make? Heart rateBlood pressure (BP) Increases in edema Sodium level Heart rate Furosemide (Lasix) has been ordered for a client with heart failure, shortness of breath, and 3+ pitting edema of the lower extremities. Which assessment finding indicates to the nurse that the medication has been effective? The client's potassium level is 5.1 mEq/L (5.1 mmol/L). The client's heart rate is 101 beats per minute. The client is free from adventitious breath sounds. The client has experienced a weight gain of 1 pound (0.5 kg). The nurse is discussing safety when administering bumetanide with a nursing student. The nurse recognizes that the student understands side effects of this medication when the student makes which statement? "The client's PT and INR may be prolonged while taking this medication." "The client may develop hypoglycemia during treatment." "Inverted T waves and a U wave may appear on the ECG." "I need to tell the client to avoid salt substitutes." "Inverted T waves and a U wave may appear on the ECG." The nurse is teaching a client who is taking a potassium-sparing diuretic about precautions while taking this medication. Which of these does the nurse teach the client to avoid or use cautiously? Select all that apply. Apples Bananas ACE inhibitors Grapes Salt substitute The nurse is assessing a client with a sodium level of 118 mEq/L (118 mmol/L). Which activity takes priority? Monitoring urine output encouraging sodium rich fluids and foods throughout the day instructing the client not to ambulate without assistance assessing deep tendon reflexes instructing the client not to ambulate without assistance The nurse is infusing 3% saline for a client with syndrome of inappropriate secretion (SIADH). Which of these complications does the nurse report to the primary care provider? Peripheral edema Crackles ½ way up the lung fields Serum osmolarity of 294 mOsm/kg (294 mmol/kg) Urine output of 1300 mL over 24 hours The nurse is caring for a client who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical? Monitoring 24-hour urine output Asking the client about feeling depressed Assessing the blood pressure hourly Monitoring the serum calcium levelsA client is brought to the emergency department for increasing weakness and muscle twitching. The laboratory results include a potassium level of 7.0 mEq/L (7.0 mmol/L). Which assessments does the nurse make? Select all that apply. History of liver disease Use of salt substitute Use of an ACE inhibitor Potassium-sparing diuretics Prescription for insulin Use of salt substitute Use of an ACE inhibitor Potassium-sparing diuretics After receiving change-of-shift report, which client does the RN assess first? A client with nausea and vomiting who complains of abdominal cramps A client with a nasogastric (NG) tube who has dry oral mucosa and is complaining of thirst A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hg A client with normal saline infusing at 150 mL/hr whose hourly urine output has been averaging 75 mL A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hg The primary care provider writes prescriptions for a client who is admitted with a serum potassium level of 6.9 mEq/L (6.9 mmol/L). What does the nurse implement first? Administer sodium polystyrene sulfonate (Kayexalate) orally. Ensure that a potassium-restricted diet is ordered. Place the client on a cardiac monitor. Teach the client about foods that are high in potassium. Place the client on a cardiac monitor. The nurse is planning care for a 72-year-old resident of a long-term care facility who has a history of dehydration. Which action does the nurse delegate to unlicensed assistive personnel (UAP)? Assessing oral mucosa for dryness Choosing appropriate oral fluids Monitoring skin turgor for tenting Offering fluids to drink every hour Offering fluids to drink every hour The nurse at a long-term care facility is teaching a group of unlicensed assistive personnel (UAP) about fluid intake principles for older adults. Which of these should be included in the education session? "Be careful not to overload them with too many oral fluids." "Offer fluids that they prefer frequently and on a regular schedule." "Restrict their fluids if they are incontinent." "Wake them every 2 hours during the night with a drink." "Offer fluids that they prefer frequently and on a regular schedule." The nurse is preparing a client a diagnosis of congestive heart failure (CHF) for discharge. Which statement by the client indicates a correct understanding of self-management of CHF? "I can gain 2 pounds (1 kg) of water a day without risk." "I should call my provider if I gain more than 1 pound (0.5 kg) a week." "Weighing myself daily can determine if my caloric intake is adequate." "Weighing myself daily can reveal increased fluid retention." "Weighing myself daily can reveal increased fluid retention."The nurse is caring for a group of clients on a medical surgical unit. Which newly written prescription will the nurse administer first? Intravenous normal saline to a client with a serum sodium of 132 mEq/L (132 mmol/L) Oral calcium supplements to a client with severe osteoporosis Oral phosphorus supplements to a client with acute hypophosphatemia Oral potassium chloride to a client whose serum potassium is 3 mEq/L (3 mmol/L) Oral potassium chloride to a client whose serum potassium is 3 mEq/L (3 mmol/L) Which client is most appropriate for the nurse manager of the medical-surgical unit to assign to the LPN/LVN? A client admitted with dehydration who has a heart rate of 126 beats/min A client just admitted with hyperkalemia who takes a potassium-sparing diuretic at home A client admitted yesterday with heart failure with dependent pedal edema A client who has just been admitted with severe nausea, vomiting, and diarrhea A client admitted yesterday with heart failure with dependent pedal edema A client with hypermagnesemia is seen in the emergency department (ED). Which of these interventions is most appropriate? Monitor for hyperactive reflexes prepare for endotracheal intubation Institute teaching on avoiding magnesium rich foods Place the client on a cardiac monitor Place the client on a cardiac monitor. The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The client with which electrolyte laboratory value is assigned to the LPN/LVN? Calcium level of 9.5 mg/dL (2.4 mmol/L) Magnesium level of 4.1 mEq/L (2.1 mmol/L) Potassium level of 6.0 mEq/L (6.0 mmol/L) Sodium level of 120 mEq/L (120 mmol/L) Calcium level of 9.5 mg/dL (2.4 mmol/L) The step down unit receives a new admission who has uncontrolled diabetes, polyuria, and a blood pressure of 86/46 mm Hg. Which staff member is assigned to care for her? LPN/LVN who has floated from the hospital's long-term care unit LPN/LVN who frequently administers medications to multiple clients RN who has floated from the intensive care unit RN who usually works as a diabetes educator RN who has floated from the intensive care unit The nurse is caring for an older adult with hypernatremia. Which of these interventions does the nurse perform first? Restrict the client's intake of sodium Administer a diuretic Monitor the serum osmolarity Encourage fluid intake Encourage fluid intake The nurse is caring for a group of clients with electrolytes and blood chemistry abnormalities. Which client will the nurse see first? The client with a random glucose reading of 123 mg/dL (6.8 mmol/L) The client who has a magnesium level of 2.1 mEq/L (1.0 mmol/L) The client whose potassium is 6.2 mEq/L (6.2 mmol/L) The client with a sodium level of 143 mEq/L (143 mmol/L) The client whose potassium is 6.2 mEq/L (6.2 mmol/L)The RN is caring for a client who is severely dehydrated. Which nursing action can be delegated to the unlicensed assistive personnel (UAP)? Consulting with a health care provider about a client's laboratory results Infusing 500 mL of normal saline over 60 minutes Monitoring IV fluid to maintain the drip rate at 75 mL/hr Providing oral care every 1 to 2 hours Providing oral care every 1 to 2 hours The charge nurse on a medical-surgical unit is completing assignments for the day shift. Which client is most appropriate to assign to the LPN/LVN? A 44-year-old with congestive heart failure (CHF) who has gained 3 pounds (1.4 kg) since the previous day A 58-year-old with chronic renal failure (CRF) who has a serum potassium level of 6 mEq/L (6.0 mmol/L) A 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/kg (300 mmol/kg) An 80-year-old with 3+ peripheral edema and crackles throughout the posterior chest A 76- year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/kg (300 mmol/kg) The nurse is caring for a client receiving lactated Ringer's solution IV for rehydration. Which assessments will the nurse monitor during intravenous therapy? Select all that apply. Blood serum glucose Blood pressure Pulse rate and quality Urinary output Urine specific gravity Blood pressure Pulse rate and quality Urinary output Urine specific gravity The rapid response team (RRT) is called to the bedside of a client with heart rate of 38 beats per minute and a potassium level of 7.0 mEq/L (7.0 mmol/L). For which medication will the nurse anticipate a prescription? Insulin atropine Sodium polystyrene sulfonate (Kayexalate) potassium phosphate Insulin A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first? Draws blood for laboratory tests Elevates the head of the bed Places the extremities in a dependent position Puts the client in a side-lying position Elevates the head of the bed An older adult is admitted to the medical surgical unit with dehydration. The nurse performs which of these assessments to determine whether the client is safe for independent ambulation? Assesses for dry oral mucous membranes Checks for orthostatic blood pressure changes Notes pulse rate is 72 beats/min and boundingEvaluates that the serum potassium level is 4.0 mEq/L (4.0 mmol/L) Checks for orthostatic blood pressure changes The nurse is assessing fluid balance in the client with heart failure. Which of these strategies will the nurse employ? Ask the client how much fluid was consumed yesterday. Place an indwelling catheter to measure urine output. Auscultate the lungs for adventitious sounds. Weigh the client daily, at the same time. Weigh the client daily, at the same time. A client is admitted to the hospital with dehydration secondary to influenza and vomiting. The provider orders an intravenous (IV) potassium replacement for potassium level of 2.7 mEq/L (2.7 mmol/L). Which of these best practice techniques does the nurse include when administering this medication? Select all that apply. Ensuring that the concentration is no greater than 1?9?mEq/10?9?mL of solution Use a vein in the hand for better flow Use an IV pump to deliver the medication Check IV access for blood return after the infusion Push the medication over 5 minutes Ensuring that the concentration is no greater than 1?9? mEq/10?9?mL of solution Use an IV pump to deliver the medication A client with mild hypokalemia caused by diuretic use is discharged home. The home health nurse delegates which of these interventions to the home health aide? Assessment of muscle tone and strength Education about potassium-rich foods Instruction on the proper use of drugs Measurement of the client's weight Measurement of the client's weight Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications? Tetanic contractions Jugular vein distention Weight loss Polyuria Jugular vein distention Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? Confusion and seizures Sunken eyeballs and spasticity Flaccidity and thirst Tetany and increased blood urea nitrogen (BUN) levels Confusion and seizures A priority nursing intervention for a client with hypervolemia involves which of the following? Establishing I.V. access with a large-bore catheter. Drawing a blood sample for typing and crossmatching.Monitoring respiratory status for signs and symptoms of pulmonary complications. Encouraging the client to consume sodium-free fluids. Monitoring respiratory status for signs and symptoms of pulmonary complications. Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply. Distended neck veins Crackles in the lung fields Shortness of breath Decreased blood pressure Bradycardia Distended neck veins Crackles in the lung fields Shortness of breath Which of the following is a factor affecting an increase in urine osmolality? Syndrome of inappropriate antidiuretic hormone release (SIADH) Alkalosis Fluid volume excess Myocardial infarction Syndrome of inappropriate antidiuretic hormone release (SIADH) Which of the following is the most common cause of symptomatic hypomagnesemia in the United States? Alcoholism Intestinal resection Inflammatory bowel disease Loss of gastric acid Alcoholism The nurse is caring for a client undergoing alcohol withdrawal. Which serum laboratory value should the nurse monitor most closely? Magnesium Calcium Phosphorus Potassium Magnesium A client with cancer is being treated on the oncology unit for bilateral breast cancer. The client is undergoing chemotherapy. The nurse notes the client's serum calcium concentration is 12.3 mg. Given this laboratory finding, the nurse should suspect that the malignancy is causing the electrolyte imbalance. client's diet is lacking in calcium-rich food products. client may be developing hyperaldosteronism. client has a history of alcohol abuse. malignancy is causing the electrolyte imbalance. A nurse is caring for a client with acute renal failure and hypernatremia. In this case, which action can be delegated to the nursing assistant? Provide oral care every 2-3 hours. Monitor for signs and symptoms of dehydration.Teach the client about increased fluid intake. Assess the client's weight daily for trends. Provide oral care every 2-3 hours. An adult client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and lethargy. The nurse reconciles the client's medication list and notes that salt tablets had been prescribed. What would the nurse do next? Continue to monitor client with another appointment. Be prepared to administer a lactated Ringer's IV. Be prepared to administer a sodium chloride IV. Consider sodium restriction with discontinuation of salt tablets. Consider sodium restriction with discontinuation of salt tablets. A nurse is assessing a client's reflexes. Which condition does the nurse need to confirm when tapping the facial nerve of a client who has dysphagia? hypervolemia hypercalcemia hypomagnesemia hypermagnesemia hypomagnesemia A client who is semiconscious presents with restlessness and weakness. The nurse assesses a dry, swollen tongue; body temperature of 99.3 °F; and a urine specific gravity of 1.020. What is the most likely serum sodium value for this client? 110 mEqL 130 mEqL 145 mEqL 165 mEqL 165 mEqL A client's potassium level is moderately elevated. The nurse is reviewing the ECG tracing. Where the nurse would expect to see a peak on the ECG? There will not be a peak Near P Wave At QRS complex At the T Wave At the T Wave Which is considered an isotonic solution? 0.9% normal saline Dextran in normal saline 0.45% normal saline 3% NaCl 0.9% normal saline Fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area? osmosis filtration evaporation active transport osmosisThe nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which? Lung function Summer allergies Cardiovascular compromise Insensible fluid loss Insensible fluid loss The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance? A 7-year-old with a fracture tibia A 65-year-old with a myocardial infarction A 52-year-old with diarrhea A 72-year-old with a total knee repair A 52-year-old with diarrhea The physician has prescribed a hypotonic IV solution for a patient. Which IV solution should the nurse administer? 0.45% sodium chloride 0.9% sodium chloride 5% glucose in water 5% glucose in normal saline solution 0.45% sodium chloride Oral intake is controlled by the thirst center, located in which of the following cerebral areas? Hypothalamus Cerebellum Brainstem Thalamus Hypothalamus A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported "dry mouth." The nurse suspects the client is experiencing which condition? dehydration hypervolemia hypercalcemia hyperkalemia dehydration Below which serum sodium concentration might convulsions or coma occur? 135 145 140 142 135 Which is an insensible mechanism of fluid loss? Urination Bowel eliminationBreathing NauseaBreathing Which nerve is implicated in the Chvostek's sign? Facial Hypoglossal Optic Spinal accessory Facial The nurse is correct to state that a client's body needs to have adequate nutrition to maintain energy. Which type of transport of dissolved substances requires adenosine triphosphate (ATP)? Osmosis Passive diffusion Facilitated diffusion Active transport Active transport The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9 Which statement made by the client indicates the need for further teaching? "I can use laxatives and enemas but only once a week." "A good breakfast for me will include milk and a couple of bananas." "I will be sure to buy frozen vegetables when I grocery shop." "I will take a potassium supplement daily as prescribed." "I can use laxatives and enemas but only once a week." Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration? Abnormal potassium level Elevated hematocrit level Low white blood count Low urine specific gravity Elevated hematocrit level A client reports tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the client's laboratory work has returned? Potassium Phosphorus Calcium Iron Calcium Which solution is hypotonic? Lactated Ringer solution 0.45% NaCl 0.9% NaCl 5% NaCl 0.45% NaClThe nurse is caring for a client in the intensive care unit (ICU) following a near-drowning event in saltwater. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen and dry tongue, flushed skin, and peripheral edema. The nurse anticipates that the client's serum sodium value would be 155 145 135 125 155 Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality? Sodium Potassium Calcium Magnesium Sodium The nurse is caring for a client diagnosed with hyperchloremia. Which are signs and symptoms of hyperchloremia? Select all that apply. Tachypnea Weakness Lethargy Dehydration Hypotension Tachypnea Weakness Lethargy A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise? Cerebral edema Hypovolemic shock Severe hyperkalemia Tetany Cerebral edema To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body? Bradycardia Tachycardia Vasodilation Increased urine outputTachycardia A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? Specific gravity of 1.02Urine pH of 3.0 Absence of protein Absence of glucose Urine pH of 3.0 Which electrolyte is a major cation in body fluid? Chloride Bicarbonate Potassium Phosphate Potassium A volume-depleted patient would present with which of the following diagnostic lab results? BUN-to-creatinine ratio of 24:1 Urinary output of 1.2 L in 24 hours Urine specific gravity of 1.02 Capillary refill time of 3 seconds BUN-to-creatinine ratio of 24:1 A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply. Drink at least eight glasses of fluid each day. Drink caffeinated beverages to retain fluid. Drink carbonated beverages to help balance fluid volume. Drink water as an inexpensive way to meet fluid needs. Respond to thirst Drink at least eight glasses of fluid each day. Drink water as an inexpensive way to meet fluid needs. Respond to thirst The nurse is caring for a client with a serum sodium concentration of 113 .The nurse should monitor the client for the development of which condition? Confusion Headache Nausea Hallucinations Confusion Early signs of hypervolemia include a decrease in blood pressure. thirst. moist breath sounds. increased breathing effort and weight gain. increased breathing effort and weight gain A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. The laboratory values are as follows: Sodium 147 Potassium 3.0 Chloride 112 Magenesium 2.3What laboratory value is consistent with the client's symptoms? Sodium 147 Potassium 3.0 Chloride 112 Magenesium 2.3 Potassium 3.0 The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? Low heart rate Elevated blood pressure Rapid respiration Subnormal temperature Elevated blood pressure The nurse is instructing a client with recurrent hyperkalemia about following a potassiumrestricted diet. Which statement by the client indicates the need for additional instruction? "I will not salt my food; instead I'll use salt substitute." "Bananas have a lot of potassium in them; I'll stop buying them." "I'll drink cranberry juice with my breakfast instead of coffee." "I need to check to see whether my cola beverage has potassium in it." "I will not salt my food; instead I'll use salt substitute." A patient has been involved in a traumatic accident and is hemorrhaging from multiple sites. The nurse expects that the compensatory mechanisms associated with hypovolemia would cause what clinical manifestations? (Select all that apply.) Hypertension Oliguria Tachycardia Bradycardia Tachypnea Oliguria Tachycardia Tachypnea A patient with diabetes insipidus presents to the emergency room for treatment of dehydration. The nurse knows to review serum laboratory results for which of the diagnostic indicators? Sodium 137 Potassium 3.8 Sodium 150 Potassium 6 Sodium 150 A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? Serum sodium level of 124 Serum creatinine level of 0.4 Hematocrit of 52% Serum blood urea nitrogen (BUN) level of 8.6 Serum sodium level of 124 Which is a correct route of administration for potassium?Subcutaneous Intramuscular Oral IV (intravenous) push Oral Which laboratory result does the nurse identify as a direct result of the client's hypovolemic status with hemoconcentration? Abnormal potassium level Elevated hematocrit level Low white blood count Low urine specific gravity Elevated hematocrit level A client is being treated in the ICU 24 hours after having a radical neck dissection completed. The client's serum calcium concentration is 7.6 Which physical examination finding is consistent with this electrolyte imbalance? Presence of Trousseau sign Slurred speech Negative Chvostek sign Muscle weakness Muscle weakness The nurse is analyzing the electrocardiographic (ECG) rhythm tracing of a client experiencing hypercalcemia. Which ECG change is typically associated with this electrolyte imbalance? Prolonged PR intervals Prolonged QT intervals Peaked T waves Elevated ST segments Prolonged PR intervals A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which test result is most significant? Blood urea nitrogen (BUN) level of 29 Serum sodium level of 132 Urine specific gravity of 1.025 Serum potassium level of 3 Serum potassium level of 3 The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration? Cool and pale skin Crackles in the lung fields Distended jugular veins Dark, concentrated urine Dark, concentrated urine A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values. sodium 130 potassium 4.6 chloride 94calcium 12.9 What laboratory value is consistent with the client's symptoms? sodium 130 potassium 4.6 chloride 94 calcium 12.9 calcium 12.9 A client with chronic renal failure has a serum potassium level of 6.8 . What should the nurse assess first? Blood pressure Respirations Temperature Pulse Pulse A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status? vital signs edema intake and output weight weight