NUR104 | NUR104 Medsurg 2 Exam 4 Version 2 |
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A patient undergoing chemotherapy has an absolute neutrophil count (ANC) of
450/mm3. Which nursing intervention is the highest priority for this patient?
A. Implement strict hand hygiene and limit visitors.
B. Check the patient’s blood pressure every 4 hours.
C. Administer a stool softener to prevent constipation.
D. Encourage the patient to eat fresh fruits and vegetables.
Correct Answer: A
Expert Explanation: Neutropenia is defined as an ANC less than 1,000/mm3,
significantly increasing the risk of life-threatening infections. Implementing strict
hand hygiene is the most effective way to prevent the transmission of pathogens.
The nurse must also limit visitors and exclude anyone with active infections from
the room. Fresh fruits and vegetables are often restricted in a neutropenic diet due
to potential bacterial contamination. These precautions are essential during the
nadir when the patient’s immune system is most vulnerable.
,2. Which clinical manifestation is an early indicator of Superior Vena Cava Syndrome
(SVCS) in a patient with lung cancer?
A. Lower extremity edema
B. Facial edema in the morning
C. Numbness in the fingers
D. Severe hypotension
Correct Answer: B
Expert Explanation: Superior Vena Cava Syndrome occurs when a tumor
compresses the superior vena cava, obstructing venous return from the upper body.
Early signs include periorbital and facial edema, particularly noticed when the
patient wakes up. As the condition progresses, the patient may experience tightness
of the shirt collar and distended neck veins. This is considered an oncologic
emergency that requires immediate medical intervention like radiation or
chemotherapy. Proper assessment and documentation of these symptoms can lead
to faster stabilization and treatment.
3. A nurse is caring for a patient with internal radiation (brachytherapy). Which action
should the nurse take to ensure safety?
A. Discard soiled linens in the general hospital waste container.
B. Allow pregnant staff to care for the patient if they wear a lead apron.
,C. Keep the patient’s room door open for better visualization.
D. Limit time spent in the room to 30 minutes per shift.
Correct Answer: D
Expert Explanation: Safety protocols for brachytherapy focus on the principles of
time, distance, and shielding to minimize radiation exposure. Nurses should limit
cumulative direct contact with the patient to a maximum of 30 minutes per 8-hour
shift. Pregnant healthcare workers and children should be strictly prohibited from
entering the patient’s room. Lead-lined rooms and lead aprons provide necessary
shielding against ionizing radiation. All linens and waste must be kept in the room
until they are cleared by a radiation safety officer.
4. A patient with leukemia is developing Tumor Lysis Syndrome (TLS). Which
laboratory finding should the nurse expect?
A. Hypouricemia
B. Hyperkalemia
C. Hypercalcemia
D. Hypophosphatemia
Correct Answer: B
, Expert Explanation: Tumor Lysis Syndrome is an oncologic emergency caused by
the rapid destruction of large numbers of tumor cells. This cellular breakdown
releases intracellular contents into the bloodstream, leading to metabolic
imbalances. Specifically, the nurse should anticipate hyperkalemia, hyperuricemia,
and hyperphosphatemia. High potassium levels are dangerous because they can
lead to lethal cardiac arrhythmias. Management involves aggressive hydration and
the administration of medications like allopurinol to lower uric acid levels.
5. The nurse is providing education to a patient receiving external beam radiation.
Which statement by the patient indicates a need for further teaching?
A. I will apply an over-the-counter lotion to the marks to prevent dryness.
B. I will wash the area gently with mild soap and water.
C. I will wear loose-fitting cotton clothing over the area.
D. I will protect the treatment area from direct sunlight exposure.
Correct Answer: A
Expert Explanation: Patients receiving radiation should not apply any lotions,
powders, or ointments to the treatment area without medical approval. Many over-
the-counter products contain metals or chemicals that can irritate the skin or
interfere with radiation delivery. The skin marks placed by the radiologist should
never be washed off or modified by the patient. Mild soap and water are acceptable
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A patient undergoing chemotherapy has an absolute neutrophil count (ANC) of
450/mm3. Which nursing intervention is the highest priority for this patient?
A. Implement strict hand hygiene and limit visitors.
B. Check the patient’s blood pressure every 4 hours.
C. Administer a stool softener to prevent constipation.
D. Encourage the patient to eat fresh fruits and vegetables.
Correct Answer: A
Expert Explanation: Neutropenia is defined as an ANC less than 1,000/mm3,
significantly increasing the risk of life-threatening infections. Implementing strict
hand hygiene is the most effective way to prevent the transmission of pathogens.
The nurse must also limit visitors and exclude anyone with active infections from
the room. Fresh fruits and vegetables are often restricted in a neutropenic diet due
to potential bacterial contamination. These precautions are essential during the
nadir when the patient’s immune system is most vulnerable.
,2. Which clinical manifestation is an early indicator of Superior Vena Cava Syndrome
(SVCS) in a patient with lung cancer?
A. Lower extremity edema
B. Facial edema in the morning
C. Numbness in the fingers
D. Severe hypotension
Correct Answer: B
Expert Explanation: Superior Vena Cava Syndrome occurs when a tumor
compresses the superior vena cava, obstructing venous return from the upper body.
Early signs include periorbital and facial edema, particularly noticed when the
patient wakes up. As the condition progresses, the patient may experience tightness
of the shirt collar and distended neck veins. This is considered an oncologic
emergency that requires immediate medical intervention like radiation or
chemotherapy. Proper assessment and documentation of these symptoms can lead
to faster stabilization and treatment.
3. A nurse is caring for a patient with internal radiation (brachytherapy). Which action
should the nurse take to ensure safety?
A. Discard soiled linens in the general hospital waste container.
B. Allow pregnant staff to care for the patient if they wear a lead apron.
,C. Keep the patient’s room door open for better visualization.
D. Limit time spent in the room to 30 minutes per shift.
Correct Answer: D
Expert Explanation: Safety protocols for brachytherapy focus on the principles of
time, distance, and shielding to minimize radiation exposure. Nurses should limit
cumulative direct contact with the patient to a maximum of 30 minutes per 8-hour
shift. Pregnant healthcare workers and children should be strictly prohibited from
entering the patient’s room. Lead-lined rooms and lead aprons provide necessary
shielding against ionizing radiation. All linens and waste must be kept in the room
until they are cleared by a radiation safety officer.
4. A patient with leukemia is developing Tumor Lysis Syndrome (TLS). Which
laboratory finding should the nurse expect?
A. Hypouricemia
B. Hyperkalemia
C. Hypercalcemia
D. Hypophosphatemia
Correct Answer: B
, Expert Explanation: Tumor Lysis Syndrome is an oncologic emergency caused by
the rapid destruction of large numbers of tumor cells. This cellular breakdown
releases intracellular contents into the bloodstream, leading to metabolic
imbalances. Specifically, the nurse should anticipate hyperkalemia, hyperuricemia,
and hyperphosphatemia. High potassium levels are dangerous because they can
lead to lethal cardiac arrhythmias. Management involves aggressive hydration and
the administration of medications like allopurinol to lower uric acid levels.
5. The nurse is providing education to a patient receiving external beam radiation.
Which statement by the patient indicates a need for further teaching?
A. I will apply an over-the-counter lotion to the marks to prevent dryness.
B. I will wash the area gently with mild soap and water.
C. I will wear loose-fitting cotton clothing over the area.
D. I will protect the treatment area from direct sunlight exposure.
Correct Answer: A
Expert Explanation: Patients receiving radiation should not apply any lotions,
powders, or ointments to the treatment area without medical approval. Many over-
the-counter products contain metals or chemicals that can irritate the skin or
interfere with radiation delivery. The skin marks placed by the radiologist should
never be washed off or modified by the patient. Mild soap and water are acceptable
