NURS 209 Exam HESI Questions and Correct
Answers with Detailed Explanations (IGGY
BOOK) | Verified Answers | Just Released
A client who is undergoing chemotherapy for breast cancer reports problems with
concentration and memory. Which nursing intervention is indicated at this time?
A. Explain that this occurs in some clients and is usually permanent.
B. Inform the client that a small glass of wine may help her relax.
C. Protect the client from infection.
D. Allow the client an opportunity to express her feelings. ---------CORRECT
ANSWER-----------------D. Allow the client an opportunity to express her feelings.
Although no specific intervention for this side effect is known, therapeutic
communication and listening may be helpful to the client. Evidence regarding
problems with concentration and memory loss with chemotherapy is not
complete, but the current thinking is that this process is usually temporary. The
client should be advised to avoid the use of alcohol and recreational drugs at
this time because they also impair memory. Chemotherapeutic agents are
implicated in central nervous system function in this scenario, not infection.
Which client problem does the nurse set as the priority for the client experiencing
chemotherapy-induced peripheral neuropathy?
A. Potential for lack of understanding related to side effects of chemotherapy
B. Potential for injury related to sensory and motor deficits
C. Potential for ineffective coping strategies related to loss of motor control
,D. Altered sexual function related to erectile dysfunction ---------CORRECT
ANSWER-----------------B. Potential for injury related to sensory and motor deficits
The highest priority is safety. Although knowing the side effects of
chemotherapy may be helpful, the priority is the client's safety because of the
lack of sensation or innervation to the extremities. The nurse should address
the client's coping only after providing for safety. Erectile dysfunction may be a
manifestation of peripheral neuropathy, but the priority is still the client's
safety.
The oncology nurse should use which intervention to prevent disseminated
intravascular coagulation (DIC)?
A. Monitoring platelets
B. Administering packed red blood cells
C. Using strict aseptic technique to prevent infection
D. Administering low-dose heparin therapy for clients on bedrest ---------CORRECT
ANSWER-----------------C. Using strict aseptic technique to prevent infection
Sepsis is a major cause of DIC, especially in the oncology client. Monitoring
platelets will help detect DIC, but will not prevent it. Red blood cells are used
for anemia, not for bleeding/coagulation disorders. Heparin may be
administered to clients with DIC who have developed clotting, but this has not
been proven to prevent the disorder.
The nurse is caring for a client receiving chemotherapy who reports anorexia.
Which measure does the nurse use to best monitor for cachexia?
,A. Monitor weight
B. Trend red blood cells and hemoglobin and hematocrit
C. Monitor platelets
D. Observe for motor deficits ---------CORRECT ANSWER-----------------A. Monitor
weight
Cachexia results in extreme body wasting and malnutrition; severe weight loss
is expected. Anemia and bleeding tendencies result from bone marrow
suppression secondary to invasion of bone marrow by a cancer or a side effect
of chemotherapy. Motor deficits result from spinal cord compression.
Which finding alarms the nurse when caring for a client receiving chemotherapy
who has a platelet count of 17,000/mm3?
A. Increasing shortness of breath
B. Diminished bilateral breath sounds
C. Change in mental status
D. Weight gain of 4 pounds in 1 day ---------CORRECT ANSWER-----------------C.
Change in mental status
A change in mental status could result from spontaneous bleeding; in this case,
a cerebral hemorrhage may have developed. Increasing shortness of breath is
typically related to anemia, not to thrombocytopenia. Diminished breath
sounds may be related to many factors, including poor respiratory excursion,
infection, and atelectasis, which is not related to thrombocytopenia. A large
weight gain in a short period may be related to kidney or heart failure; bleeding
is the major complication of thrombocytopenia.
, Which instruction is most appropriate for the nurse to convey to the client with
chemotherapy-induced neuropathy?
A. Bathe in cold water.
B. Wear cotton gloves when cooking.
C. Consume a diet high in fiber.
D. Make sure shoes are snug. ---------CORRECT ANSWER-----------------C. Consume a
diet high in fiber.
A high-fiber diet will assist with constipation due to neuropathy. The client
should bathe in warm water, not hotter than 96° F. Cotton gloves may prevent
harm from scratching; protective gloves should be worn for washing dishes and
gardening. Wearing cotton gloves while cooking can increase the risk for burns.
Shoes should allow sufficient length and width to prevent blisters. Shoes that
are snug can increase the risk for blisters in a client with peripheral neuropathy.
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. A 30-year-old with acute lymphocytic leukemia who will receive combination
chemotherapy today
B. A 40-year-old with chemotherapy-induced nausea and vomiting who has had
no urine output for 16 hours
C. A 45-year-old with pancytopenia who will require IV administration of
erythropoietin (Procrit)
D. A 72-year-old with tumor lysis syndrome who is receiving normal saline IV at a
rate of 250 mL/hr ---------CORRECT ANSWER-----------------C. A 45-year-old with
pancytopenia who will require IV administration of erythropoietin (Procrit)
Answers with Detailed Explanations (IGGY
BOOK) | Verified Answers | Just Released
A client who is undergoing chemotherapy for breast cancer reports problems with
concentration and memory. Which nursing intervention is indicated at this time?
A. Explain that this occurs in some clients and is usually permanent.
B. Inform the client that a small glass of wine may help her relax.
C. Protect the client from infection.
D. Allow the client an opportunity to express her feelings. ---------CORRECT
ANSWER-----------------D. Allow the client an opportunity to express her feelings.
Although no specific intervention for this side effect is known, therapeutic
communication and listening may be helpful to the client. Evidence regarding
problems with concentration and memory loss with chemotherapy is not
complete, but the current thinking is that this process is usually temporary. The
client should be advised to avoid the use of alcohol and recreational drugs at
this time because they also impair memory. Chemotherapeutic agents are
implicated in central nervous system function in this scenario, not infection.
Which client problem does the nurse set as the priority for the client experiencing
chemotherapy-induced peripheral neuropathy?
A. Potential for lack of understanding related to side effects of chemotherapy
B. Potential for injury related to sensory and motor deficits
C. Potential for ineffective coping strategies related to loss of motor control
,D. Altered sexual function related to erectile dysfunction ---------CORRECT
ANSWER-----------------B. Potential for injury related to sensory and motor deficits
The highest priority is safety. Although knowing the side effects of
chemotherapy may be helpful, the priority is the client's safety because of the
lack of sensation or innervation to the extremities. The nurse should address
the client's coping only after providing for safety. Erectile dysfunction may be a
manifestation of peripheral neuropathy, but the priority is still the client's
safety.
The oncology nurse should use which intervention to prevent disseminated
intravascular coagulation (DIC)?
A. Monitoring platelets
B. Administering packed red blood cells
C. Using strict aseptic technique to prevent infection
D. Administering low-dose heparin therapy for clients on bedrest ---------CORRECT
ANSWER-----------------C. Using strict aseptic technique to prevent infection
Sepsis is a major cause of DIC, especially in the oncology client. Monitoring
platelets will help detect DIC, but will not prevent it. Red blood cells are used
for anemia, not for bleeding/coagulation disorders. Heparin may be
administered to clients with DIC who have developed clotting, but this has not
been proven to prevent the disorder.
The nurse is caring for a client receiving chemotherapy who reports anorexia.
Which measure does the nurse use to best monitor for cachexia?
,A. Monitor weight
B. Trend red blood cells and hemoglobin and hematocrit
C. Monitor platelets
D. Observe for motor deficits ---------CORRECT ANSWER-----------------A. Monitor
weight
Cachexia results in extreme body wasting and malnutrition; severe weight loss
is expected. Anemia and bleeding tendencies result from bone marrow
suppression secondary to invasion of bone marrow by a cancer or a side effect
of chemotherapy. Motor deficits result from spinal cord compression.
Which finding alarms the nurse when caring for a client receiving chemotherapy
who has a platelet count of 17,000/mm3?
A. Increasing shortness of breath
B. Diminished bilateral breath sounds
C. Change in mental status
D. Weight gain of 4 pounds in 1 day ---------CORRECT ANSWER-----------------C.
Change in mental status
A change in mental status could result from spontaneous bleeding; in this case,
a cerebral hemorrhage may have developed. Increasing shortness of breath is
typically related to anemia, not to thrombocytopenia. Diminished breath
sounds may be related to many factors, including poor respiratory excursion,
infection, and atelectasis, which is not related to thrombocytopenia. A large
weight gain in a short period may be related to kidney or heart failure; bleeding
is the major complication of thrombocytopenia.
, Which instruction is most appropriate for the nurse to convey to the client with
chemotherapy-induced neuropathy?
A. Bathe in cold water.
B. Wear cotton gloves when cooking.
C. Consume a diet high in fiber.
D. Make sure shoes are snug. ---------CORRECT ANSWER-----------------C. Consume a
diet high in fiber.
A high-fiber diet will assist with constipation due to neuropathy. The client
should bathe in warm water, not hotter than 96° F. Cotton gloves may prevent
harm from scratching; protective gloves should be worn for washing dishes and
gardening. Wearing cotton gloves while cooking can increase the risk for burns.
Shoes should allow sufficient length and width to prevent blisters. Shoes that
are snug can increase the risk for blisters in a client with peripheral neuropathy.
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. A 30-year-old with acute lymphocytic leukemia who will receive combination
chemotherapy today
B. A 40-year-old with chemotherapy-induced nausea and vomiting who has had
no urine output for 16 hours
C. A 45-year-old with pancytopenia who will require IV administration of
erythropoietin (Procrit)
D. A 72-year-old with tumor lysis syndrome who is receiving normal saline IV at a
rate of 250 mL/hr ---------CORRECT ANSWER-----------------C. A 45-year-old with
pancytopenia who will require IV administration of erythropoietin (Procrit)
