Lewis’s Medical Surgical Nursing 11th Edition Harding Test Bank

NU RS IN GT B.CO M Chapter 15: Cancer Harding: Lewis’s Medical-Surgical Nursing, 11th Edition MULTIPLE CHOICE 1. A patient who is scheduled for a breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is accurate? a. “Benign tumors do not cause damage to other tissues.” b. “Benign tumors are likely to recur in the same location.” c. “Malignant tumors may spread to other tissues or organs.” d. “Malignant cells reproduce more rapidly than normal cells.” ANS: C The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors do not metastasize. The other statements are inaccurate. Both types of tumors may cause damage to adjacent tissues. Malignant cells do not reproduce more rapidly than normal cells. Benign tumors do not usually recur. DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse is caring for a patient receiving intravesical bladder chemotherapy. The nurse should monitor for which adverse effect? a. Nausea b. Alopecia c. Hematuria d. Xerostomia ANS: C The adverse effects of intravesical chemotherapy are confined to the bladder. The other adverse effects are associated with systemic chemotherapy. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 3. The nurse is caring for a patient who smokes 2 packs/day. Which action by the nurse could help reduce the patient’s risk of lung cancer? a. Teach the patient about the seven warning signs of cancer. b. Plan to monitor the patient’s carcinoembryonic antigen (CEA) level. c. Teach the patient about annual chest x-rays for lung cancer screening. d. Discuss risks associated with cigarettes during each patient encounter. ANS: D Teaching about the risks associated with cigarette smoking is recommended at every patient encounter because cigarette smoking is associated with multiple health problems. The other options may detect lung cancer that is already present but do not reduce the risk. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M 4. The nurse should suggest which food choice for a patient scheduled to receive external-beam radiation for abdominal cancer? a. Fruit salad b. Baked chicken c. Creamed broccoli d. Toasted wheat bread ANS: B Protein is needed for wound healing. To minimize the diarrhea that is associated with bowel radiation, the patient should avoid foods high in roughage, such as fruits and whole grains. Lactose intolerance may develop secondary to radiation, so dairy products should also be avoided. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 5. During a routine health examination, a 40-yr-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next? a. Schedule a sigmoidoscopy to provide baseline data. b. Obtain more information about the patient’s relatives. c. Teach the patient about the need for a colonoscopy at age 50. d. Teach the patient how to do home testing for fecal occult blood. ANS: B The patient may be at increased risk for colon cancer, but the nurse’s first action should be further assessment. The other actions may be appropriate, depending on the information that is obtained from the patient with further questioning. DIF: Cognitive Level: Analyze (analysis) TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. A patient who is diagnosed with cervical cancer classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is accurate? a. “The cancer involves only the cervix.” b. “The cancer cells look like normal cells.” c. “Further testing is needed to determine the spread of the cancer.” d. “It is difficult to determine the original site of the cervical cancer.” ANS: A Cancer in situ indicates that the cancer is localized to the cervix and is not invasive at this time. Cell differentiation is not indicated by clinical staging. Because the cancer is in situ, the origin is the cervix. Further testing is not indicated given that the cancer has not spread. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 7. The nurse teaches a patient who is scheduled for a prostate needle biopsy about the procedure. Which statement by the patient indicates that teaching was effective? a. “The biopsy will remove the cancer in my prostate gland.” b. “The biopsy will determine how much longer I have to live.” c. “The biopsy will help decide the treatment for my enlarged prostate.” d. “The biopsy will indicate whether the cancer has spread to other organs.” NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M ANS: C A biopsy is used to determine whether the prostate enlargement is benign or malignant and determines the type of treatment that will be needed. A biopsy does not give information about metastasis, life expectancy, or the impact of cancer on the patient’s life. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 8. The nurse teaches a postmenopausal patient with stage III breast cancer about the expected outcomes of cancer treatment. Which patient statement indicates that the teaching has been effective? a. “After cancer has not recurred for 5 years, it is considered cured.” b. “The cancer will be cured if the entire tumor is surgically removed.” c. “I will need follow-up examinations for many years after treatment before I can be considered cured.” d. “Cancer is never cured, but the tumor can be controlled with surgery, chemotherapy, and radiation.” ANS: C The risk of recurrence varies by the type of cancer. Some cancers are considered cured after a shorter time span or after surgery, but stage III breast cancer will require additional therapies and ongoing follow-up. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 9. A patient with a large stomach tumor attached to the liver is scheduled for a debulking procedure. What should the nurse teach the patient about the outcome of this procedure? a. Pain will be relieved by cutting sensory nerves in the stomach. b. Decreasing the tumor size will improve the effects of other therapy. c. Relieving the pressure in the stomach will promote optimal nutrition. d. Tumor growth will be controlled by removing all the cancerous tissue. ANS: B A debulking surgery reduces the size of the tumor and makes radiation and chemotherapy more effective. Debulking surgeries do not control tumor growth. The tumor is debulked because it is attached to the liver, a vital organ (not to relieve pressure on the stomach). Debulking does not sever the sensory nerves, although pain may be lessened by the reduction in pressure on the abdominal organs. DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 10. External-beam radiation is planned for a patient with cervical cancer. What instructions should the nurse give to the patient to prevent complications from the effects of the radiation? a. Test all stools for the presence of blood. b. Maintain a high-residue, high-fiber diet. c. Clean the perianal area carefully after every bowel movement. d. Inspect the mouth and throat daily for the appearance of thrush. ANS: C NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M Radiation to the abdomen will affect organs in the radiation path, such as the bowel, and cause frequent diarrhea. Careful cleaning of this area will help decrease the risk for skin breakdown and infection. Stools are likely to have occult blood from the inflammation associated with radiation, so routine testing of stools for blood is not indicated. Radiation to the abdomen will not cause stomatitis. A low-residue diet is recommended to avoid irritation of the bowel when patients receive abdominal radiation. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 11. A patient with Hodgkin’s lymphoma who is undergoing external radiation therapy tells the nurse, “I am so tired I can hardly get out of bed in the morning.” Which intervention should the nurse add to the plan of care? a. Minimize activity until the treatment is completed. b. Establish time to take a short walk almost every day. c. Consult with a psychiatrist for treatment of depression. d. Arrange for delivery of a hospital bed to the patient’s home. ANS: B Walking programs are used to keep the patient active without excessive fatigue. Having a hospital bed does not necessarily address the fatigue. The better option is to stay as active as possible while combating fatigue. Fatigue is expected during treatment and is not an indication of depression. Minimizing activity may lead to weakness and other complications of immobility. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 12. The nurse is caring for a patient with colon cancer who is scheduled for external radiation therapy to the abdomen. Which information obtained by the nurse would indicate a need for patient teaching? a. The patient has a history of dental caries. b. The patient swims several days each week. c. The patient snacks frequently during the day. d. The patient showers each day with mild soap. ANS: B The patient is instructed to avoid swimming in salt water or chlorinated pools during the treatment period. The patient does not need to change habits of eating frequently or showering with a mild soap. A history of dental caries will not impact the patient who is scheduled for abdominal radiation. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 13. A patient undergoing external radiation has developed a dry desquamation of the skin in the treatment area. The nurse teaches the patient about the management of the skin reaction. Which statement, if made by the patient, indicates the teaching was effective? a. “I can use ice packs to relieve itching.” b. “I will scrub the area with warm water.” c. “I will expose my skin to a sun lamp each day.” NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M d. “I can buy some aloe vera gel to use on my skin.” ANS: D Aloe vera gel and cream may be used on the radiated skin area. Ice and sunlamps may injure the skin. Treatment areas should be cleaned gently to avoid further injury. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 14. A patient with metastatic colon cancer has severe vomiting after each administration of chemotherapy. Which action by the nurse is appropriate? a. Have the patient eat large meals when nausea is not present. b. Offer dry crackers and carbonated fluids during chemotherapy. c. Administer prescribed antiemetics 1 hour before the treatments. d. Give the patient a glass of a citrus fruit beverage during treatments. ANS: C Treatment with antiemetics before chemotherapy may help prevent nausea. The patient should eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea. The acidity of citrus fruits may be further irritating to the stomach. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse administers an IV vesicant chemotherapeutic agent to a patient. Which action is most important for the nurse to take? a. Infuse the medication over a short period of time. b. Stop the infusion if swelling is observed at the site. c. Administer the chemotherapy through a small-bore catheter. d. Hold the medication unless a central venous line is available. ANS: B Swelling at the site may indicate extravasation, and the IV should be stopped immediately. The medication generally should be given slowly to avoid irritation of the vein. The size of the catheter is not as important as administration of vesicants into a running IV line to allow dilution of the chemotherapy drug. These medications can be given through peripheral lines, although central vascular access devices are preferred. DIF: Cognitive Level: Analyze (analysis) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 16. A chemotherapy drug that causes alopecia is prescribed for a patient. Which action should the nurse take to support the patient’s self-esteem? a. Suggest that the patient limit social contacts until hair regrowth occurs. b. Encourage the patient to purchase a wig or hat to wear when hair loss begins. c. Teach the patient to wash hair gently with mild shampoo to minimize hair loss. d. Inform the patient that hair usually grows back once chemotherapy is complete. ANS: B NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M The patient is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats. Limiting social contacts is not appropriate at a time when the patient is likely to need a good social support system. The damage occurs at the hair follicles and will occur regardless of gentle washing or use of a mild shampoo. The information that the hair will grow back is not immediately helpful in maintaining the patient’s self-esteem. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity 17. A patient who has ovarian cancer is crying and tells the nurse, “My husband rarely visits. He just doesn’t care.” The husband tells the nurse that he does not know what to say to his wife. Which problem is appropriate for the nurse to address in the plan of care? a. Anxiety b. Death anxiety c. Difficulty coping d. Lack of knowledge ANS: C The data indicate that difficulty coping with the situation may be present reflected by the poor communication among the family members. The data given does not suggest death anxiety, anxiety, or lack of knowledge as an etiology. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Analysis MSC: NCLEX: Psychosocial Integrity 18. A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient? a. Remove food debris from the teeth and oral mucosa with a stiff toothbrush. b. Use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth. c. Gargle and rinse the mouth several times a day with an antiseptic mouthwash. d. Rinse the mouth before and after each meal and at bedtime with a saline solution. ANS: D The patient should rinse the mouth with a saline solution frequently. A soft toothbrush is used for oral care. Hydrogen peroxide may damage tissues. Antiseptic mouthwashes may irritate the oral mucosa and are not recommended. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 19. A patient has inadequate nutrition due to painful oral ulcers. Which nursing action will be most effective in improving oral intake? a. Offer the patient frequent small snacks between meals. b. Assist the patient to choose favorite foods from the menu. c. Apply prescribed anesthetic gel to oral lesions before meals. d. Teach the patient about the importance of nutritional intake. ANS: C NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M Because the cause of the patient’s poor nutrition is the painful oral ulcers, the best intervention is to apply anesthetic gel to the lesions before the patient eats. The other actions might be helpful for other patients with impaired nutrition but would not be as helpful for this patient. DIF: Cognitive Level: Analyze (analysis) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 20. A widowed mother of 4 school-age children is hospitalized with metastatic ovarian cancer. The patient is crying and tells the nurse that she does not know what will happen to her children when she dies. Which response by the nurse is most appropriate? a. “Don’t you have any friends that will raise the children for you?” b. “Would you like to talk about options for the care of your children?” c. “For now you need to concentrate on getting well and not worrying about your children.” d. “Many patients with cancer live for a long time, so there is time to plan for your children.” ANS: B This response expresses the nurse’s willingness to listen and recognizes the patient’s concern. The responses beginning “Many patients with cancer live for a long time” and “For now you need to concentrate on getting well” close off discussion of the topic and indicate that the nurse is uncomfortable with the topic. In addition, the patient with metastatic ovarian cancer may not have a long time to plan. Although it is possible that the patient’s friends will raise the children, more assessment information is needed before making plans. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 21. A patient who has severe pain with terminal pancreatic cancer is being cared for at home by family members. Which finding by the nurse indicates that teaching about pain management has been effective? a. The patient uses the ordered opioid pain medication whenever the pain is greater than 5 (0 to 10 scale). b. The patient agrees to take the medications by the IV route to improve analgesic effectiveness. c. The patient takes opioids around the clock on a regular schedule and uses additional doses when breakthrough pain occurs. d. The patient states that nonopioid analgesics may be used if the maximal dose of the opioid is reached without adequate pain relief. ANS: C For chronic cancer pain, analgesics should be taken on a scheduled basis, with additional doses as needed for breakthrough pain. Taking the medications only when pain reaches a certain level does not provide effective pain control. Although nonopioid analgesics may also be used, there is no maximum dose of opioid. Opioids are given until pain control is achieved. The IV route is not more effective than the oral route, and usually the oral route is preferred. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M 22. Interleukin-2 (IL-2) is used as adjuvant therapy for a patient with metastatic renal cell carcinoma. Which information should the nurse include when explaining the purpose of this therapy to the patient? a. IL-2 enhances the body’s immunologic response to tumor cells. b. IL-2 prevents bone marrow depression caused by chemotherapy. c. IL-2 protects normal cells from harmful effects of chemotherapy. d. IL-2 stimulates cancer cells in their resting phase to enter mitosis. ANS: A IL-2 enhances the ability of the patient’s own immune response to suppress tumor cells. IL-2 does not protect normal cells from damage caused by chemotherapy, stimulate cancer cells to enter mitosis, or prevent bone marrow depression. DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 23. The home health nurse is caring for a patient who has been receiving interferon therapy for treatment of cancer. Which statement by the patient indicates a need for further assessment? a. “I have frequent muscle aches and pains.” b. “I rarely have the energy to get out of bed.” c. “I experience chills after I inject the interferon.” d. “I take acetaminophen (Tylenol) every 4 hours.” ANS: B Fatigue can be a dose-limiting toxicity for use of immunotherapy. Flu-like symptoms, such as muscle aches and chills, are common side effects with interferon use. Patients are advised to use acetaminophen every 4 hours. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 24. A patient with leukemia is considering whether to have hematopoietic stem cell transplantation (HSCT). Which information should the nurse include in the patient’s teaching plan? a. Donor bone marrow is transplanted through a sternal or hip incision. b. Hospitalization is required for several weeks after the stem cell transplant. c. The transplant procedure takes place in a sterile operating room to decrease the risk for infection. d. Transplant of the donated cells can be very painful because of the nerves in the tissue lining the bone. ANS: B The patient requires strict protective isolation to prevent infection for 2 to 4 weeks after HSCT while waiting for the transplanted marrow to start producing cells. The transplanted cells are infused through an IV line so the transplant is not painful, nor is an operating room or incision required. DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 25. The nurse teaches a patient with liver cancer about high-protein, high-calorie diet choices. Which snack choice by the patient indicates that the teaching has been effective? NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M a. Lime sherbet b. Blueberry yogurt c. Fresh strawberries d. Cream cheese bagel ANS: B Yogurt has high biologic value because of the protein and fat content. Fruit salad does not have high amounts of protein or fat. Lime sherbet is lower in fat and protein than yogurt. Cream cheese is low in protein. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 26. A patient with cancer is eating very little due to altered taste sensation. Which nursing action would address the cause of the patient problem? a. Add protein powder to foods such as casseroles. b. Tell the patient to eat foods that are high in nutrition. c. Avoid giving the patient foods that are strongly disliked. d. Add spices to enhance the flavor of foods that are served. ANS: C The patient will eat more if disliked foods are avoided and foods that the patient likes are included instead. Additional spice is not usually an effective way to enhance taste. Adding protein powder does not address the issue of taste. The patient’s poor intake is not caused by a lack of information about nutrition. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 27. During the teaching session for a patient who has a new diagnosis of acute leukemia, the patient is restless and looks away without making eye contact. The patient asks the nurse to repeat the information about the complications associated with chemotherapy. Based on this assessment, which patient problem should the nurse identify? a. Denial b. Anxiety c. Acute confusion d. Ineffective adherence to treatment ANS: B The patient who has a new cancer diagnosis is likely to have high anxiety, which may affect learning and require that the nurse repeat and reinforce information about health maintenance. There is no evidence to support confusion. The patient asks for the information to be repeated, indicating that denial is not present. The patient has recently been diagnosed, so adherence has not yet been required. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Analysis MSC: NCLEX: Psychosocial Integrity 28. A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse indicates a need for further teaching? a. The patient ambulates around the room. b. The patient’s visitors bring in fresh peaches. NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M c. The patient cleans with a warm washcloth after having a stool. d. The patient uses soap and shampoo to shower every other day. ANS: B Fresh, thinned-skin fruits are not permitted in a neutropenic diet because of the risk of bacteria being present. The patient should ambulate in the room rather than the hospital hallway to avoid exposure to other patients or visitors. Because overuse of soap can dry the skin and increase infection risk, showering every other day is acceptable. Careful cleaning after having a bowel movement will help prevent skin breakdown and infection. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 29. The nurse is caring for a patient diagnosed with stage I colon cancer. When assessing the need for psychologic support, which question by the nurse will provide the most information? a. “How long ago were you diagnosed with this cancer?” b. “Do you have any concerns about body image changes?” c. “Can you tell me what has been helpful when coping with past stressful events?” d. “Are you familiar with the stages of emotional adjustment to cancer of the colon?” ANS: C Information about how the patient has coped with past stressful situations helps the nurse determine usual coping mechanisms and their effectiveness. The length of time since the diagnosis will not provide much information about the patient’s need for support. The patient’s knowledge of typical stages in adjustment to a critical diagnosis does not provide insight into patient needs for assistance. Because surgical interventions for stage I cancer of the colon may not cause any body image changes, this question is not appropriate at this time. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity 30. The nurse assesses a patient who is receiving interleukin-2. Which finding should the nurse report immediately to the health care provider? a. Generalized muscle aches b. Crackles at the lung bases c. Reports of nausea and anorexia d. Oral temperature of 100.6° F (38.1° C) ANS: B Capillary leak syndrome and acute pulmonary edema are possible toxic effects of interleukin-2. The patient may need oxygen and the nurse should rapidly notify the health care provider. The other findings are common side effects of interleukin-2. DIF: Cognitive Level: Analyze (analysis) TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 31. The nurse obtains information about a hospitalized patient who is receiving chemotherapy for colorectal cancer. Which information about the patient alerts the nurse to discuss a possible change in cancer therapy with the health care provider? a. Frequent loose stools b. Nausea and vomiting c. Elevated white blood count (WBC) NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M d. Increased carcinoembryonic antigen (CEA) ANS: D An increase in CEA indicates that the chemotherapy is not effective for the patient’s cancer and may need to be modified. Gastrointestinal adverse effects are common with chemotherapy. The nurse may need to address these, but they would not necessarily indicate a need for a change in therapy. An elevated WBC may indicate infection but does not reflect the effectiveness of the colorectal cancer therapy. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 32. The nurse reviews the laboratory results of a patient who is receiving chemotherapy. Which laboratory result is most important to report to the health care provider? a. Hematocrit 30% b. Platelets 95,000/µL c. Hemoglobin 10 g/L d. White blood cells (WBC) 2700/µL ANS: D The low WBC count places the patient at risk for severe infection and is an indication that the chemotherapy dose may need to be lower or that WBC growth factors such as filgrastim (Neupogen) are needed. Although the other laboratory data indicate decreased levels, they do not indicate any immediate life-threatening adverse effects of the chemotherapy. DIF: Cognitive Level: Analyze (analysis) OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 33. When caring for a patient who is pancytopenic, which action by unlicensed assistive personnel (UAP) indicates a need for the nurse to intervene? a. The UAP assists the patient to use dental floss after eating. b. The UAP adds baking soda to the patient’s saline oral rinses. c. The UAP puts fluoride toothpaste on the patient’s toothbrush. d. The UAP has the patient rinse after meals with a saline solution. ANS: A Use of dental floss is avoided in patients with pancytopenia because of the risk for infection and bleeding. The other actions are appropriate for oral care of a pancytopenic patient. DIF: Cognitive Level: Apply (application) OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 34. The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention? a. The UAP flushes the toilet once after emptying the patient’s bedpan. b. The UAP stands by the patient’s bed for 30 minutes talking with the patient. c. The UAP places the patient’s bedding in the laundry container in the hallway. d. The UAP gives the patient an alcohol-containing mouthwash to use for oral care. NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M ANS: B Because patients with temporary implants emit radioactivity while the implants are in place, exposure to the patient is limited. Laundry and urine and feces do not have any radioactivity and do not require special precautions. Cervical radiation will not affect the oral mucosa, and alcohol-based mouthwash is not contraindicated. DIF: Cognitive Level: Apply (application) OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 35. The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first? a. A 35-yr-old patient who has wet desquamation associated with abdominal radiation b. A 42-yr-old patient who is sobbing after receiving a new diagnosis of ovarian cancer c. A 24-yr-old patient who received neck radiation and has blood oozing from the neck d. A 56-yr-old patient who developed a new pericardial friction rub after chest radiation ANS: C Because neck bleeding may indicate possible carotid artery rupture in a patient who is receiving radiation to the neck, this patient should be seen first. The diagnoses and clinical manifestations for the other patients are not immediately life threatening. DIF: Cognitive Level: Analyze (analysis) OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 36. Which action should the nurse take when caring for a patient who is receiving chemotherapy and reports problems with concentration? a. Suggest use of a daily planner and encourage adequate sleep. b. Teach the patient to rest the brain by avoiding new activities. c. Teach that “chemo-brain” is a short-term effect of chemotherapy. d. Report patient symptoms immediately to the health care provider. ANS: A Use of tools to enhance memory and concentration such as a daily planner and adequate rest are helpful for patients who develop “chemo-brain” while receiving chemotherapy. Patients should be encouraged to exercise the brain through new activities. Chemo-brain may be short or long term. There is no urgent need to report common chemotherapy side effects to the provider. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 37. The nurse assesses a patient with non-Hodgkin’s lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse? a. Shortness of breath NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M b. Shivering and chills c. Muscle aches and pains d. Temperature of 100.2° F (37.9° C) ANS: A Rituximab (Rituxan) is a monoclonal antibody. Shortness of breath should be investigated rapidly because anaphylaxis is a possible reaction to monoclonal antibody administration. The nurse will need to rapidly take actions such as stopping the infusion, assessing the patient further, and notifying the health care provider. The other findings will also require action by the nurse but are not indicative of life-threatening complications. DIF: Cognitive Level: Analyze (analysis) OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 38. A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first? a. Give the patient the prescribed PRN opioid. b. Assess for sensation and strength in the legs. c. Notify the health care provider about the symptoms. d. Teach the patient how to use relaxation to reduce pain. ANS: B Spinal cord compression, an oncologic emergency, can occur with invasion of tumor into the epidural space. The nurse will need to assess the patient further for symptoms such as decreased leg sensation and strength and then notify the health care provider. Administration of opioids or the use of relaxation may be appropriate but only after the nurse has assessed for possible spinal cord compression. DIF: Cognitive Level: Analyze (analysis) OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 39. The nurse is caring for a patient with left-sided lung cancer. Which finding would be most important for the nurse to report to the health care provider? a. Hematocrit of 32% b. Pain with deep inspiration c. Serum sodium of 126 mEq/L d. Decreased breath sounds on left side ANS: C The syndrome of inappropriate antidiuretic hormone (and the resulting hyponatremia) is an oncologic metabolic emergency and requires rapid treatment to prevent complications such as seizures and coma. The other findings also require intervention but are common in patients with lung cancer and not immediately life threatening. DIF: Cognitive Level: Analyze (analysis) OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M 40. An older adult patient who has colorectal cancer is receiving IV fluids at 175 mL/hr in conjunction with the prescribed chemotherapy. Which finding by the nurse is most important to report to the health care provider? a. Patient reports having severe fatigue. b. Patient voids every hour during the day. c. Patient takes only 50% of meals and refuses snacks. d. Patient has crackles up to the midline posterior chest. ANS: D Rapid fluid infusions may cause heart failure, especially in older patients. The other findings are common in patients who have cancer or are receiving chemotherapy. DIF: Cognitive Level: Analyze (analysis) OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 41. After change-of-shift report on the oncology unit, which patient should the nurse assess first? a. Patient who has a platelet count of 82,000/µL after chemotherapy. b. Patient who has xerostomia after receiving head and neck radiation. c. Patient who is neutropenic and has a temperature of 100.5° F (38.1° C). d. Patient who is worried about getting the prescribed long-acting opioid on time. ANS: C Fever is an emergency in neutropenic patients because of the risk for rapid progression to severe infections and sepsis. The other patients also require assessments or interventions but do not need to be assessed as urgently. Patients with thrombocytopenia do not have spontaneous bleeding until the platelets are 20,000/µL. Xerostomia does not require immediate intervention. Although breakthrough pain needs to be addressed rapidly, the patient does not appear to have breakthrough pain. DIF: Cognitive Level: Analyze (analysis) OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. The nurse at the clinic is interviewing a 64-yr-old woman who is 5 feet, 3 inches tall and weighs 125 lb (57 kg). The patient has not seen a health care provider for 20 years. She walks 5 miles most days and has a glass of wine 2 or 3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk? (Select all that apply.) a. Pap testing b. Tobacco use c. Sunscreen use d. Mammography e. Colorectal screening ANS: A, C, D, E The patient’s age, gender, and history indicate a need for screening and teaching about colorectal cancer, mammography, Pap smears, and sunscreen. The patient does not use tobacco or excessive alcohol, she is physically active, and her body weight is healthy. NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M DIF: Cognitive Level: Analyze (analysis) TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 2. A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan? (Select all that apply.) a. Cook food thoroughly before eating. b. Choose low fiber, low residue foods. c. Avoid public transportation such as buses. d. Use rectal suppositories if needed for constipation. e. Talk to the oncologist before having any dental work. ANS: A, C, E Eating only cooked food and avoiding public transportation will decrease infection risk. A high-fiber diet is recommended for neutropenic patients to decrease constipation. Because bacteria may enter the circulation during dental work or oral surgery, the patient may need to postpone dental work or take antibiotics. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M Chapter 38: Assessment: Gastrointestinal System Harding: Lewis’s Medical-Surgical Nursing, 11th Edition MULTIPLE CHOICE 1. Which information about an 80-yr-old male patient at the senior center is of most concern to the nurse? a. Decreased appetite b. Occasional indigestion c. Unintended weight loss d. Difficulty chewing food ANS: C Unintentional weight loss is not a normal finding and may indicate a problem such as cancer or depression. Poor appetite, difficulty in chewing, and indigestion are common in older patients. These will need to be addressed but are not of as much concern as the weight loss. DIF: Cognitive Level: Analyze (analysis) OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. An older patient reports chronic constipation. To promote bowel evacuation, when should the nurse suggest that the patient attempt defecation? a. In the mid-afternoon b. After eating breakfast c. Right after awakening in the morning d. Immediately before the first daily meal ANS: B The gastrocolic reflex is most active after the first daily meal. Awakening, the anticipation of eating, and mid-afternoon timing do not stimulate these reflexes. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 3. What condition should the nurse anticipate when caring for a patient with a history of a total gastrectomy? a. Constipation b. Dehydration c. Elevated total serum cholesterol d. Cobalamin (vitamin B12) deficiency ANS: D The patient with a total gastrectomy does not secrete intrinsic factor, which is needed for cobalamin (vitamin B12) absorption. Because the stomach absorbs only small amounts of water and nutrients, the patient is not at higher risk for dehydration, elevated cholesterol, or constipation. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M 4. The nurse is caring for a patient with an obstructed common bile duct. What condition should the nurse expect? a. Melena b. Steatorrhea c. Decreased serum cholesterol level d. Increased serum indirect bilirubin level ANS: B A common bile duct obstruction will reduce the absorption of fat in the small intestine, leading to fatty stools. Gastrointestinal bleeding is not caused by common bile duct obstruction. Serum cholesterol levels are increased with biliary obstruction. Direct bilirubin level is increased with biliary obstruction. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 5. The nurse receives the following information about a patient who is scheduled for a colonoscopy. Which information should be communicated to the health care provider before sending the patient for the procedure? a. The patient declined to drink the prescribed laxative solution. b. The patient has had an allergic reaction to shellfish and iodine. c. The patient has a permanent pacemaker to prevent bradycardia. d. The patient is worried about discomfort during the examination. ANS: A If the patient has had inadequate bowel preparation, the colon cannot be visualized and the procedure would be rescheduled. Because contrast solution is not used during colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to magnetic resonance imaging but not to colonoscopy. The nurse should instruct the patient about the sedation used during the examination to decrease the patient’s anxiety about discomfort. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 6. Which statement to the nurse from a patient with jaundice indicates a need for teaching? a. “I used cough syrup several times a day last week.” b. “I take a baby aspirin every day to prevent strokes.” c. “I take an antacid for indigestion several times a week” d. “I use acetaminophen (Tylenol) every 4 hours for pain.” ANS: D Chronic use of high doses of acetaminophen can be hepatotoxic and may have caused the patient’s jaundice. The other patient statements require further assessment by the nurse but do not indicate a need for patient education. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 7. Which is the correct technique for the nurse to palpate the liver during a head-to-toe physical assessment? a. Place one hand on top of the other and use the upper fingers to apply pressure and the bottom fingers to feel for the liver edge. NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M b. Place one hand on the patient’s back and press upward and inward with the other hand below the patient’s right costal margin. c. Press slowly and firmly over the right costal margin with one hand and withdraw the fingers quickly after the liver edge is felt. d. Place one hand under the patient’s lower ribs and press the left lower rib cage forward, palpating below the costal margin with the other hand. ANS: B The liver is normally not palpable below the costal margin. The nurse needs to push inward below the right costal margin while lifting the patient’s back slightly with the left hand. The other methods will not allow palpation of the liver. DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 8. Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment? a. Loud gurgles b. High-pitched gurgles c. Absent bowel sounds d. Frequent clicking sounds ANS: C Absent bowel sounds are abnormal and require further assessment by the nurse. The other sounds may be heard normally. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 9. What action should the nurse take after assisting with a needle biopsy of the liver at a patient’s bedside? a. Elevate the head of the bed to facilitate breathing. b. Place the patient on the right side with the bed flat. c. Check the patient’s postbiopsy coagulation studies. d. Position a sandbag over the liver to provide pressure. ANS: B After a biopsy, the patient lies on the right side with the bed flat to splint the biopsy site. Coagulation studies are checked before the biopsy. A sandbag does not exert adequate pressure to splint the site. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 10. A patient is admitted to the outpatient testing area for an ultrasound of the gallbladder. Which information obtained by the nurse indicates that the ultrasound may need to be rescheduled? a. The patient took a laxative the previous evening. b. The patient had a high-fat meal the previous evening. c. The patient has a permanent gastrostomy tube in place. d. The patient ate a low-fat bagel 4 hours ago for breakfast. ANS: D NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M Food intake can cause the gallbladder to contract and result in a suboptimal study. The patient should be NPO for 8 to 12 hours before the test. A high-fat meal the previous evening, laxative use, or a gastrostomy tube will not affect the results of the study. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 11. The nurse is assessing an alert and independent older adult patient for malnutrition risk. Which is the most appropriate initial question? a. “How do you get to the store to buy your food?” b. “Can you tell me the food that you ate yesterday?” c. “Do you have any difficulty in preparing or eating food?” d. “Are you taking any medications that alter your taste for food?” ANS: B This question is the most open-ended and will provide the best overall information about the patient’s daily intake and risk for poor nutrition. The other questions may be asked, depending on the patient’s response to the first question. DIF: Cognitive Level: Analyze (analysis) TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 12. A patient has just arrived in the recovery area after an upper endoscopy. Which information collected by the nurse is most important to communicate to the health care provider? a. The patient is very drowsy. b. The patient reports a sore throat. c. The oral temperature is 101.4° F. d. The apical pulse is 100 beats/min. ANS: C A temperature elevation may indicate that an acute perforation has occurred. The other assessment data are normal immediately after the procedure. DIF: Cognitive Level: Analyze (analysis) OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 13. An adult with a body mass index (BMI) of 22 kg/m2 is being admitted to the hospital for elective knee surgery. Which assessment finding should the nurse report to the health care provider? a. Tympany on percussion of the abdomen b. Liver edge 3 cm below the costal margin c. Bowel sounds of 20/min in each quadrant d. Aortic pulsations visible in the epigastric area ANS: B Normally the lower border of the liver is not palpable below the ribs, so this finding suggests hepatomegaly. Visible aortic pulsations in the epigastrium, active bowel sounds, and abdominal tympany are within normal findings for an adult of normal weight. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M 14. A 58-yr-old patient has just returned to the nursing unit after an esophagogastroduodenoscopy (EGD). Which action by unlicensed assistive personnel (UAP) requires that the registered nurse (RN) intervene? a. Offering the patient a pitcher of water b. Positioning the patient on the right side c. Checking the vital signs every 30 minutes d. Swabbing the patient’s mouth with a wet cloth ANS: A Immediately after EGD, the patient will have a decreased gag reflex and is at risk for aspiration. Assessment for return of the gag reflex should be done by the RN. The other actions by the UAP are appropriate. DIF: Cognitive Level: Apply (application) OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 15. A patient is being scheduled for endoscopic retrograde cholangiopancreatography (ERCP) as soon as possible. Which prescribed action should the nurse take first? a. Place the patient on NPO status. b. Administer sedative medications. c. Ensure the consent form is signed. d. Teach the patient about the procedure. ANS: A The patient will need to be NPO for 8 hours before the ERCP is done, so the nurse’s initial action should be to place the patient on NPO status. The other actions can be done after the patient is NPO. DIF: Cognitive Level: Analyze (analysis) OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 16. While interviewing a young adult patient, the nurse learns that the patient has a family history of familial adenomatous polyposis (FAP). What area of patient knowledge should the nurse plan to assess? a. Preventing noninfectious hepatitis b. Treating inflammatory bowel disease c. Risk for developing colorectal cancer d. Using antacids and proton pump inhibitors ANS: C FAP is a genetic condition that greatly increases the risk for colorectal cancer. Noninfectious hepatitis, use of medications that treat increased gastric pH, and inflammatory bowel disease are not related to FAP. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 17. Which area of the abdomen shown in the accompanying figure will the nurse palpate to assess for splenomegaly? NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M a. 1 b. 2 c. 3 d. 4 ANS: B The spleen is usually not palpable, but when palpated, it is located in left upper quadrant of abdomen. DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M Chapter 39: Nutritional Problems Harding: Lewis’s Medical-Surgical Nursing, 11th Edition MULTIPLE CHOICE 1. Which finding for a young adult who follows a vegan diet may indicate the need for cobalamin supplementation? a. Paresthesias b. Ecchymoses c. Dry, scaly skin d. Gingival swelling ANS: A Cobalamin (vitamin B12) cannot be obtained from foods of plant origin, so the patient will be most at risk for signs of cobalamin deficiency, such as paresthesias, peripheral neuropathy, and anemia. The other symptoms listed are associated with other nutritional deficiencies but would not be associated with a vegan diet. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. A 76-yr-old woman with a body mass index (BMI) of 17 kg/m2 and a low serum albumin level is being admitted. Which assessment finding will the nurse expect? a. Restlessness b. Hypertension c. Pitting edema d. Food allergies ANS: C Edema occurs when serum albumin levels and plasma oncotic pressure decrease. The blood pressure and level of consciousness are not directly affected by malnutrition. Food allergies are not an indicator of nutritional status. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. Which menu choice best indicates that the patient is implementing the nurse’s suggestion to choose high-calorie, high-protein foods? a. Baked fish with applesauce b. Beef noodle soup and canned corn c. Fresh fruit salad with yogurt topping d. Fried chicken with potatoes and gravy ANS: D Foods that are high in calories include fried foods and those covered with sauces. High-protein foods include meat and dairy products. The other choices are lower in calories and protein. DIF: Cognitive Level: Analyze (analysis) TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M 4. A patient has a body mass index (BMI) of 31 kg/m2 , a normal C-reactive protein level, and low serum transferrin and albumin levels. What should the nurse encourage the patient to increase in the diet? a. Iron b. Protein c. Calories d. Carbohydrate ANS: B The patient’s C-reactive protein and transferrin levels indicate low protein stores. The BMI is in the obese range, so increasing caloric intake is not indicated. The data do not indicate a need for increased carbohydrate or iron intake. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 5. A patient who has just been started on enteral nutrition of full-strength formula at 100 mL/hr has 6 liquid stools the first day. Which action should the nurse plan to take? a. Slow the infusion rate of the feeding. b. Check gastric residual volumes more often. c. Change the enteral feeding system and formula every 8 hours. d. Discontinue administration of water through the feeding tube. ANS: A Loose stools indicate poor absorption of nutrients and indicate a need to slow the feeding rate or decrease the concentration of the feeding. Water should be given when patients receive enteral feedings to prevent dehydration. When a closed enteral feeding system is used, the tubing and formula are changed every 24 hours. High residual volumes do not contribute to diarrhea. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 6. A young adult with extensive facial injuries from a motor vehicle crash is receiving continuous enteral nutrition through a percutaneous endoscopic gastrostomy (PEG). Which action will the nurse include in the plan of care? a. Keep the patient positioned lying on the left side. b. Flush the tube with 30 mL of water every 4 hours. c. Crush and mix medications in with the feeding formula. d. Obtain a daily abdominal radiograph to verify tube placement. ANS: B The tube is flushed every 4 hours during continuous feedings to avoid tube obstruction. The patient should be positioned with the head of the bed elevated. Crushed medications mixed in with the formula are likely to clog the tube. An x-ray is obtained immediately after placement of the PEG tube to check position, but daily x-rays are not needed. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M 7. A malnourished patient is receiving a parenteral nutrition (PN) infusion containing amino acids and dextrose from a bag that was hung with a new tubing and filter 24 hours ago. The nurse observes that about 50 mL remain in the PN container. Which action should the nurse take? a. Add a new container of PN using the current tubing and filter. b. Hang a new container of PN and change the IV tubing and filter. c. Infuse the remaining 50 mL and then hang a new container of PN. d. Ask the health care provider to clarify the written PN prescription. ANS: B All PN solutions and tubings are changed at 24 hours. Infusion of the additional 50 mL will increase patient risk for infection. The nurse (not the health care provider) is responsible for knowing the indicated times for tubing and filter changes. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 8. A patient’s capillary blood glucose level is 120 mg/dL 6 hours after the nurse initiated a parenteral nutrition (PN) infusion. What is the appropriate action by the nurse? a. Obtain a venous blood glucose specimen. b. Slow the infusion rate of the PN infusion. c. Recheck the capillary blood glucose level in 4 to 6 hours. d. Contact the health care provider for infusion rate changes. ANS: C Mild hyperglycemia is expected during the first few days after PN is started and requires ongoing monitoring. Because the glucose elevation is small and expected, infusion rate changes are not needed. There is no need to obtain a venous specimen for comparison. Slowing the rate of the infusion is beyond the nurse’s scope of practice and will decrease the patient’s nutritional intake. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 9. After abdominal surgery, a patient with protein calorie malnutrition is receiving parenteral nutrition (PN). Which is the best indicator that the patient is receiving adequate nutrition? a. Serum albumin level is 3.5 mg/dL. b. Fluid intake and output are balanced. c. Surgical incision is healing normally. d. Blood glucose is less than 110 mg/dL. ANS: C Because poor wound healing is a possible complication of malnutrition for this patient, normal healing of the incision is an indicator of the effectiveness of the PN in providing adequate nutrition. Blood glucose is monitored to prevent the complications of hyperglycemia and hypoglycemia, but it does not indicate that the patient’s nutrition is adequate. The intake and output will be monitored, but do not indicate that the PN is effective. The albumin level is in the low-normal range but does not reflect adequate caloric intake, which is also important for the patient. DIF: Cognitive Level: Analyze (analysis) TOP: Nursing Process: Evaluation NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M MSC: NCLEX: Physiological Integrity 10. A 60-yr-old man who is hospitalized with an abdominal wound infection has been eating very little and states, “Nothing on the menu sounds good.” Which action by the nurse will be most effective in improving the patient’s oral intake? a. Order six small meals daily. b. Make a referral to the dietitian. c. Teach the patient about high-calorie foods. d. Ask family members to bring favorite foods. ANS: D The patient’s statement that the hospital foods are unappealing indicates that favorite home-cooked foods might improve intake. The other interventions may also help improve the patient’s intake, but the most effective action will be to offer the patient more appealing foods. DIF: Cognitive Level: Analyze (analysis) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 11. What action should the nurse take when caring for a patient with a soft, silicone nasogastric tube in place for enteral nutrition? a. Avoid giving medications through the feeding tube. b. Keep head of bed elevated to 30- to 45-degree angle. c. Replace the tube every 3 days to avoid mucosal damage. d. Administer medications mixed with enteral feeding formula. ANS: B Elevate the head of the bed to decrease the risk of aspiration. The tubes are less likely to cause mucosal damage than the stiffer polyvinyl chloride tubes used for nasogastric suction and do not need to be replaced at certain intervals. Medications can be given through these tubes but flushing after medication administration is important to avoid clogging. Do not mix medications with formula, as the combination can clog the tube. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 12. A patient is receiving continuous enteral nutrition through a small-bore silicone feeding tube. What should the nurse plan for when this patient has a computed tomography (CT) scan ordered? a. Ask the health care provider to reschedule the scan. b. Shut the feeding off 30 to 60 minutes before the scan. c. Connect the feeding tube to continuous suction before and during the scan. d. Send a suction catheter with the patient in case of aspiration during the scan. ANS: B The feeding should be shut off 30 to 60 minutes before any procedure requiring the patient to lie flat. Because the CT scan is ordered for diagnosis of patient problems, rescheduling is not usually an option. Prevention, rather than treatment, of aspiration is needed. Small-bore feeding tubes are soft and collapse easily with aspiration or suction, making nasogastric suction of gastric contents unreliable. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity NURSINGTB.COM Lewis's Medical Surgical Nursing 11th Edition Harding Test Bank NU RS IN GT B.CO M 13. A healthy adult woman who weighs 145 lb (66 kg) asks the clinic nurse about the minimum daily requirement for protein. How many grams of protein will the nurse recommend? a. 53 b. 66 c. 79 d. 98 ANS: A The recommended daily protein intake is 0.8 to 1 g/kg of body weight. Therefore, the minimum for this patient is 66 kg  0.8 g = 52.8 or 53 g/day. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 14. A 20-yr-old woman is being admitted with electrolyte disorders of unknown etiology. Which assessment finding is most important to report to the health care provider? a. The patient uses laxatives daily. b. The patient’s knuckles are macerated. c. The patient’s serum potassium level is 2.9 mEq/L. d. The patient has a history of extreme weight fluctuations. ANS: C The low serum potassium level may cause life-threatening cardiac dysrhythmias, and potassium supplementation is needed rapidly. The other information will also be reported because it suggests that bulimia may be the etiology of the patient’s electrolyte disturbances, but it does not suggest imminent life-threatening complications. DIF: Cognitive Level: Analyze (analysis) OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 15. Which action for a patient receiving enteral nutrition through a percutaneous endoscopic gastrostomy (PEG) may be delegated to a licensed practical/vocational nurse (LPN/VN)? a. Assessing the patient’s nutritional status weekly b. Providing skin care to the area around the tube site c. Teaching the patient how to administer the feedings d. Determining the need for adding water to the feedings ANS: B LPN/VN education and scope of practice include actions such as dressing changes and wound care. Patient teaching and complex assessments (such as patient nutrition and hydration status) require registered nurse (RN)–level education and scope of practice. DIF: Cognitive Level: Apply (application) OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 16. The nurse is preparing to teach a frail 79-yr-old Hispanic man who lives with an adult daughter about ways to improve nutrition