NUR 402 Exam 4 NCLEX Questions With
Complete Answers
The nurse is caring for a patient receiving an initial dose of chemotherapy to
treat a rapidly growing metastatic colon cancer. The nurse is aware that this
patient is at risk for tumor lysis syndrome (TLS) and will monitor the patient
closely for which abnormality associated with this oncologic emergency?
A) Hypokalemia
B) Hypouricemia
C) Hypocalcemia
D) Hypophosphatemia
C) Hypocalcemia
TLS is a metabolic complication characterized by rapid release of intracellular
components in response to chemotherapy. This can rapidly lead to acute renal
injury. The hallmark signs of TLS are hyperuricemia, hyperphosphatemia,
hyperkalemia, and hypocalcemia.
The nurse is caring for a patient suffering from anorexia secondary to
chemotherapy. Which strategy would be most appropriate for the nurse to use
to increase the patient's nutritional intake?
A) Increase intake of liquids at mealtime to stimulate the appetite.
B) Serve three large meals per day plus snacks between each meal.
C) Avoid the use of liquid protein supplements to encourage eating at
mealtime.
D) Add items such as skim milk powder, cheese, honey, or peanut butter to
selected foods.
D) Add items such as skim milk powder, cheese, honey, or peanut butter to selected
foods.
The nurse can increase the nutritional density of foods by adding items high in
protein and/or calories (such as peanut butter, skim milk powder, cheese, honey, or
brown sugar) to foods the patient will eat. Increasing fluid intake at mealtime fills the
stomach with fluid and decreases the desire to eat. Small frequent meals are best
tolerated. Supplements can be helpful.
Which item would be most beneficial when providing oral care to a patient with
metastatic cancer who is at risk for oral tissue injury secondary to
chemotherapy?
A) Firm-bristle toothbrush
B) Hydrogen peroxide rinse
C) Alcohol-based mouthwash
D) 1 tsp salt in 1 L water mouth rinse
D) 1 tsp salt in 1 L water mouth rinse
A salt-water mouth rinse will not cause further irritation to oral tissue that is fragile
because of mucositis, which is a side effect of chemotherapy. A soft-bristle
toothbrush will be used. One teaspoon of sodium bicarbonate may be added to the
salt-water solution to decrease odor, alleviate pain, and dissolve mucin. Hydrogen
,peroxide and alcohol-based mouthwash are not used because they would damage
the oral tissue.
Which nursing diagnosis is most appropriate for a patient experiencing
myelosuppression secondary to chemotherapy for cancer treatment?
A) Acute pain
B) Hypothermia
C) Powerlessness
D) Risk for infection
D) Risk for infection
Myelosuppression is accompanied by a high risk of infection and sepsis.
Hypothermia, powerlessness, and acute pain are also possible nursing diagnoses for
patients undergoing chemotherapy, but the threat of infection is paramount.
Previous administrations of chemotherapy agents to a cancer patient have
resulted in diarrhea. Which dietary modification should the nurse recommend?
A) A bland, low-fiber diet
B) A high-protein, high-calorie diet
C) A diet high in fresh fruits and vegetables
D) A diet emphasizing whole and organic foods
A) A bland, low-fiber diet
Patients experiencing diarrhea secondary to chemotherapy and/or radiation therapy
often benefit from a diet low in seasonings and roughage before the treatment.
Foods should be easy to digest and low in fat. Fresh fruits and vegetables are high in
fiber and should be minimized during treatment. Whole and organic foods do not
prevent diarrhea.
A 33-year-old patient has recently been diagnosed with stage II cervical
cancer. What should the nurse understand about the patient's cancer?
A) It is in situ.
B) It has metastasized.
C) It has spread locally.
D) It has spread extensively.
C) It has spread locally.
Stage II cancer is associated with limited local spread. Stage 0 denotes cancer in
situ; stage I denotes tumor limited to the tissue of origin with localized tumor growth.
Stage III denotes extensive local and regional spread. Stage IV denotes metastasis.
Which cellular dysfunction in the process of cancer development allows
defective cell proliferation?
A) Proto-oncogenes
B) Cell differentiation
C) Dynamic equilibrium
D) Activation of oncogenes
C) Dynamic equilibrium
Dynamic equilibrium is the regulation of proliferation that usually only occurs to equal
cell degeneration or death or when the body has a physiologic need for more cells.
Cell differentiation is the orderly process that progresses a cell from a state of
immaturity to a state of differentiated maturity. Mutations that alter the expression of
, proto-oncogenes can activate them to function as oncogenes, which are tumor-
inducing genes and alter their differentiation.
A patient has been diagnosed with Burkitt's lymphoma. In the initiation stage
of cancer, the cells genetic structure is mutated. Exposure to what may have
functioned as a carcinogen for this patient?
A) Bacteria
B) Sun exposure
C) Most chemicals
D) Epstein-Barr virus
D) Epstein-Barr virus
Burkitt's lymphoma consistently shows evidence of the presence of Epstein-Barr
virus in vitro. Bacteria do not initiate cancer. Sun exposure causes cell alterations
leading to melanoma and squamous and basal cell skin carcinoma. Long-term
exposure to certain chemicals (e.g., ethylene oxide, chloroform, benzene) is known
to initiate cancer.
What can the nurse do to facilitate cancer prevention for the patient in the
promotion stage of cancer development?
A) Teach the patient to exercise daily.
B) Teach the patient promoting factors to avoid.
C) Tell the patient to have the cancer surgically removed now.
D) Teach the patient which vitamins will improve the immune system.
B) Teach the patient promoting factors to avoid.
The promotion stage of cancer is characterized by the reversible proliferation of the
altered cells. Changing the lifestyle to avoid promoting factors (dietary fat, obesity,
cigarette smoking, and alcohol consumption) can reduce the chance of cancer
development. Daily exercise and vitamins alone will not prevent cancer. Surgery at
this stage may not be possible without a critical mass of cells, and this advice would
not be the nurse's role.
When caring for the patient with cancer, what does the nurse understand as
the response of the immune system to antigens of the malignant cells?
A) Metastasis
B) Tumor angiogenesis
C) Immunologic escape
D) Immunologic surveillance
D) Immunologic surveillance
Immunologic surveillance is the process where lymphocytes check cell surface
antigens and detect and destroy cells with abnormal or altered antigenic
determinants to prevent these cells from developing into clinically detectable tumors.
Metastasis is increased growth rate of the tumor, increased invasiveness, and
spread of the cancer to a distant site in the progression stage of cancer
development. Tumor angiogenesis is the process of blood vessels forming within the
tumor itself. Immunologic escape is the cancer cells' evasion of immunologic
surveillance that allows the cancer cells to reproduce.
The patient is told that the adenoma tumor is not encapsulated but has
normally differentiated cells and that surgery will be needed. The patient asks
the nurse what this means. What should the nurse tell the patient?
A) It will recur.
Complete Answers
The nurse is caring for a patient receiving an initial dose of chemotherapy to
treat a rapidly growing metastatic colon cancer. The nurse is aware that this
patient is at risk for tumor lysis syndrome (TLS) and will monitor the patient
closely for which abnormality associated with this oncologic emergency?
A) Hypokalemia
B) Hypouricemia
C) Hypocalcemia
D) Hypophosphatemia
C) Hypocalcemia
TLS is a metabolic complication characterized by rapid release of intracellular
components in response to chemotherapy. This can rapidly lead to acute renal
injury. The hallmark signs of TLS are hyperuricemia, hyperphosphatemia,
hyperkalemia, and hypocalcemia.
The nurse is caring for a patient suffering from anorexia secondary to
chemotherapy. Which strategy would be most appropriate for the nurse to use
to increase the patient's nutritional intake?
A) Increase intake of liquids at mealtime to stimulate the appetite.
B) Serve three large meals per day plus snacks between each meal.
C) Avoid the use of liquid protein supplements to encourage eating at
mealtime.
D) Add items such as skim milk powder, cheese, honey, or peanut butter to
selected foods.
D) Add items such as skim milk powder, cheese, honey, or peanut butter to selected
foods.
The nurse can increase the nutritional density of foods by adding items high in
protein and/or calories (such as peanut butter, skim milk powder, cheese, honey, or
brown sugar) to foods the patient will eat. Increasing fluid intake at mealtime fills the
stomach with fluid and decreases the desire to eat. Small frequent meals are best
tolerated. Supplements can be helpful.
Which item would be most beneficial when providing oral care to a patient with
metastatic cancer who is at risk for oral tissue injury secondary to
chemotherapy?
A) Firm-bristle toothbrush
B) Hydrogen peroxide rinse
C) Alcohol-based mouthwash
D) 1 tsp salt in 1 L water mouth rinse
D) 1 tsp salt in 1 L water mouth rinse
A salt-water mouth rinse will not cause further irritation to oral tissue that is fragile
because of mucositis, which is a side effect of chemotherapy. A soft-bristle
toothbrush will be used. One teaspoon of sodium bicarbonate may be added to the
salt-water solution to decrease odor, alleviate pain, and dissolve mucin. Hydrogen
,peroxide and alcohol-based mouthwash are not used because they would damage
the oral tissue.
Which nursing diagnosis is most appropriate for a patient experiencing
myelosuppression secondary to chemotherapy for cancer treatment?
A) Acute pain
B) Hypothermia
C) Powerlessness
D) Risk for infection
D) Risk for infection
Myelosuppression is accompanied by a high risk of infection and sepsis.
Hypothermia, powerlessness, and acute pain are also possible nursing diagnoses for
patients undergoing chemotherapy, but the threat of infection is paramount.
Previous administrations of chemotherapy agents to a cancer patient have
resulted in diarrhea. Which dietary modification should the nurse recommend?
A) A bland, low-fiber diet
B) A high-protein, high-calorie diet
C) A diet high in fresh fruits and vegetables
D) A diet emphasizing whole and organic foods
A) A bland, low-fiber diet
Patients experiencing diarrhea secondary to chemotherapy and/or radiation therapy
often benefit from a diet low in seasonings and roughage before the treatment.
Foods should be easy to digest and low in fat. Fresh fruits and vegetables are high in
fiber and should be minimized during treatment. Whole and organic foods do not
prevent diarrhea.
A 33-year-old patient has recently been diagnosed with stage II cervical
cancer. What should the nurse understand about the patient's cancer?
A) It is in situ.
B) It has metastasized.
C) It has spread locally.
D) It has spread extensively.
C) It has spread locally.
Stage II cancer is associated with limited local spread. Stage 0 denotes cancer in
situ; stage I denotes tumor limited to the tissue of origin with localized tumor growth.
Stage III denotes extensive local and regional spread. Stage IV denotes metastasis.
Which cellular dysfunction in the process of cancer development allows
defective cell proliferation?
A) Proto-oncogenes
B) Cell differentiation
C) Dynamic equilibrium
D) Activation of oncogenes
C) Dynamic equilibrium
Dynamic equilibrium is the regulation of proliferation that usually only occurs to equal
cell degeneration or death or when the body has a physiologic need for more cells.
Cell differentiation is the orderly process that progresses a cell from a state of
immaturity to a state of differentiated maturity. Mutations that alter the expression of
, proto-oncogenes can activate them to function as oncogenes, which are tumor-
inducing genes and alter their differentiation.
A patient has been diagnosed with Burkitt's lymphoma. In the initiation stage
of cancer, the cells genetic structure is mutated. Exposure to what may have
functioned as a carcinogen for this patient?
A) Bacteria
B) Sun exposure
C) Most chemicals
D) Epstein-Barr virus
D) Epstein-Barr virus
Burkitt's lymphoma consistently shows evidence of the presence of Epstein-Barr
virus in vitro. Bacteria do not initiate cancer. Sun exposure causes cell alterations
leading to melanoma and squamous and basal cell skin carcinoma. Long-term
exposure to certain chemicals (e.g., ethylene oxide, chloroform, benzene) is known
to initiate cancer.
What can the nurse do to facilitate cancer prevention for the patient in the
promotion stage of cancer development?
A) Teach the patient to exercise daily.
B) Teach the patient promoting factors to avoid.
C) Tell the patient to have the cancer surgically removed now.
D) Teach the patient which vitamins will improve the immune system.
B) Teach the patient promoting factors to avoid.
The promotion stage of cancer is characterized by the reversible proliferation of the
altered cells. Changing the lifestyle to avoid promoting factors (dietary fat, obesity,
cigarette smoking, and alcohol consumption) can reduce the chance of cancer
development. Daily exercise and vitamins alone will not prevent cancer. Surgery at
this stage may not be possible without a critical mass of cells, and this advice would
not be the nurse's role.
When caring for the patient with cancer, what does the nurse understand as
the response of the immune system to antigens of the malignant cells?
A) Metastasis
B) Tumor angiogenesis
C) Immunologic escape
D) Immunologic surveillance
D) Immunologic surveillance
Immunologic surveillance is the process where lymphocytes check cell surface
antigens and detect and destroy cells with abnormal or altered antigenic
determinants to prevent these cells from developing into clinically detectable tumors.
Metastasis is increased growth rate of the tumor, increased invasiveness, and
spread of the cancer to a distant site in the progression stage of cancer
development. Tumor angiogenesis is the process of blood vessels forming within the
tumor itself. Immunologic escape is the cancer cells' evasion of immunologic
surveillance that allows the cancer cells to reproduce.
The patient is told that the adenoma tumor is not encapsulated but has
normally differentiated cells and that surgery will be needed. The patient asks
the nurse what this means. What should the nurse tell the patient?
A) It will recur.
