NUR 402 EXAM 4 NCLEX QUESTIONS WITH
COMPLETE SOLUTIONS!!
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 Answer - 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. Answer - 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 Answer - 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 Answer - 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 Answer - 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. Answer - 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 Answer - 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 Answer - 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.
COMPLETE SOLUTIONS!!
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 Answer - 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. Answer - 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 Answer - 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 Answer - 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 Answer - 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. Answer - 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 Answer - 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 Answer - 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.
