Burns 1

Burns- Answers and Rationale
1. The newly admitted client has burns on both legs. The burned areas appear white
and leather-like. No blisters or bleeding are present, and the client states that he or
she has little pain. How should this injury be categorized?
A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness
ANS: D
The characteristics of the wound meet the criteria for a full-thickness injury (color
that is black, brown, yellow, white or red; no blisters; pain minimal; outer layer firm
and inelastic).
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological
Integrity;
2. The newly admitted client has a large burned area on the right arm. The burned
area appears red, has blisters, and is very painful. How should this injury be
categorized?
A. Superficial
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full thickness
ANS: B
The characteristics of the wound meet the criteria for a superficial partial thickness
injury (color that is pink or red; blisters; pain present and high).

Integrity;
3. The burned client newly arrived from an accident scene is prescribed to receive 4
mg of morphine sulfate by IV push. What is the most important reason to administer
the opioid analgesic to this client by the intravenous route?
A. The medication will be effective more quickly than if given intramuscularly.

B. It is less likely to interfere with the clients breathing and oxygenation.
C. The danger of an overdose during fluid remobilization is reduced.
D. The client delayed gastric emptying.
ANS: C
Although providing some pain relief has a high priority, and giving the drug by the
IV route instead of IM, SC, or orally does increase the rate of effect, the most
important reason is to prevent an overdose from accumulation of drug in the
interstitial space during the fluid shift of the emergent phase. When edema is
present, cumulative doses are rapidly absorbed when the fluid shift is resolving. This
delayed absorption can result in lethal blood levels of analgesics.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment;
4. Which vitamin deficiency is most likely to be a long-term consequence of a fullthickness burn injury?
A. Vitamin A
B. Vitamin B
C. Vitamin C
D. Vitamin D
ANS: D
Skin exposed to sunlight activates vitamin D. Partial-thickness burns reduce the
activation of vitamin D. Activation of vitamin D is lost completely in fullthickness
burns.
DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Health Promotion and Maintenance
5. Which client factors should alert the nurse to potential increased complications
with a burn injury?
A. The client is a 26-year-old male.

B. The client has had a burn injury in the past.
C. The burned areas include the hands and perineum.
D. The burn took place in an open field and ignited the client's clothing.
ANS: C
Burns of the perineum increase the risk for sepsis. Burns of the hands require
special attention to ensure the best functional outcome.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity/Safe, Effective Care
Environment;
6. The burned client is ordered to receive intravenous cimetidine, an H2 histamine

blocking agent, during the emergent phase. When the client's family asks why this
drug is being given, what is the nurses best response?
A. To increase the urine output and prevent kidney damage.

B. To stimulate intestinal movement and prevent abdominal bloating.
C. To decrease hydrochloric acid production in the stomach and prevent ulcers.
D. To inhibit loss of fluid from the circulatory system and prevent hypovolemic
shock.
ANS: C
Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn
as a result of increased hydrochloric acid production and decreased mucosal barrier.
Cimetidine inhibits the production and release of hydrochloric acid.

MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and
Maintenance;
7. At what point after a burn injury should the nurse be most alert for the
complication of hypokalemia?
A. Immediately following the injury

B. During the fluid shift
C. During fluid remobilization
D. During the late acute phase
ANS: C
Hypokalemia is most likely to occur during the fluid remobilization period as a result
of dilution, potassium movement back into the cells, and increased potassium
excreted into the urine with the greatly increased urine output.
8. What clinical manifestation should alert the nurse to possible carbon monoxide
poisoning in a client who experienced a burn injury during a house fire?
A. Pulse oximetry reading of 80%

B. Expiratory stridor and nasal flaring
C. Cherry red color to the mucous membranes
D. Presence of carbonaceous particles in the sputum
ANS: C
The saturation of hemoglobin molecules with carbon monoxide and the subsequent
vasodilation induces a cherry red color of the mucous membranes in these clients.
The other manifestations are associated with inhalation injury, but not specifically
carbon monoxide poisoning.
Integrity;
9. What clinical manifestation indicates that an escharotomy is needed on a

circumferential extremity burn?
A. The burn is full thickness rather than partial thickness.

B. The client is unable to fully pronate and supinate the extremity.
C. Capillary refill is slow in the digits and the distal pulse is absent.
D. The client cannot distinguish the sensation of sharp versus dull in the
extremity.
ANS: C
Circumferential eschar can act as a tourniquet when edema forms from the fluid
shift, increasing tissue pressure and preventing blood flow to the distal extremities
and increasing the risk for tissue necrosis. This problem is an emergency and,
without intervention, can lead to loss of the distal limb. This problem can be
reduced or corrected with an escharotomy.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Evaluation
10. What additional laboratory test should be performed on any African American
client who sustains a serious burn injury?
A. Total protein
B. Tissue type antigens
C. Prostate specific antigen
D. Hemoglobin S electrophoresis
ANS: D
Sickle cell disease and sickle cell trait are more common among African Americans.
Although clients with sickle cell disease usually know their status, the client with
sickle cell trait may not. The fluid, circulatory, and respiratory alterations that occur
in the emergent phase of a burn injury could result in decreased tissue perfusion
that is sufficient to cause sickling of cells, even in a person who only has the trait.
Determining the clients sickle cell status by checking the percentage of hemoglobin
S is essential for any African American client who has a burn injury.
Maintenance;
11. Which type of fluid should the nurse expect to prepare and administer as fluid
resuscitation during the emergent phase of burn recovery?
A. Colloids
B. Crystalloids
C. Fresh-frozen plasma
D. Packed red blood cells
ANS: B
Although not universally true, most fluid resuscitation for burn injuries starts with
crystalloid solutions, such as normal saline and Ringers lactate. The burn client
rarely requires blood during the emergent phase unless the burn is complicated by
another injury that involved hemorrhage. Colloids and plasma are not generally
used during the fluid shift phase because these large particles pass through the
leaky capillaries into the interstitial fluid, where they increase the osmotic pressure.
Increased osmotic pressure in the interstitial fluid can worsen the capillary leak
syndrome and make maintaining the circulating fluid volume even more difficult.
12. The client with a dressing covering the neck is experiencing some respiratory
difficulty. What is the nurses best first action?
A. Administer oxygen.
B. Loosen the dressing.
C. Notify the emergency team.
D. Document the observation as the only action.
ANS: B
Respiratory difficulty can arise from external pressure. The first action in this
situation would be to loosen the dressing and then reassess the client's respiratory
status.

Integrity;
13. The client who experienced an inhalation injury 6 hours ago has been wheezing.
When the client is assessed, wheezes are no longer heard. What is the nurses best
action?
A. Raise the head of the bed.

B. Notify the emergency team.
C. Loosen the dressings on the chest.
D. Document the findings as the only action.
ANS: B
Clients with severe inhalation injuries may sustain such progressive obstruction that
they may lose effective movement of air. When this occurs, wheezing is no longer
heard and neither are breath sounds. The client requires the establishment of an
emergency airway and the swelling usually precludes intubation.

14. Ten hours after the client with 50% burns is admitted, her blood glucose level is
90 mg/dL. What is the nurses best action?
A. Notify the emergency team.

B. Document the finding as the only action.
C. Ask the client if anyone in her family has diabetes mellitus.
D. Slow the intravenous infusion of dextrose 5% in Ringer's lactate.
ANS: B
Neural and hormonal compensation to the stress of the burn injury in the emergent
phase increases liver glucose production and release. An acute rise in the blood
glucose level is an expected client response and is helpful in the generation of
energy needed for the increased metabolism that accompanies this trauma.

15. On admission to the emergency department the burned client's blood pressure
is 90/60, with an apical pulse rate of 122. These findings are an expected result of
what thermal injuryrelated response?
A. Fluid shift
B. Intense pain
C. Hemorrhage
D. Carbon monoxide poisoning
ANS: A
Intense pain and carbon monoxide poisoning increase blood pressure. Hemorrhage
is unusual in a burn injury. The physiologic effect of histamine release in injured
tissues is a loss of vascular volume to the interstitial space, with a resulting
decrease in blood pressure.

MSC: Client Needs Category: Physiological Integrity/Safe, Effective Care
Environment;
16. Twelve hours after the client was initially burned, bowel sounds are absent in all
four abdominal quadrants. What is the nurses best action?
A. Reposition the client onto the right side.

B. Document the finding as the only action.
C. Notify the emergency team.
D. Increase the IV flow rate.
ANS: B Decreased or absent peristalsis is an expected response during the

emergent phase of burn injury as a result of neural and hormonal compensation to
the stress of injury. No currently accepted intervention changes this response, and it
is not the highest priority of care at this time.

Integrity;
17. Which clinical manifestation indicates that the burned client is moving into the
fluid remobilization phase of recovery?
A. Increased urine output, decreased urine specific gravity

B. Increased peripheral edema, decreased blood pressure
C. Decreased peripheral pulses, slow capillary refill
D. Decreased serum sodium level, increased hematocrit
ANS: A
The fluid remobilization phase improves renal blood flow, increasing diuresis and
restoring fluid and electrolyte levels. The increased water content of the urine
reduces its specific gravity.

TOP: Nursing Process Step: Evaluation
Integrity;
18. What is the priority nursing diagnosis during the first 24 hours for a client with
full-thickness chemical burns on the anterior neck, chest, and all surfaces of the left
arm?
A. Risk for Ineffective Breathing Pattern

B. Decreased Tissue Perfusion
C. Risk for Disuse Syndrome
D. Disturbed Body Image
ANS: C
During the emergent phase, fluid shifts into interstitial tissue in burned areas. When
the burn is circumferential on an extremity, the swelling can compress blood vessels
to such an extent that circulation is impaired distal to the injury, necessitating the
intervention of an escharotomy. Chemical burns do not cause inhalation injury.

TOP: Nursing Process Step: Analysis
19. All of the following laboratory test results on a burned client's blood are present
during the emergent phase. Which result should the nurse report to the physician
immediately?
A. Serum sodium elevated to 131 mmol/L (mEq/L)

B. Serum potassium 7.5 mmol/L (mEq/L)
C. Arterial pH is 7.32
D. Hematocrit is 52%
ANS: B
All these findings are abnormal; however, only the serum potassium level is
changed to the degree that serious, life-threatening responses could result. With
such a rapid rise in the potassium level, the client is at high risk for experiencing
severe cardiac dysrhythmias and death.

TOP: Nursing Process Step: Assessment/Analysis
20. The client has experienced an electrical injury, with the entrance site on the left
hand and the exit site on the left foot. What are the priority assessment data to
obtain from this client on admission?
A. Airway patency
B. Heart rate and rhythm
C. Orientation to time, place, and person
D. Current range of motion in all extremities
ANS: B
The airway is not at any particular risk with this injury. Electric current travels
through the body from the entrance site to the exit site and can seriously damage
all tissues between the two sites. Early cardiac damage from electrical injury
includes irregular heart rate, rhythm, and ECG changes.

21. In assessing the client's potential for an inhalation injury as a result of a flame
burn, what is the most important question to ask the client on admission?
A. Are you a smoker?

B. When was your last chest x-ray?
C. Have you ever had asthma or any other lung problem?
D. In what exact place or space were you when you were burned?
ANS: D
The risk for inhalation injury is greatest when flame burns occur indoors in small,
poorly ventilated rooms. although smoking increases the risk for some problems, it
does not predispose the client for an inhalation injury.

22. Which information obtained by assessment ensures that the client's respiratory
efforts are currently adequate?
A. The client is able to talk.

B. The client is alert and oriented.
C. The client's oxygen saturation is 97%.
D. The client's chest movements are uninhibited
ANS: C
Clients may have ineffective respiratory efforts and gas exchange even though they
are able to talk, have good respiratory movement, and are alert. The best indicator
for respiratory effectiveness is the maintenance of oxygen saturation within the
normal range.

Integrity;
23. Which information obtained by assessment ensures that the client's respiratory
efforts are currently adequate?
A. The client is able to talk.

B. The client is alert and oriented.
C. The client's oxygen saturation is 97%.
D. The client's chest movements are uninhibited
ANS: C
Clients may have ineffective respiratory efforts and gas exchange even though they
are able to talk, have good respiratory movement, and are alert. The best indicator
for respiratory effectiveness is the maintenance of oxygen saturation within the
normal range.

Integrity;
24. The burned client's family ask at what point the client will no longer be at
increased risk for infection. What is the nurses best response?
A. When fluid remobilization has started.

B. When the burn wounds are closed.
C. When IV fluids are discontinued.
D. When body weight is normal.
ANS: B
Intact skin is a major barrier to infection and other disruptions in homeostasis. No
matter how much time has passed since the burn injury, the client remains at great
risk for infection as long as any area of skin is open.

Maintenance;
25. The burned client relates the following history of previous health problems.
Which one should alert the nurse to the need for alteration of the fluid resuscitation
plan?
A. Seasonal asthma
B. Hepatitis B 10 years ago
C. Myocardial infarction 1 year ago
D. Kidney stones within the last 6 month
ANS: C
It is likely the client has a diminished cardiac output as a result of the old MI and
would be at greater risk for the development of congestive heart failure and
pulmonary edema during fluid resuscitation.

Integrity;
26. The burned client on admission is drooling and having difficulty swallowing.
What is the nurses best first action?
A. Assess level of consciousness and pupillary reactions.

B. Ask the client at what time food or liquid was last consumed.
C. Auscultate breath sounds over the trachea and mainstem bronchi.
D. Measure abdominal girth and auscultate bowel sounds in all four quadrants.
ANS: C
Difficulty swallowing and drooling are indications of oropharyngeal edema and can
precede pulmonary failure. The clients airway is in severe jeopardy and intubation
is highly likely to be needed shortly.

27. Which intervention is most important for the nurse to use to prevent infection by
cross-contamination in the client who has open burn wounds?
A. Handwashing on entering the client's room

B. Encouraging the client to cough and deep breathe
C. Administering the prescribed tetanus toxoid vaccine
D. Changing gloves between cleansing different burn areas
ANS: A
Cross-contamination occurs when microorganisms from another person or the
environment are transferred to the client. Although all the interventions listed above
can help reduce the risk for infection, only handwashing can prevent
crosscontamination.

28. In reviewing the burned client's laboratory report of white blood cell count with
differential, all the following results are listed. Which laboratory finding indicates the
possibility of sepsis?
A. The total white blood cell count is 9000/mm3.
B. The lymphocytes outnumber the basophils.

C. The bands outnumber the segs.
D. The monocyte count is 1,800/mm3.
ANS: C
Normally, the mature segmented neutrophils (segs) are the major population of
circulating leukocytes, constituting 55% to 70% of the total white blood count.
Fewer than 3% to 5% of the circulating white blood cells should be the less mature
band neutrophils. A left shift occurs when the bone marrow releases more
immature neutrophils than mature neutrophils. Such a shift indicates severe
infection or sepsis, in which the clients immune system cannot keep pace with the
infectious process.

Maintenance;
29. The client has a deep partial-thickness injury to the posterior neck. Which
intervention is most important to use during the acute phase to prevent
contractures associated with this injury?
A. Place a towel roll under the client's neck or shoulder.

B. Keep the client in a supine position without the use of pillows.
C. Have the client turn the head from side to side 90 degrees every hour while
awake.
D. Keep the client in a semi-Fowlers position and actively raise the arms above
the head every hour while awake.
ANS: C
The function that would be disrupted by a contracture to the posterior neck is
flexion. Moving the head from side to side prevents such a loss of flexion.

MSC: Client Needs Category: Health Promotion and Maintenance/Safe, Effective Care
Environment;
30. The client has severe burns around the right hip. Which position is most
important to be emphasized by the nurse that the client maintain to retain
maximum function of this joint?
A. Hip maintained in 30-degree flexion, no knee flexion

B. Hip flexed 90 degrees and knee flexed 90 degrees
C. Hip, knee, and ankle all at maximum flexion
D. Hip at zero flexion with leg flat
ANS: D
Maximum function for ambulation occurs when the hip and leg are maintained at
full extension with neutral rotation. Although the client does not have to spend 24
hours at a time in this position, he or she should be in this position (in bed or
standing) more of the time than with the hip in any degree of flexion.

Maintenance;
31. During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic)
to the burn before dressing the wound. The client has all the following
manifestations. Which manifestation indicates that the client is having an adverse
reaction to this topical agent?
A. Increased wound pain 30 to 40 minutes after drug application
B. Presence of small, pale pink bumps in the wound beds

C. Decreased white blood cell count
D. Increased serum creatinine level
ANS: D
Gentamicin does not stimulate pain in the wound. The small, pale pink bumps in the
wound bed are areas of re-epithelialization and not an adverse reaction. Gentamicin
is nephrotoxic and sufficient amounts can be absorbed through burn wounds to
affect kidney function. Any client receiving gentamicin by any route should have
kidney function monitored.

32. The client, who is 2 weeks postburn with a 40% deep partial-thickness injury,
still has open wounds. On taking the morning vital signs, the client is found to have
a below-normal temperature, is hypotensive, and has diarrhea. What is the nurses
best action?
A. Nothing, because the findings are normal for clients during the acute phase of
recovery.
B. Increase the temperature in the room and increase the IV infusion rate.
C. Assess the clients airway and oxygen saturation.
D. Notify the burn emergency team.
ANS: D
These findings are associated with systemic gram-negative infection and sepsis.
This is a medical emergency and requires prompt attention.

33. Which intervention is most important to use to prevent infection by

autocontamination in the burned client during the acute phase of recovery?
A. Changing gloves between wound care on different parts of the client's body.
B. Avoiding sharing equipment such as blood pressure cuffs between clients.
C. Using the closed method of burn wound management.
D. Using proper and consistent handwashing.
ANS: A
Autocontamination is the transfer of microorganisms from one area to another area
of the same client's body, causing infection of a previously uninfected area.
Although all techniques listed can help reduce the risk for infection, only changing
gloves between carrying out wound care on difference parts of the clients body can
prevent autocontamination.

Integrity;
34. When should ambulation be initiated in the client who has sustained a major
burn?
A. When all full-thickness areas have been closed with skin grafts
B. When the client's temperature has remained normal for 24 hours
C. As soon as possible after wound debridement is complete
D. As soon as possible after resolution of the fluid shift
ANS: D
Regular, progressive ambulation is initiated for all burn clients who do not have
contraindicating concomitant injuries as soon as the fluid shift resolves. Clients can
be ambulated with extensive dressings, open wounds, and nearly any type of
attached lines, tubing, and other equipment.

Maintenance;
35. What statement by the client indicates the need for further discussion regarding
the outcome of skin grafting (allografting) procedures?
A. For the first few days after surgery, the donor sites will be painful.
B. Because the graft is my own skin, there is no chance it won't 'take'.
C. I will have some scarring in the area when the skin is removed for grafting.
D. Once all grafting is completed, my risk for infection is the same as it was
before I was burned.
ANS: B
Factors other than tissue type, such as circulation and infection, influence whether
and how well a graft takes. The client should be prepared for the possibility that
not all grafting procedures will be successful.

MSC: Client Needs Category: Health Promotion and Maintenance/Psychosocial
Integrity
36. Which statement by the client indicates correct understanding of rehabilitation

after burn injury?
A. I will never be fully recovered from the burn.

B. I am considered fully recovered when all the wounds are closed.
C. I will be fully recovered when I am able to perform all the activities I did
before my injury.
D. I will be fully recovered when I achieve the highest possible level of
functioning that I can.
ANS: D
Although a return to preburn functional levels is rarely possible, burned clients are
considered fully recovered or rehabilitated when they have achieved their highest
possible level of physical, social, and emotional functioning.

MSC: Client Needs Category: Psychosocial Integrity
37. Which statement made by the client with facial burns who has been prescribed
to wear a facial mask pressure garment indicates correct understanding of the
purpose of this treatment?
A. After this treatment, my ears will not stick out.

B. The mask will help protect my skin from sun damage.
C. Using this mask will prevent scars from being permanent.
D. My facial scars should be less severe with the use of this mask.
ANS: D
The purpose of wearing the pressure garment over burn injuries for up to 1 year is
to prevent hypertrophic scarring and contractures from forming. Scars will still be
present. Although the mask does provide protection of sensitive newly healed skin
and grafts from sun exposure, this is not the purpose of wearing the mask. The
pressure garment will not change the angle of ear attachment to the head.

MSC: Client Needs Category: Psychosocial Integrity/Health Promotion and
Maintenance
38. What is the priority nursing diagnosis for a client in the rehabilitative phase of
recovery from a burn injury?
A. Acute Pain
B. Impaired Adjustment
C. Deficient Diversional Activity
D. Imbalanced Nutrition: Less than Body Requirements
ANS: B
Recovery from a burn injury requires a lot of work on the part of the client and
significant others. Seldom is the client restored to the preburn level of functioning.
Adjustments to changes in appearance, family structure, employment opportunities,
role, and functional limitations are only a few of the numerous life-changing
alterations that must be made or overcome by the client. By the rehabilitation
phase, acute pain from the injury or its treatment is no longer a problem.

TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Psychosocial Integrity
NCLEX Practice Test for Oncology 2
1. Nina, an oncology nurse educator is speaking to a womens group about breast

cancer. Questions and comments from the audience reveal a misunderstanding of
some aspects of the disease. Various members of the audience have made all of the
following statements. Which one is accurate?
a. Mammography is the most reliable method for detecting breast cancer.

b. Breast cancer is the leading killer of women of childbearing age.
c. Breast cancer requires a mastectomy.
d. Men can develop breast cancer.
1. Answer D. Men can develop breast cancer, although they seldom do. The most
reliable method for detecting breast cancer is monthly self-examination, not
mammography. Lung cancer causes more deaths than breast cancer in women of all
ages. A mastectomy may not be required if the tumor is small, confined, and in an
early stage.
2. Nurse Meredith is instructing a premenopausal woman about breast selfexamination. The nurse should tell the client to do her self-examination:
a. at the end of her menstrual cycle.
b. on the same day each month.

c. on the 1st day of the menstrual cycle.
d. immediately after her menstrual period.
Answer D. Premenopausal women should do their self-examination immediately
after the menstrual period, when the breasts are least tender and least lumpy. On
the 1st and last days of the cycle, the womans breasts are still very tender.
Postmenopausal women because their bodies lack fluctuation of hormone levels,
should select one particular day of the month to do breast self-examination.
3. Nurse Kent is teaching a male client to perform monthly testicular selfexaminations. Which of the following points would be appropriate to make?
a. Testicular cancer is a highly curable type of cancer.

b. Testicular cancer is very difficult to diagnose.
c. Testicular cancer is the number one cause of cancer deaths in males.
d. Testicular cancer is more common in older men.
Answer A. Testicular cancer is highly curable, particularly when its treated in its
early stage. Self-examination allows early detection and facilitates the early
initiation of treatment. The highest mortality rates from cancer among men are in
men with lung cancer. Testicular cancer is found more commonly in younger men.
4. Rhea, has malignant lymphoma. As part of her chemotherapy, the physician

prescribes chlorambucil (Leukeran), 10 mg by mouth daily. When caring for the
client, the nurse teaches her about adverse reactions to chlorambucil, such as
alopecia. How soon after the first administration of chlorambucil might this reaction
occur?
a. Immediately
b. 1 week
c. 2 to 3 weeks
d. 1 month
Answer C. Chlorambucil-induced alopecia occurs 2 to 3 weeks after therapy begins.
5. A male client is receiving the cell cyclenonspecific alkylating agent thiotepa

(Thioplex), 60 mg weekly for 4 weeks by bladder instillation as part of a
chemotherapeutic regimen to treat bladder cancer. The client asks the nurse how
the drug works. How does thiotepa exert its therapeutic effects?
a. It interferes with deoxyribonucleic acid (DNA) replication only.

b. It interferes with ribonucleic acid (RNA) transcription only.
c. It interferes with DNA replication and RNA transcription.
d. It destroys the cell membrane, causing lysis.
Answer C. Thiotepa interferes with DNA replication and RNA transcription. It doesnt
destroy the cell membrane.
6. The nurse is instructing the 35 year old client to perform a testicular selfexamination. The nurse tells the client:
a. To examine the testicles while lying down

b. That the best time for the examination is after a shower
c. To gently feel the testicle with one finger to feel for a growth
d. That testicular self-examination should be done at least every 6 months
Answer B. The testicular-self examination is recommended monthly after a warm
bath or shower when the scrotal skin is relaxed. The client should stand to examine
the testicles. Using both hands, with fingers under the scrotum and thumbs on top,
the client should gently roll the testicles, feeling for any lumps.
7. A female client with cancer is receiving chemotherapy and develops

thrombocytopenia. The nurse identifies which intervention as the highest priority in
the nursing plan of care?
a. Monitoring temperature
b. Ambulation three times daily
c. Monitoring the platelet count
d. Monitoring for pathological fractures
Answer C. Thrombocytopenia indicates a decrease in the number of platelets in the
circulating blood. A major concern is monitoring for and preventing bleeding. Option
A elates to monitoring for infection, particularly if leukopenia is present. Options B

and D, although important in the plan of care, are not related directly to
thrombocytopenia.
8. Gian, a community health nurse is instructing a group of female clients about

breast self-examination. The nurse instructs the client to perform the examination:
a. At the onset of menstruation

b. Every month during ovulation
c. Weekly at the same time of day
d. 1 week after menstruation begins
Answer D. The breast self-examination should be performed monthly 7 days after
the onset of the menstrual period. Performing the examination weekly is not
recommended. At the onset of menstruation and during ovulation, hormonal
changes occur that may alter breast tissue.
9. Nurse Cecilia is caring for a client who has undergone a vaginal hysterectomy.
The nurse avoids which of the following in the care of this client?
a. Elevating the knee gatch on the bed

b. Assisting with range-of-motion leg exercises
c. Removal of antiembolism stockings twice daily
d. Checking placement of pneumatic compression boots
Answer A. The client is at risk of deep vein thrombosis or thrombophlebitis after this
surgery, as for any other major surgery. For this reason, the nurse implements
measures that will prevent this complication. Range-of-motion exercises,
antiembolism stockings, and pneumatic compression boots are helpful. The nurse
should avoid using the knee gatch in the bed, which inhibits venous return, thus
placing the client more at risk for deep vein thrombosis or thrombophlebitis.
10. Mina, who is suspected of an ovarian tumor is scheduled for a pelvic ultrasound.
The nurse provides which preprocedure instruction to the client?
a. Eat a light breakfast only
b. Maintain an NPO status before the procedure

c. Wear comfortable clothing and shoes for the procedure
d. Drink six to eight glasses of water without voiding before the test
Answer D. A pelvic ultrasound requires the ingestion of large volumes of water just
before the procedure. A full bladder is necessary so that it will be visualized as such
and not mistaken for a possible pelvic growth. An abdominal ultrasound may require
that the client abstain from food or fluid for several hours before the procedure.
Option C is unrelated to this specific procedure.
11. A male client is diagnosed as having a bowel tumor and several diagnostic tests
are prescribed. The nurse understands that which test will confirm the diagnosis of
malignancy?
a. Biopsy of the tumor

b. Abdominal ultrasound
c. Magnetic resonance imaging
d. Computerized tomography scan
Answer A. A biopsy is done to determine whether a tumor is malignant or benign.
Magnetic resonance imaging, computed tomography scan, and ultrasound will
visualize the presence of a mass but will not confirm a diagnosis of malignancy.
12. A female client diagnosed with multiple myeloma and the client asks the nurse
about the diagnosis. The nurse bases the response on which description of this
disorder?
a. Altered red blood cell production

b. Altered production of lymph nodes
c. Malignant exacerbation in the number of leukocytes
d. Malignant proliferation of plasma cells within the bone
Answer D. Multiple myeloma is a B-cell neoplastic condition characterized by
abnormal malignant proliferation of plasma cells and the accumulation of mature
plasma cells in the bone marrow. Options A and B are not characteristics of multiple
myeloma. Option C describes the leukemic process.
13. Nurse Bea is reviewing the laboratory results of a client diagnosed with multiple
myeloma. Which of the following would the nurse expect to note specifically in this
disorder?
a. Increased calcium
b. Increased white blood cells
c. Decreased blood urea nitrogen level
d. Decreased number of plasma cells in the bone marrow
Answer A. Findings indicative of multiple myeloma are an increased number of
plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of
calcium from the deteriorating bone tissue, and an elevated blood urea nitrogen
level. An increased white blood cell count may or may not be present and is not
related specifically to multiple myeloma.
14. Vanessa, a community health nurse conducts a health promotion program

regarding testicular cancer to community members. The nurse determines that
further information needs to be provided if a community member states that which
of the following is a sign of testicular cancer?
a. Alopecia
b. Back pain
c. Painless testicular swelling
d. Heavy sensation in the scrotum
Answer A. Alopecia is not an assessment finding in testicular cancer. Alopecia may
occur, however, as a result of radiation or chemotherapy. Options B, C, and D are
assessment findings in testicular cancer. Back pain may indicate metastasis to the
retroperitoneal lymph nodes.
15. The male client is receiving external radiation to the neck for cancer of the
larynx. The most likely side effect to be expected is:
a. Dyspnea
b. Diarrhea
c. Sore throat
d. Constipation
Answer C. In general, only the area in the treatment field is affected by the
radiation. Skin reactions, fatigue, nausea, and anorexia may occur with radiation to
any site, whereas other side effects occur only when specific areas are involved in
treatment. A client receiving radiation to the larynx is most likely to experience a
sore throat. Options B and D may occur with radiation to the gastrointestinal tract.
Dyspnea may occur with lung involvement.
16. Nurse Joy is caring for a client with an internal radiation implant. When caring
for the client, the nurse should observe which of the following principles?
a. Limit the time with the client to 1 hour per shift

b. Do not allow pregnant women into the clients room
c. Remove the dosimeter badge when entering the clients room
d. Individuals younger than 16 years old may be allowed to go in the room as long
as they are 6 feet away from the client
Answer B. The time that the nurse spends in a room of a client with an internal
radiation implant is 30 minutes per 8-hour shift. The dosimeter badge must be worn
when in the clients room. Children younger than 16 years of age and pregnant
women are not allowed in the clients room.
17. A cervical radiation implant is placed in the client for treatment of cervical
cancer. The nurse initiates what most appropriate activity order for this client?
a. Bed rest
b. Out of bed ad lib
c. Out of bed in a chair only
d. Ambulation to the bathroom only
Answer A. The client with a cervical radiation implant should be maintained on bed
rest in the dorsal position to prevent movement of the radiation source. The head of
the bed is elevated to a maximum of 10 to 15 degrees for comfort. The nurse avoids
turning the client on the side. If turning is absolutely necessary, a pillow is placed
between the knees and, with the body in straight alignment, the client is logrolled.
18. A female client is hospitalized for insertion of an internal cervical radiation

implant. While giving care, the nurse finds the radiation implant in the bed. The
initial action by the nurse is to:
a. Call the physician

b. Reinsert the implant into the vagina immediately
c. Pick up the implant with gloved hands and flush it down the toilet
d. Pick up the implant with long-handled forceps and place it in a lead container.
Answer D. A lead container and long-handled forceps should be kept in the clients
room at all times during internal radiation therapy. If the implant becomes
dislodged, the nurse should pick up the implant with long-handled forceps and place
it in the lead container. Options A, B, and C are inaccurate interventions.
19. The nurse is caring for a female client experiencing neutropenia as a result of
chemotherapy and develops a plan of care for the client. The nurse plans to:
a. Restrict all visitors

b. Restrict fluid intake
c. Teach the client and family about the need for hand hygiene
d. Insert an indwelling urinary catheter to prevent skin breakdown
Answer C. In the neutropenic client, meticulous hand hygiene education is
implemented for the client, family, visitors, and staff. Not all visitors are restricted,
but the client is protected from persons with known infections. Fluids should be
encouraged. Invasive measures such as an indwelling urinary catheter should be
avoided to prevent infections.
20. The home health care nurse is caring for a male client with cancer and the client
is complaining of acute pain. The appropriate nursing assessment of the clients
pain would include which of the following?
a. The clients pain rating

b. Nonverbal cues from the client
c. The nurses impression of the clients pain
d. Pain relief after appropriate nursing intervention
Answer A. The clients self-report is a critical component of pain assessment. The

nurse should ask the client about the description of the pain and listen carefully to
the clients words used to describe the pain. The nurses impression of the clients
pain is not appropriate in determining the clients level of pain. Nonverbal cues from
the client are important but are not the most appropriate pain assessment measure.
Assessing pain relief is an important measure, but this option is not related to the
subject of the question.
21. Nurse Mickey is caring for a client who is postoperative following a pelvic
exenteration and the physician changes the clients diet from NPO status to clear
liquids. The nurse makes which priority assessment before administering the diet?
a. Bowel sounds
b. Ability to ambulate
c. Incision appearance
d. Urine specific gravity
Answer A. The client is kept NPO until peristalsis returns, usually in 4 to 6 days.
When signs of bowel function return, clear fluids are given to the client. If no
distention occurs, the diet is advanced as tolerated. The most important
assessment is to assess bowel sounds before feeding the client. Options B, C, and D
are unrelated to the subject of the question.
22. A male client is admitted to the hospital with a suspected diagnosis of Hodgkins
disease. Which assessment findings would the nurse expect to note specifically in
the client?
a. Fatigue
b. Weakness
c. Weight gain
d. Enlarged lymph nodes
Answer D. Hodgkins disease is a chronic progressive neoplastic disorder of
lymphoid tissue characterized by the painless enlargement of lymph nodes with
progression to extralymphatic sites, such as the spleen and liver. Weight loss is
most likely to be noted. Fatigue and weakness may occur but are not related
significantly to the disease.
23. During the admission assessment of a 35 year old client with advanced ovarian
cancer, the nurse recognizes which symptom as typical of the disease?
a. Diarrhea
b. Hypermenorrhea
c. Abdominal bleeding
d. Abdominal distention
Answer D. Clinical manifestations of ovarian cancer include abdominal distention,
urinary frequency and urgency, pleural effusion, malnutrition, pain from pressure
caused by the growing tumor and the effects of urinary or bowel obstruction,
constipation, ascites with dyspnea, and ultimately general severe pain. Abnormal
bleeding, often resulting in hypermenorrhea, is associated with uterine cancer.
24. Nurse Kate is reviewing the complications of colonization with a client who has
microinvasive cervical cancer. Which complication, if identified by the client,
indicates a need for further teaching?
a. Infection
b. Hemorrhage
c. Cervical stenosis
d. Ovarian perforation
Answer D. Conization procedure involves removal of a cone-shaped area of the
cervix. Complications of the procedure include hemorrhage, infection, and cervical
stenosis. Ovarian perforation is not a complication.
25. Mr. Miller has been diagnosed with bone cancer. You know this type of cancer is
classified as:
a. sarcoma.
b. lymphoma.
c. carcinoma.
d. melanoma.
Answer A. Tumors that originate from bone,muscle, and other connective tissue are
called sarcomas.
26. Sarah, a hospice nurse visits a client dying of ovarian cancer. During the visit,
the client expresses that If I can just live long enough to attend my daughters
graduation, Ill be ready to die. Which phrase of coping is this client experiencing?
a. Anger
b. Denial
c. Bargaining
d. Depression
Answer C. Denial, bargaining, anger, depression, and acceptance are recognized
stages that a person facing a life-threatening illness experiences. Bargaining
identifies a behavior in which the individual is willing to do anything to avoid loss or
change prognosis or fate. Denial is expressed as shock and disbelief and may be the
first response to hearing bad news. Depression may be manifested by hopelessness,
weeping openly, or remaining quiet or withdrawn. Anger also may be a first
response to upsetting news and the predominant theme is why me? or the
blaming of others.
27. Nurse Farah is caring for a client following a mastectomy. Which assessment
finding indicates that the client is experiencing a complication related to the
surgery?
a. Pain at the incisional site

b. Arm edema on the operative side
c. Sanguineous drainage in the Jackson-Pratt drain
d. Complaints of decreased sensation near the operative site
Answer B. Arm edema on the operative side (lymphedema) is a complication
following mastectomy and can occur immediately postoperatively or may occur
months or even years after surgery. Options A, C, and D are expected occurrences
following mastectomy and do not indicate a complication.
28. The nurse is admitting a male client with laryngeal cancer to the nursing unit.
The nurse assesses for which most common risk factor for this type of cancer?
a. Alcohol abuse
b. Cigarette smoking
c. Use of chewing tobacco
d. Exposure to air pollutants
Answer B. The most common risk factor associated with laryngeal cancer is
cigarette smoking. Heavy alcohol use and the combined use of tobacco increase the
risk. Another risk factor is exposure to environmental pollutants.
29. The female client who has been receiving radiation therapy for bladder cancer
tells the nurse that it feels as if she is voiding through the vagina. The nurse
interprets that the client may be experiencing:
a. Rupture of the bladder

b. The development of a vesicovaginal fistula
c. Extreme stress caused by the diagnosis of cancer
d. Altered perineal sensation as a side effect of radiation therapy
Answer B. A vesicovaginal fistula is a genital fistula that occurs between the bladder
and vagina. The fistula is an abnormal opening between these two body parts and,
if this occurs, the client may experience drainage of urine through the vagina. The
clients complaint is not associated with options A, C, and D.
30. The client with leukemia is receiving busulfan (Myleran) and allopurinol
(Zyloprim). The nurse tells the client that the purpose if the allopurinol is to prevent:
a. Nausea
b. Alopecia
c. Vomiting
d. Hyperuricemia
Answer D. Allopurinol decreases uric acid production and reduces uric acid
concentrations in serum and urine. In the client receiving chemotherapy, uric acid
levels increase as a result of the massive cell destruction that occurs from the
chemotherapy. This medication prevents or treats hyperuricemia caused by
chemotherapy. Allopurinol is not used to prevent alopecia, nausea, or vomiting.
NCLEX Practice Test for Oncology 1
1. A female client has an abnormal result on a Papanicolaou test. After admitting,

she read his chart while the nurse was out of the room, the client asks what
dysplasia means. Which definition should the nurse provide?
a. Presence of completely undifferentiated tumor cells that dont resemble cells of

the tissues of their origin
b. Increase in the number of normal cells in a normal arrangement in a tissue or an
organ
c. Replacement of one type of fully differentiated cell by another in tissues where
the second type normally isnt found
d. Alteration in the size, shape, and organization of differentiated cells
Answer D. Dysplasia refers to an alteration in the size, shape, and organization of
differentiated cells. The presence of completely undifferentiated tumor cells that
dont resemble cells of the tissues of their origin is called anaplasia. An increase in
the number of normal cells in a normal arrangement in a tissue or an organ is called
hyperplasia. Replacement of one type of fully differentiated cell by another in
tissues where the second type normally isnt found is called metaplasia.
2. For a female client with newly diagnosed cancer, the nurse formulates a nursing
diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis.
Which expected outcome would be appropriate for this client?
a. Client verbalizes feelings of anxiety.

b. Client doesnt guess at prognosis.
c. Client uses any effective method to reduce tension.
d. Client stops seeking information.
Answer A. Verbalizing feelings is the clients first step in coping with the situational
crisis. It also helps the health care team gain insight into the clients feelings,
helping guide psychosocial care. Option B is inappropriate because suppressing
speculation may prevent the client from coming to terms with the crisis and
planning accordingly. Option C is undesirable because some methods of reducing
tension, such as illicit drug or alcohol use, may prevent the client from coming to
terms with the threat of death as well as cause physiologic harm. Option D isnt
appropriate because seeking information can help a client with cancer gain a sense
of control over the crisis.
3. A male client with a cerebellar brain tumor is admitted to an acute care facility.
The nurse formulates a nursing diagnosis of Risk for injury. Which related-to
phrase should the nurse add to complete the nursing diagnosis statement?
a. Related to visual field deficits

b. Related to difficulty swallowing
c. Related to impaired balance
d. Related to psychomotor seizures
Answer C. A client with a cerebellar brain tumor may suffer injury from impaired
balance as well as disturbed gait and incoordination. Visual field deficits, difficulty
swallowing, and psychomotor seizures may result from dysfunction of the pituitary
gland, pons, occipital lobe, parietal lobe, or temporal lobe not from a cerebellar
brain tumor. Difficulty swallowing suggests medullary dysfunction. Psychomotor
seizures suggest temporal lobe dysfunction.
4. A female client with cancer is scheduled for radiation therapy. The nurse knows
that radiation at any treatment site may cause a certain adverse effect. Therefore,
the nurse should prepare the client to expect:
a. hair loss.
b. stomatitis.
c. fatigue.
d. vomiting.
Answer C. Radiation therapy may cause fatigue, skin toxicities, and anorexia
regardless of the treatment site. Hair loss, stomatitis, and vomiting are site-specific,
not generalized, adverse effects of radiation therapy.
5. Nurse April is teaching a client who suspects that she has a lump in her breast.
The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
a. breast self-examination.
b. mammography.
c. fine needle aspiration.
d. chest X-ray.
Answer C. Fine needle aspiration and biopsy provide cells for histologic examination
to confirm a diagnosis of cancer. A breast self-examination, if done regularly, is the
most reliable method for detecting breast lumps early. Mammography is used to
detect tumors that are too small to palpate. Chest X-rays can be used to pinpoint rib
metastasis.
6. A male client undergoes a laryngectomy to treat laryngeal cancer. When teaching

the client how to care for the neck stoma, the nurse should include which
instruction?
a. Keep the stoma uncovered.

b. Keep the stoma dry.
c. Have a family member perform stoma care initially until you get used to the
procedure.
d. Keep the stoma moist.
Answer D. The nurse should instruct the client to keep the stoma moist, such as by
applying a thin layer of petroleum jelly around the edges, because a dry stoma may
become irritated. The nurse should recommend placing a stoma bib over the stoma
to filter and warm air before it enters the stoma. The client should begin performing
stoma care without assistance as soon as possible to gain independence in self-care
activities.
7. A female client is receiving chemotherapy to treat breast cancer. Which

assessment finding indicates a fluid and electrolyte imbalance induced by
chemotherapy?
a. Urine output of 400 ml in 8 hours

b. Serum potassium level of 3.6 mEq/L
c. Blood pressure of 120/64 to 130/72 mm Hg
d. Dry oral mucous membranes and cracked lips
Answer D. Chemotherapy commonly causes nausea and vomiting, which may lead
to fluid and electrolyte imbalances. Signs of fluid loss include dry oral mucous
membranes, cracked lips, decreased urine output (less than 40 ml/hour),
abnormally low blood pressure, and a serum potassium level below 3.5 mEq/L.
8. Nurse April is teaching a group of women to perform breast self-examination. The

nurse should explain that the purpose of performing the examination is to discover:
a. cancerous lumps.
b. areas of thickness or fullness.
c. changes from previous self-examinations.
d. fibrocystic masses.
Answer C. Women are instructed to examine themselves to discover changes that
have occurred in the breast. Only a physician can diagnose lumps that are
cancerous, areas of thickness or fullness that signal the presence of a malignancy,
or masses that are fibrocystic as opposed to malignant.
9. A client, age 41, visits the gynecologist. After examining her, the physician
suspects cervical cancer. The nurse reviews the clients history for risk factors for
this disease. Which history finding is a risk factor for cervical cancer?
a. Onset of sporadic sexual activity at age 17

b. Spontaneous abortion at age 19
c. Pregnancy complicated with eclampsia at age 27
d. Human papillomavirus infection at age 32
Answer D. Like other viral and bacterial venereal infections, human papillomavirus
is a risk factor for cervical cancer. Other risk factors for this disease include frequent
sexual intercourse before age 16, multiple sex partners, and multiple pregnancies. A
spontaneous abortion and pregnancy complicated by eclampsia arent risk factors
for cervical cancer.
10. A female client is receiving methotrexate (Mexate), 12 g/m2 I.V., to treat

osteogenic carcinoma. During methotrexate therapy, the nurse expects the client to
receive which other drug to protect normal cells?
a. probenecid (Benemid)
b. cytarabine (ara-C, cytosine arabinoside [Cytosar-U])
c. thioguanine (6-thioguanine, 6-TG)
d. leucovorin (citrovorum factor or folinic acid [Wellcovorin])
Answer D. Leucovorin is administered with methotrexate to protect normal cells,

which methotrexate could destroy if given alone. Probenecid should be avoided in
clients receiving methotrexate because it reduces renal elimination of
methotrexate, increasing the risk of methotrexate toxicity. Cytarabine and
thioguanine arent used to treat osteogenic carcinoma.
11. The nurse is interviewing a male client about his past medical history. Which
preexisting condition may lead the nurse to suspect that a client has colorectal
cancer?
a. Duodenal ulcers
b. Hemorrhoids
c. Weight gain
d. Polyps
Answer D. Colorectal polyps are common with colon cancer. Duodenal ulcers and
hemorrhoids arent preexisting conditions of colorectal cancer. Weight loss not
gain is an indication of colorectal cancer.
12. Nurse Amy is speaking to a group of women about early detection of breast
cancer. The average age of the women in the group is 47. Following the American
Cancer Society guidelines, the nurse should recommend that the women:
a. perform breast self-examination annually.

b. have a mammogram annually.
c. have a hormonal receptor assay annually.
d. have a physician conduct a clinical examination every 2 years.
Answer B. The American Cancer Society guidelines state, "Women older than age 40
should have a mammogram annually and a clinical examination at least annually
[not every 2 years]; all women should perform breast self-examination monthly [not
annually]." The hormonal receptor assay is done on a known breast tumor to
determine whether the tumor is estrogen- or progesterone-dependent.
13. A male client with a nagging cough makes an appointment to see the physician
after reading that this symptom is one of the seven warning signs of cancer. What is
another warning sign of cancer?
a. Persistent nausea
b. Rash
c. Indigestion
d. Chronic ache or pain
.Answer C. Indigestion, or difficulty swallowing, is one of the seven warning signs of
cancer. The other six are a change in bowel or bladder habits, a sore that does not
heal, unusual bleeding or discharge, a thickening or lump in the breast or
elsewhere, an obvious change in a wart or mole, and a nagging cough or
hoarseness. Persistent nausea may signal stomach cancer but isnt one of the seven
major warning signs. Rash and chronic ache or pain seldom indicate cancer.
14. For a female client newly diagnosed with radiation-induced thrombocytopenia,

the nurse should include which intervention in the plan of care?
a. Administering aspirin if the temperature exceeds 102 F (38.8 C)

b. Inspecting the skin for petechiae once every shift
c. Providing for frequent rest periods
d. Placing the client in strict isolation
Answer B. Because thrombocytopenia impairs blood clotting, the nurse should
inspect the client regularly for signs of bleeding, such as petechiae, purpura,
epistaxis, and bleeding gums. The nurse should avoid administering aspirin because
it may increase the risk of bleeding. Frequent rest periods are indicated for clients
with anemia, not thrombocytopenia. Strict isolation is indicated only for clients who
have highly contagious or virulent infections that are spread by air or physical
contact.
15. Nurse Lucia is providing breast cancer education at a community facility. The
American Cancer Society recommends that women get mammograms:
a. yearly after age 40.

b. after the birth of the first child and every 2 years thereafter.
c. after the first menstrual period and annually thereafter.
d. every 3 years between ages 20 and 40 and annually thereafter.
Answer A. The American Cancer Society recommends a mammogram yearly for
women over age 40. The other statements are incorrect. Its recommended that
women between ages 20 and 40 have a professional breast examination (not a

mammogram) every 3 years.
16. Which intervention is appropriate for the nurse caring for a male client in severe
pain receiving a continuous I.V. infusion of morphine?
a. Assisting with a naloxone challenge test before therapy begins

b. Discontinuing the drug immediately if signs of dependence appear
c. Changing the administration route to P.O. if the client can tolerate fluids
d. Obtaining baseline vital signs before administering the first dose
Answer D. The nurse should obtain the clients baseline blood pressure and pulse
and respiratory rates before administering the initial dose and then continue to
monitor vital signs throughout therapy. A naloxone challenge test may be
administered before using a narcotic antagonist, not a narcotic agonist. The nurse
shouldnt discontinue a narcotic agonist abruptly because withdrawal symptoms
may occur. Morphine commonly is used as a continuous infusion in clients with
severe pain regardless of the ability to tolerate fluids.
17. A 35 years old client with ovarian cancer is prescribed hydroxyurea (Hydrea), an
antimetabolite drug. Antimetabolites are a diverse group of antineoplastic agents
that interfere with various metabolic actions of the cell. The mechanism of action of
antimetabolites interferes with:
a. cell division or mitosis during the M phase of the cell cycle.

b. normal cellular processes during the S phase of the cell cycle.
c. the chemical structure of deoxyribonucleic acid (DNA) and chemical binding
between DNA molecules (cell cyclenonspecific).
d. one or more stages of ribonucleic acid (RNA) synthesis, DNA synthesis, or both
(cell cyclenonspecific).
Answer B. Antimetabolites act during the S phase of the cell cycle, contributing to
cell destruction or preventing cell replication. Theyre most effective against rapidly
proliferating cancers. Miotic inhibitors interfere with cell division or mitosis during
the M phase of the cell cycle. Alkylating agents affect all rapidly proliferating cells
by interfering with DNA; they may kill dividing cells in all phases of the cell cycle
and may also kill nondividing cells. Antineoplastic antibiotic agents interfere with
one or more stages of the synthesis of RNA, DNA, or both, preventing normal cell
growth and reproduction.
18. The ABCD method offers one way to assess skin lesions for possible skin cancer.
What does the A stand for?
a. Actinic
b. Asymmetry
c. Arcus
d. Assessment
Answer B. When following the ABCD method for assessing skin lesions, the A stands
for "asymmetry," the B for "border irregularity," the C for "color variation," and the
D for "diameter."
19. When caring for a male client diagnosed with a brain tumor of the parietal lobe,
the nurse expects to assess:
a. short-term memory impairment.

b. tactile agnosia.
c. seizures.
d. contralateral homonymous hemianopia.
Answer B. Tactile agnosia (inability to identify objects by touch) is a sign of a
parietal lobe tumor. Short-term memory impairment occurs with a frontal lobe
tumor. Seizures may result from a tumor of the frontal, temporal, or occipital lobe.
Contralateral homonymous hemianopia suggests an occipital lobe tumor.
20. A female client is undergoing tests for multiple myeloma. Diagnostic study
findings in multiple myeloma include:
a. a decreased serum creatinine level.

b. hypocalcemia.
c. Bence Jones protein in the urine.
d. a low serum protein level.
Answer C. Presence of Bence Jones protein in the urine almost always confirms the
disease, but absence doesnt rule it out. Serum calcium levels are elevated because
calcium is lost from the bone and reabsorbed in the serum. Serum protein
electrophoresis shows elevated globulin spike. The serum creatinine level may also
be increased.
21. A 35 years old client has been receiving chemotherapy to treat cancer. Which
assessment finding suggests that the client has developed stomatitis (inflammation
of the mouth)?
a. White, cottage cheeselike patches on the tongue

b. Yellow tooth discoloration
c. Red, open sores on the oral mucosa
d. Rust-colored sputum
Answer C. The tissue-destructive effects of cancer chemotherapy typically cause
stomatitis, resulting in ulcers on the oral mucosa that appear as red, open sores.
White, cottage cheeselike patches on the tongue suggest a candidal infection,
another common adverse effect of chemotherapy. Yellow tooth discoloration may
result from antibiotic therapy, not cancer chemotherapy. Rust-colored sputum
suggests a respiratory disorder, such as pneumonia.
22. During chemotherapy, an oncology client has a nursing diagnosis of impaired

oral mucous membrane related to decreased nutrition and immunosuppression
secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is
most likely to decrease the pain of stomatitis?
a. Recommending that the client discontinue chemotherapy

b. Providing a solution of hydrogen peroxide and water for use as a mouth rinse
c. Monitoring the clients platelet and leukocyte counts
d. Checking regularly for signs and symptoms of stomatitis
.Answer B. To decrease the pain of stomatitis, the nurse should provide a solution of
hydrogen peroxide and water for the client to use as a mouth rinse. (Commercially
prepared mouthwashes contain alcohol and may cause dryness and irritation of the
oral mucosa.) The nurse also may administer viscous lidocaine or systemic
analgesics as prescribed. Stomatitis occurs 7 to 10 days after chemotherapy begins;
thus, stopping chemotherapy wouldnt be helpful or practical. Instead, the nurse
should stay alert for this potential problem to ensure prompt treatment. Monitoring
platelet and leukocyte counts may help prevent bleeding and infection but wouldnt
decrease pain in this highly susceptible client. Checking for signs and symptoms of
stomatitis also wouldnt decrease the pain.
23. What should a male client over age 52 do to help ensure early identification of
prostate cancer?
a. Have a digital rectal examination and prostate-specific antigen (PSA) test done
yearly.
b. Have a transrectal ultrasound every 5 years.
c. Perform monthly testicular self-examinations, especially after age 50.
d. Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine
levels checked yearly.
Answer A. The incidence of prostate cancer increases after age 50. The digital rectal
examination, which identifies enlargement or irregularity of the prostate, and PSA
test, a tumor marker for prostate cancer, are effective diagnostic measures that
should be done yearly. Testicular self-examinations wont identify changes in the
prostate gland due to its location in the body. A transrectal ultrasound, CBC, and
BUN and creatinine levels are usually done after diagnosis to identify the extent of
the disease and potential metastases
24. A male client complains of sporadic epigastric pain, yellow skin, nausea,
vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician
orders a diagnostic workup, which reveals gallbladder cancer. Which nursing
diagnosis may be appropriate for this client?
a. Anticipatory grieving
b. Impaired swallowing
c. Disturbed body image
d. Chronic low self-esteem
Answer A. Anticipatory grieving is an appropriate nursing diagnosis for this client
because few clients with gallbladder cancer live more than 1 year after diagnosis.
Impaired swallowing isnt associated with gallbladder cancer. Although surgery
typically is done to remove the gallbladder and, possibly, a section of the liver, it
isnt disfiguring and doesnt cause Disturbed body image. Chronic low self-esteem
isnt an appropriate nursing diagnosis at this time because the diagnosis has just
been made.
25. A male client is in isolation after receiving an internal radioactive implant to

treat cancer. Two hours later, the nurse discovers the implant in the bed linens.
What should the nurse do first?
a. Stand as far away from the implant as possible and call for help.
b. Pick up the implant with long-handled forceps and place it in a lead-lined
container.
c. Leave the room and notify the radiation therapy department immediately.
d. Put the implant back in place, using forceps and a shield for self-protection, and
call for help.
Answer B. If a radioactive implant becomes dislodged, the nurse should pick it up
with long-handled forceps and place it in a lead-lined container, then notify the
radiation therapy department immediately. The highest priority is to minimize
radiation exposure for the client and the nurse; therefore, the nurse must not take
any action that delays implant removal. Standing as far from the implant as
possible, leaving the room with the implant still exposed, or attempting to put it
back in place can greatly increase the risk of harm to the client and the nurse from
excessive radiation exposure.
26. Jeovina, with advanced breast cancer is prescribed tamoxifen (Nolvadex). When
teaching the client about this drug, the nurse should emphasize the importance of
reporting which adverse reaction immediately?
a. Vision changes
b. Hearing loss
c. Headache
d. Anorexia
Answer A. The client must report changes in visual acuity immediately because this
adverse effect may be irreversible. Tamoxifen isnt associated with hearing loss.
Although the drug may cause anorexia, headache, and hot flashes, the client need
not report these adverse effects immediately because they dont warrant a change
in therapy.
27. A female client with cancer is being evaluated for possible metastasis. Which of
the following is one of the most common metastasis sites for cancer cells?
a. Liver
b. Colon
c. Reproductive tract
d. White blood cells (WBCs)
Answer A. The liver is one of the five most common cancer metastasis sites. The
others are the lymph nodes, lung, bone, and brain. The colon, reproductive tract,
and WBCs are occasional metastasis sites.
28. A 34-year-old female client is requesting information about mammograms and

breast cancer. She isnt considered at high risk for breast cancer. What should the
nurse tell this client?
a. She should have had a baseline mammogram before age 30.

b. She should eat a low-fat diet to further decrease her risk of breast cancer.
c. She should perform breast self-examination during the first 5 days of each
menstrual cycle.
d. When she begins having yearly mammograms, breast self-examinations will no
longer be necessary.
Answer B. A low-fat diet (one that maintains weight within 20% of recommended
body weight) has been found to decrease a womans risk of breast cancer. A
baseline mammogram should be done between ages 30 and 40. Monthly breast
self-examinations should be done between days 7 and 10 of the menstrual cycle.
The client should continue to perform monthly breast self-examinations even when
receiving yearly mammograms.
29. Nurse Brian is developing a plan of care for marrow suppression, the major
dose-limiting adverse reaction to floxuridine (FUDR). How long after drug
administration does bone marrow suppression become noticeable?
a. 24 hours
b. 2 to 4 days
c. 7 to 14 days
d. 21 to 28 days
Answer C. Bone marrow suppression becomes noticeable 7 to 14 days after
floxuridine administration. Bone marrow recovery occurs in 21 to 28 days.
30. The nurse is preparing for a female client for magnetic resonance imaging (MRI)
to confirm or rule out a spinal cord lesion. During the MRI scan, which of the
following would pose a threat to the client?
a. The client lies still.

b. The client asks questions.
c. The client hears thumping sounds.
d. The client wears a watch and wedding band.
Answer D. During an MRI, the client should wear no metal objects, such as jewelry,
because the strong magnetic field can pull on them, causing injury to the client and
(if they fly off) to others. The client must lie still during the MRI but can talk to those
performing the test by way of the microphone inside the scanner tunnel. The client
should hear thumping sounds, which are caused by the sound waves thumping on
the magnetic field.
Multiple Choice Questions (12)

1. Multiple Organ Dysfunction Syndrome (MODS)
o
Syndrome characterized by inadequate tissue perfusion and imbalanced oxygen

supply and demand.
o
Stage of shock where the body uses defensive mechanisms to correct the insult or
cause.
o
Failure of 2 or more organ systems so that homeostasis cannot be maintained

without intervention.
Type of shock resulting from a blockage in the vessels, such as a pulmonary

embolism.
Answer:

2. Neurogenic Shock
o
In this stage of shock, compensatory mechanisms begin to fail and organs begin to
fail.
o
cause.
o

embolism.
o
Type of shock resulting from a spinal cord insult leading to massive vasodilation.
Neurogenic Shock
Answer:
3. Compensatory Stage
o

embolism.
o

supply and demand.
o
cause.
o
Type of shock resulting from an infectious organism that initiates a widespread

inflammatory response.
Compensatory Stage
Answer:
cause.
4. Shock

embolism.
o
Inflammatory state affecting the whole body, frequently a response of the immune
system to infection.
o

supply and demand.
o

Answer:

supply and demand.
5. Irreversible or Refractory Stage
o

At this stage of shock, the vital organs have failed. Brain damage and cell death
have occurred. Death will occur imminently.
o
Type of shock resulting from dysfunction of the heart- either diastolic or systolic
dysfunction.
o
Type of shock that results from the loss of blood due to trauma or hemorrhage.
Answer:
6. Septic Shock
o

supply and demand.
o
o
o

Answer:

7. Anaphylactic Shock
o
o

supply and demand.
o
Type of shock resulting from an immune response to a substance in the

environment; very rapid and dramatic decline.
o

Answer:
Type of shock resulting from an immune response to a substance in the

environment; very rapid and dramatic decline.
8. Systemic Inflammatory Response Syndrome (SIRS)
o
o
cause.
o

o

Answer:
9. Progressive or Decompensatory Stage
o
dysfunction.
o
o
fail.
Answer:
fail.
10. Hypovolemic Shock
o

o

supply and demand.
o
o
Answer:
11. Obstructive Shock
o

embolism.
o

o
fail.
cause.
Answer:

embolism.
12. Cardiogenic Shock
o
o
dysfunction.
o
o
cause.
Answer:
dysfunction.

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Burns- Answers and Rationale

DIF: Cognitive Level: Application or higher

A. The medication will be effective more quickly than if given intramuscularly.

A. The client is a 26-year-old male.

6. The burned client is ordered to receive intravenous cimetidine, an H2 histamine

A. To increase the urine output and prevent kidney damage.

DIF: Cognitive Level: Application or higher

A. Immediately following the injury

A. Pulse oximetry reading of 80%

9. What clinical manifestation indicates that an escharotomy is needed on a

A. The burn is full thickness rather than partial thickness.

MSC: Client Needs Category: Safe, Effective Care Environment;

DIF: Cognitive Level: Application or higher

A. Raise the head of the bed.

DIF: Cognitive Level: Application or higher

A. Notify the emergency team.

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment

A. Reposition the client onto the right side.

ANS: B Decreased or absent peristalsis is an expected response during the

DIF: Cognitive Level: Application or higher

A. Increased urine output, decreased urine specific gravity

DIF: Cognitive Level: Application or higher

A. Risk for Ineffective Breathing Pattern

DIF: Cognitive Level: Application or higher

A. Serum sodium elevated to 131 mmol/L (mEq/L)

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Application or higher

A. Are you a smoker?

DIF: Cognitive Level: Application or higher

A. The client is able to talk.

DIF: Cognitive Level: Application or higher

A. The client is able to talk.

DIF: Cognitive Level: Application or higher

A. When fluid remobilization has started.

DIF: Cognitive Level: Comprehension

TOP: Nursing Process Step: Implementation/Intervention

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment

A. Assess level of consciousness and pupillary reactions.

DIF: Cognitive Level: Application or higher

A. Handwashing on entering the client's room

DIF: Cognitive Level: Application or higher

A. The total white blood cell count is 9000/mm3.

B. The lymphocytes outnumber the basophils.

DIF: Cognitive Level: Application or higher

A. Place a towel roll under the client's neck or shoulder.

DIF: Cognitive Level: Application or higher

A. Hip maintained in 30-degree flexion, no knee flexion

DIF: Cognitive Level: Application or higher

A. Increased wound pain 30 to 40 minutes after drug application

B. Presence of small, pale pink bumps in the wound beds

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Application or higher

TOP: Nursing Process Step: Implementation/Intervention

33. Which intervention is most important to use to prevent infection by

DIF: Cognitive Level: Application or higher

DIF: Cognitive Level: Comprehension

DIF: Cognitive Level: Application or higher

36. Which statement by the client indicates correct understanding of rehabilitation

A. I will never be fully recovered from the burn.

DIF: Cognitive Level: Application or higher

A. After this treatment, my ears will not stick out.