NCLEX-PN
Hematology NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse is administering vesicant chemotherapy medications such as doxorubicin hydrochloride to clients. Which nursing actions should the nurse implement to prevent extravasation?
Correct Answer: A, B, D
Rationale: A peripheral IV catheter may be used for a vesicant if administration time is less than 60 minutes, a large vein is used, and there is careful monitoring of the IV site. B. Checking for patency and asking about discomfort at the IV site will help prevent an infiltration. C. IV pumps and alarms cannot be relied upon to detect extravasation because infiltration usually does not cause sufficient pressure to trigger an alarm. D. Checking for blood return in the central venous catheter prior to administration will help ensure that the medication is being administered into a vessel and not into tissues. E. Small-gauge syringes with small barrels produce high pressures and may cause injury to the blood vessel or may damage a central line catheter and should not be used.
Question 2 of 5
When reviewing the client’s medical record, the experienced nurse discovers that the client’s breast cancer is staged as T4 N3 M1. Which comment made by the experienced nurse to the new nurse is correct?
Correct Answer: B
Rationale: A. The T4 N3 M1 indicates that the client’s primary tumor is very large, involves 3 lymph nodes, with distant metastasis (T is the size and extent and ranges from 1-4; N is number of nodes involved, and M1 indicates metastasis). B. This statement is correct. The tumor-node-metastasis (TNM) system classifies solid tumors by size and degree of spread. It is an international system that allows comparison of statistics among cancer centers. C. A higher number means that a more serious situation exists. D. A different rating system is used to define the cell types of tumors as well differentiated (closely resembles normal tissue) or poorly differentiated (tumor that contains some normal cells, but most cells are abnormal).
Question 3 of 5
In which order should the nurse address the assessment findings for the client who has undergone a total laryngectomy? Place the findings in the order of priority.
Correct Answer: B, A, D, C
Rationale: . Restless and has a mucus plug in the tracheostomy is priority requiring immediate attention due to the negative impact on air exchange. The client needs immediate suctioning. A. Copious oral secretions and nasal mucus draining from the nose should be next. After a total laryngectomy the mouth does not communicate with the trachea, so copious oral secretions and nasal drainage would not influence air exchange, but these create a source of discomfort for the client. D. Oozing serosanguineous drainage around the tracheostomy tube and saturated dressing should be addressed third. Changing the dressing now would allow the nurse to inspect the site and ensure tube patency. C. NG tube used for intermittent feedings pulled halfway out can be addressed last. There is no indication that a tube feeding is infusing. The HCP should be contacted to reinsert the NG tube to prevent disruption of the suture line in the esophagus.
Question 4 of 5
The nurse assesses that the client who is receiving radiation for cervical cancer continues to have diarrhea. Which nursing advice is most appropriate for this client?
Correct Answer: A
Rationale: A. The client with diarrhea should eat a low-residue diet to decrease roughage and bowel irritability and take sitz (or tub) baths twice daily to increase comfort. B. Intake of fluids that are high in potassium (not low) is recommended to replace electrolytes lost through diarrhea. C. Milk products are discouraged because they increase bowel irritability. D. Intake of fluids high in sodium should be avoided because it contributes to water retention, but hydrocolloid pads may be used on reddened areas to promote healing.
Question 5 of 5
The nurse is preparing to administer the chemotherapeutic agent cisplatin IV to the client with ovarian cancer. The dose is 100 mg/m2 in 2 liters of DSW to be infused over 8 hours. What is the rate in milliliters (mL) per hour that the nurse should set the infusion pump to deliver the medication? __________ mL/hour (Record your answer as a whole number.)
Correct Answer: 250
Rationale: first convert liters to milliliters: 1000 mL/1L= XmL/2L. 1000mL* 2L= 1L * x mL;
2000 mL = X. Next ,CALCULATE the mL per hour 2000 mL /8 Hours =250mL/hour