a patient from the oncology unit asks the nurse about metastasis which of the following statements by the nurse requires immediate intervention by the a patient from the oncology unit asks the nurse about metastasis which of the following statements by the nurse requires immediate intervention by the
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Nursing Elites

ATI RN

Oncology Test Bank

1. A patient from the oncology unit asks the nurse about metastasis. Which of the following statements by the nurse requires immediate intervention by the head nurse?

Correct answer: A

Rationale: The correct answer is A because metastasis refers to the spread of cancer cells to distant parts of the body, not the replication of cells. Choice B is correct as metastasis can indeed occur in various body parts. Choice C is incorrect as it inaccurately combines the concepts of replication and travel of cancer cells. Choice D is also correct as it accurately defines metastasis as the spread of cancer cells.

2. A client with chronic obstructive pulmonary disease (COPD expresses difficulty in bringing up bronchial secretions. Which action should the nurse take to help the client with tenacious bronchial secretions?

Correct answer: Encouraging the client to drink eight glasses of water daily

Rationale: Encouraging the client to drink eight glasses of water daily is the most appropriate action to help with tenacious bronchial secretions in COPD. Increased fluid intake can help in thinning the mucus, making it easier for the client to cough up and clear secretions. This addresses the client's difficulty in bringing up bronchial secretions. Maintaining a semi-Fowler's position can aid in breathing but does not directly address the issue of clearing secretions. Administering oxygen may be necessary for COPD, but it does not specifically target the tenacious secretions. Selecting a low-salt diet can be helpful in managing COPD in general, but it does not directly address the client's current concern of clearing bronchial secretions.

3. A client with diabetes mellitus is receiving teaching from a nurse about foot care. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct answer is to trim toenails straight across. This instruction is crucial for clients with diabetes to prevent ingrown toenails, which can lead to infection. Soaking feet in warm water daily can increase the risk of skin breakdown. Cotton socks are recommended, but the priority in foot care for diabetes is proper nail trimming. Using a heating pad can also pose a burn risk for individuals with reduced sensation in their feet.

4. What is the most effective way to prevent sudden infant death syndrome (SIDS)?

Correct answer: B

Rationale: The correct answer is to place the baby on their back to sleep. This position is the most effective way to prevent sudden infant death syndrome (SIDS) according to research and recommendations from healthcare providers. Choice A, using a firm mattress, is important for infant safety but not as directly related to preventing SIDS. Keeping the room warm, as mentioned in choice C, is not recommended as it may increase the risk of SIDS. While breastfeeding has many benefits, choice D, breastfeeding exclusively is not the most effective method for preventing SIDS.

5. What should a healthcare provider monitor for in a patient with HIV and a CD4 T-cell count below 180 cells/mm3?

Correct answer: A

Rationale: A CD4 T-cell count below 180 cells/mm3 indicates severe immunocompromise in a patient with HIV. Monitoring for signs of infection is crucial because the patient is at high risk of developing opportunistic infections. Anemia (choice B), dehydration (choice C), and bleeding (choice D) are not directly associated with a low CD4 T-cell count in patients with HIV.

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