Question

The nurse working at a community event provides information about the primary prevention of cancer. What is an example of primary cancer prevention?

Answer 1

Correct Answers:

Immunization

Rationale :

💠 Primary cancer prevention focuses on preventing the disease before it develops, rather than detecting or treating it later.

💠 Immunization (such as HPV or Hepatitis B vaccines) prevents viral infections that are known to cause certain cancers.

💠 By stopping the initial causative factor, immunization reduces the incidence of cancer in the population.

💠 This strategy acts before cellular changes occur, aligning directly with primary prevention principles.

💠 Community-based immunization programs are a key public health approach to lowering long-term cancer risk.

Cancer screening

💠 Screening is used to detect cancer early, not to prevent its occurrence.

💠 This is classified as secondary prevention.

Colonoscopy

💠 Colonoscopy is a screening and early detection tool.

💠 It identifies disease at an early stage rather than preventing initial development.

Chemotherapy

💠 Chemotherapy is used to treat existing cancer.

💠 This represents tertiary prevention, not primary prevention.

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Answer 2

Correct Answers:

The client has a history of obstructive sleep apnea.

Rationale :

💠 Obstructive sleep apnea (OSA) significantly increases the risk of airway obstruction and respiratory depression during and after anesthesia.

💠 Clients with OSA are highly sensitive to sedatives, opioids, and anesthetic agents, which can worsen hypoventilation.

💠 Undiagnosed or unmanaged OSA can lead to postoperative hypoxia, apnea, and cardiac complications.

💠 This condition requires preoperative planning, such as anesthesia modification and postoperative monitoring.

💠 Addressing OSA before surgery is essential to ensure airway safety and adequate oxygenation, making it the most critical finding.

The client reports a fear of not waking up from anesthesia.

💠 This reflects preoperative anxiety, which is common in older adults.

💠 Anxiety should be addressed therapeutically but does not pose an immediate physiologic risk.

The client's blood pressure is 140/85 mmHg.

💠 This reading indicates mild hypertension, which is generally acceptable for surgery.

💠 It can be managed perioperatively and is not an immediate contraindication.

The client's blood glucose is 210 mg/dL.

💠 Elevated glucose increases the risk of infection and delayed healing, but it is not the most urgent pre-op threat.

💠 Blood glucose can be controlled before and after surgery with appropriate management.

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Answer 3

Correct Answers:

Ensure the client's pain is well managed.
Contact spiritual services to speak with the client.

Rationale :

Ensure the client's pain is well managed.

💠 Effective pain control is central to improving quality of life in clients with advanced cancer.

💠 Uncontrolled pain negatively affects mobility, sleep, mood, and appetite, worsening overall well-being.

💠 Adequate pain management supports participation in care decisions and daily activities.

💠 It reduces psychological distress, including anxiety and depression.

💠 Comfort-focused care aligns with palliative goals, even while receiving curative or life-prolonging treatment.

Contact spiritual services to speak with the client.

💠 Spiritual support addresses emotional and existential concerns common in stage 4 cancer.

💠 It can help clients cope with fear, uncertainty, and meaning-making during illness.

💠 Spiritual care supports holistic nursing, beyond physical symptoms.

💠 It may improve emotional comfort and inner peace, enhancing quality of life.

💠 This intervention respects individual beliefs and values in serious illness.

Bring the client to the dining hall to eat their meals.

💠 Clients admitted with an active infection may require isolation or limited mobility.

💠 This does not directly address comfort, symptom relief, or emotional support.

Provide stool softeners for loose stools.

💠 Stool softeners are contraindicated when stools are already loose or watery.

💠 This intervention may worsen diarrhea and decrease comfort.

Encourage the client to eat high fat foods.

💠 High-fat foods may be poorly tolerated during chemotherapy or infection.

💠 Nutrition plans should focus on tolerance and preference, not fat content alone.

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Answer 4

Correct Answers:

Provide pain medication and reassess use of the spirometer

Rationale :

💠 Adequate pain control is essential to allow the client to deep breathe effectively after surgery.

💠 Incisional pain limits chest expansion, increasing the risk of alveolar collapse (atelectasis).

💠 Administering analgesia first removes the primary barrier to participation in breathing exercises.

💠 Reassessing spirometer use after pain relief promotes lung expansion and oxygenation.

💠 This action follows physiologic priority and prevention-focused care.

Document the client's refusal and reattempt again later

💠 Delaying intervention allows atelectasis to develop or worsen.

💠 Documentation alone does not address the underlying cause—pain.

Encourage the client to ambulate in the hallway as tolerated

💠 Ambulation helps lung expansion but is not the initial step when pain is preventing breathing exercises.

💠 The client may still avoid deep breathing if pain is untreated.

Notify the provider that the client is refusing to deep breathe

💠 Provider notification is not required initially for a common postoperative issue.

💠 Nursing interventions should first address modifiable factors like pain.

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Answer 5

Correct Answers:

167 ml/hr

Rationale :

💠 Identify the total volume to be infused, which is 250 mL of premixed vancomycin.

💠 Convert infusion time from 90 minutes to hours (90 ÷ 60 = 1.5 hr) to match pump settings.

💠 Apply the IV pump formula: mL ÷ hr = mL/hr for accurate calculation.

💠 Calculate: 250 ÷ 1.5 = 166.7 mL/hr, which rounds to 167 mL/hr.

💠 Setting the correct rate helps prevent vancomycin infusion reactions such as red man syndrome.

250 mL/hr

💠 This rate would infuse the medication in 1 hour, not the prescribed 90 minutes.

💠 Rapid infusion increases the risk of adverse reactions.

83 mL/hr

💠 This rate would significantly delay medication delivery.

💠 Under-infusion may lead to subtherapeutic antibiotic levels.

172 mL/hr

💠 This rate exceeds the calculated and rounded value.

💠 It may result in faster-than-ordered infusion, increasing side effect risk.

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Answer 6

Correct Answers:

Respect the client's statement and immediately notify the surgeon of the client's decision.

Rationale :

💠 Clients have the legal and ethical right to withdraw consent at any time, even after signing a consent form.

💠 Once the client states they no longer agree, the consent is no longer valid, and surgery must not proceed.

💠 The nurse’s priority is to advocate for the client’s autonomy and informed decision-making.

💠 Notifying the surgeon immediately ensures the procedure is halted and the client’s wishes are respected.

💠 This action aligns with ethical principles, legal standards, and patient-centered care.

Ask the client's family to talk to them and encourage them to go through with the surgery.

💠 Family members cannot override the client’s decision.

💠 This may create undue pressure, violating patient autonomy.

Remind the client that the signed consent form is a legally binding contract.

💠 A consent form is not a binding contract and can be withdrawn at any time.

💠 Providing this statement is legally inaccurate and coercive.

Administer the prescribed antianxiety medication to help calm the client's nerves.

💠 Giving medication could impair decision-making capacity.

💠 The client’s refusal must be honored before any sedating medication is given.

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Answer 7

Correct Answers:

Pulmonary embolism

Rationale :

💠 Sudden onset chest pain with hemoptysis is a classic presentation of a pulmonary embolism, especially in the postoperative period.

💠 Postoperative clients are at increased risk due to venous stasis, immobility, and hypercoagulability.

💠 Tachypnea, restlessness, and accessory muscle use indicate acute respiratory distress and impaired gas exchange.

💠 An oxygen saturation of 92% despite supplemental oxygen suggests ventilation–perfusion mismatch.

💠 Pulmonary embolism is a life-threatening emergency requiring immediate recognition and intervention.

Respiratory depression

💠 Respiratory depression presents with slow, shallow respirations, not tachypnea.

💠 It does not cause chest pain or hemoptysis.

Pneumonia

💠 Pneumonia usually has a gradual onset with fever and productive cough.

💠 It is unlikely to cause sudden chest pain and bloody sputum on postoperative day one.

Atelectasis

💠 Atelectasis commonly causes mild dyspnea and decreased breath sounds, not hemoptysis.

💠 It does not typically produce acute chest pain or severe respiratory distress

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Answer 8

Correct Answers:

Notify the healthcare provider of possible infection.

Rationale :

💠 Increasing pain, warmth, redness, and purulent drainage are classic signs of a surgical site infection, which requires prompt medical evaluation.

💠 On postoperative day one, these findings are abnormal and suggest bacterial involvement, not normal healing.

💠 Early provider notification allows for timely cultures, antibiotics, or wound management to prevent spread.

💠 Delayed reporting can lead to systemic infection, sepsis, or wound dehiscence.

💠 This action reflects priority nursing judgment, addressing a potentially serious complication before routine care.

Rinse the wound with normal saline.

💠 Cleansing may be ordered later but does not address the underlying infection.

💠 Independent wound manipulation without provider direction may delay definitive treatment.

Reevaluate the incision site in one hour.

💠 Waiting allows the infection to progress unchecked.

💠 Signs of infection require immediate action, not reassessment alone.

Administer the prescribed analgesic.

💠 Pain medication may mask symptoms without treating the cause.

💠 Symptom control should not precede reporting suspected infection.

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Answer 9

Correct Answers:

Avoid use of cigarettes and smokeless tobacco

Rationale :

💠 Tobacco use increases cancer risk by exposing breast tissue to carcinogenic substances that promote malignant cell changes.

💠 Avoiding cigarettes and smokeless tobacco supports primary prevention, which focuses on reducing risk before disease develops.

💠 Smoking is linked to hormonal disruption and oxidative stress, both associated with breast cancer development.

💠 Eliminating tobacco use improves overall immune and vascular health, supporting cancer risk reduction.

💠 This recommendation aligns with evidence-based public health strategies for lowering cancer incidence.

Perform monthly breast examinations

💠 Breast self-exams aid in early detection, not risk reduction.

💠 This represents secondary prevention, not primary prevention.

Increase the consumption of red meats and vegetables

💠 High red meat intake is associated with increased cancer risk.

💠 This combination does not clearly support breast cancer risk reduction.

Use sunscreen when outside, even on cloudy days

💠 Sunscreen use reduces skin cancer risk, not breast cancer risk.

💠 This intervention is unrelated to breast tissue malignancy prevention.

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Answer 10

Correct Answers:

25 ml/hr

Rationale :

💠 Identify the total volume to be infused, which is 100 mL of diluted piperacillin/tazobactam.

💠 Confirm the prescribed infusion time, which is 4 hours per dose.

💠 Use the IV pump formula: mL ÷ hr = mL/hr to determine the correct rate.

💠 Calculate: 100 ÷ 4 = 25 mL/hr, ensuring accurate extended infusion delivery.

💠 This slow rate supports optimal antibiotic exposure and helps reduce the risk of adverse effects.

75 mL/hr

💠 This rate would infuse the medication in ~1.3 hours, not the prescribed 4 hours.

💠 Rapid infusion defeats the purpose of extended dosing.

100 mL/hr

💠 This would complete the infusion in 1 hour, which is incorrect.

💠 It increases the risk of infusion-related reactions.

50 mL/hr

💠 This rate would finish in 2 hours, shorter than ordered.

💠 Under-delivers the extended infusion strategy.

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Examplify RN Medsurg -Perioperative Care Unit 1

No.

1 :
The nurse working at a community event provides information about the primary prevention of cancer. What is an example of primary cancer prevention?

2 :
A 80-year-old client is scheduled for hernia surgery. Which preoperative assessment finding is most critical to address before surgery?

3 :
A client has been admitted to the hospital for an infection. The client has recently been diagnosed with stage 4 breast cancer and has been undergoing chemotherapy. What interventions can the nurse implement to improve the client's quality of life? Select all that apply.

4 :
A nurse is caring for a postoperative client who is reluctant to perform deep breathing exercises due to incisional pain. What is the most appropriate initial nursing action to help prevent atelectasis?

5 :
The healthcare provider orders 1 gram of Vancomycin IV to be infused over 90 minutes. The pharmacy delivers a premixed bag with 1 gram in 250 ml. What should the nurse set the infusion rate at?

6 :
A client in the preoperative holding area has signed their surgical consent form but tells the nurse, "I've changed my mind, I don't want this surgery anymore." What is the nurse's priority action?

8 :
A client who is one day post-surgery reports increasing pain at the incision site, warmth, redness, and purulent drainage. What is the nurse's priority intervention?

9 :
A nurse is providing education on breast cancer at the community center. What information should the nurse include when discussing ways to decrease the risk of breast cancer?

10 :
Post-op a client is prescribed piperacillin/tazobactam 3.375 g every 12 hours to run over 4 hours each dose. Pharmacy dilutes 3.375 g of piperacillin/tazobactam in 100 ml of normal saline. What should the nurse set the IV pump rate at to deliver the dose over 4 hours?

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Examplify RN Medsurg -Perioperative Care Unit 1

No.

1 : The nurse working at a community event provides information about the primary prevention of cancer. What is an example of primary cancer prevention?

2 : A 80-year-old client is scheduled for hernia surgery. Which preoperative assessment finding is most critical to address before surgery?

3 : A client has been admitted to the hospital for an infection. The client has recently been diagnosed with stage 4 breast cancer and has been undergoing chemotherapy. What interventions can the nurse implement to improve the client's quality of life? Select all that apply.

4 : A nurse is caring for a postoperative client who is reluctant to perform deep breathing exercises due to incisional pain. What is the most appropriate initial nursing action to help prevent atelectasis?

5 : The healthcare provider orders 1 gram of Vancomycin IV to be infused over 90 minutes. The pharmacy delivers a premixed bag with 1 gram in 250 ml. What should the nurse set the infusion rate at?

6 : A client in the preoperative holding area has signed their surgical consent form but tells the nurse, "I've changed my mind, I don't want this surgery anymore." What is the nurse's priority action?

8 : A client who is one day post-surgery reports increasing pain at the incision site, warmth, redness, and purulent drainage. What is the nurse's priority intervention?

9 : A nurse is providing education on breast cancer at the community center. What information should the nurse include when discussing ways to decrease the risk of breast cancer?

10 : Post-op a client is prescribed piperacillin/tazobactam 3.375 g every 12 hours to run over 4 hours each dose. Pharmacy dilutes 3.375 g of piperacillin/tazobactam in 100 ml of normal saline. What should the nurse set the IV pump rate at to deliver the dose over 4 hours?

1 :
The nurse working at a community event provides information about the primary prevention of cancer. What is an example of primary cancer prevention?

2 :
A 80-year-old client is scheduled for hernia surgery. Which preoperative assessment finding is most critical to address before surgery?

3 :
A client has been admitted to the hospital for an infection. The client has recently been diagnosed with stage 4 breast cancer and has been undergoing chemotherapy. What interventions can the nurse implement to improve the client's quality of life? Select all that apply.

4 :
A nurse is caring for a postoperative client who is reluctant to perform deep breathing exercises due to incisional pain. What is the most appropriate initial nursing action to help prevent atelectasis?

5 :
The healthcare provider orders 1 gram of Vancomycin IV to be infused over 90 minutes. The pharmacy delivers a premixed bag with 1 gram in 250 ml. What should the nurse set the infusion rate at?

6 :
A client in the preoperative holding area has signed their surgical consent form but tells the nurse, "I've changed my mind, I don't want this surgery anymore." What is the nurse's priority action?

8 :
A client who is one day post-surgery reports increasing pain at the incision site, warmth, redness, and purulent drainage. What is the nurse's priority intervention?

9 :
A nurse is providing education on breast cancer at the community center. What information should the nurse include when discussing ways to decrease the risk of breast cancer?

10 :
Post-op a client is prescribed piperacillin/tazobactam 3.375 g every 12 hours to run over 4 hours each dose. Pharmacy dilutes 3.375 g of piperacillin/tazobactam in 100 ml of normal saline. What should the nurse set the IV pump rate at to deliver the dose over 4 hours?