Question

A client with a history of metastatic lung cancer arrives in the emergency department via ambulance, with a complaint of severe back pain and urinary retention. Client states they have had midback pain of 9/10 on a 0-10 pain scale for the last two (2) days. The last chemotherapy treatment was one (1) week ago with premixed and carboplatin. Once a computerized tomography (CT) scan is complete, a diagnosis of cord compression is documented. The nurse anticipates which interventions will be

Answer 1

Correct Answers:

External beam radiation

Rationale :

✨ Spinal cord compression from metastatic cancer is an oncologic emergency that requires rapid treatment to prevent permanent neurologic damage.

✨ After diagnosis, the priority is relieving pressure and controlling tumor growth, and external beam radiation is commonly used because it treats the spinal lesion quickly and noninvasively.

✨ It helps reduce tumor size and inflammation, improving pain, motor function, and bladder/bowel symptoms.

✨ This approach is especially appropriate when metastasis is present and immediate decompression is needed without delay.

✨ External beam radiation is a standard first-line therapy for many cases of malignant cord compression.

Surgical intervention

✨Surgery is used when there is spinal instability, a single compressive lesion, or worsening neurologic deficits despite radiation.

✨It is not the most routine first-line option for all metastatic cord compression cases.

Radiation using brachytherapy

✨Brachytherapy is internal radiation and is not typically used for urgent spinal cord compression.

✨External beam is preferred for rapid, broader field treatment.

Radiofrequency ablation

✨RFA can reduce tumor pain or burden in select lesions but is not a primary emergency intervention for cord compression.

✨It does not reliably provide immediate decompression.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Medication must be tapered, never stop suddenly
Report a fever or sore throat to your health care provider
Avoid crowds and people with infections
Take medication with or soon after a meal

Rationale :

Medication must be tapered, never stop suddenly

🔶 Dexamethasone can suppress the hypothalamic–pituitary–adrenal (HPA) axis, reducing natural cortisol release.

🔶 Stopping suddenly can cause adrenal insufficiency, leading to weakness, hypotension, nausea, and potentially shock.

🔶 A gradual taper allows adrenal glands time to resume normal cortisol production.

🔶 Tapering is especially important if the dose was high or symptoms are still being controlled by the steroid.

🔶 This teaching prevents a dangerous rebound effect and protects physiologic stability.

Report a fever or sore throat to your health care provider

🔶 Steroids suppress immune function, so infections can develop more easily and progress faster.

🔶 Fever and sore throat may be early signs of a serious infection that needs prompt evaluation.

🔶 Steroids can mask inflammation, so clients might not show strong symptoms even with significant infection.

🔶 Early reporting supports rapid treatment and reduces complication risk.

🔶 This protects immunosuppressed clients from severe illness.

Avoid crowds and people with infections

🔶 Dexamethasone decreases the body’s ability to fight viruses, bacteria, and fungi effectively.

🔶 Crowds increase exposure to contagious respiratory illnesses like influenza and COVID-like viruses.

🔶 Avoiding sick contacts reduces the chance of acquiring an infection while immunity is suppressed.

🔶 This is especially important if the client recently had chemotherapy, which can further weaken immune defenses.

🔶 Infection prevention is a key safety priority during steroid therapy.

Take medication with or soon after a meal

🔶 Corticosteroids can irritate the stomach lining and increase risk for gastritis and ulceration.

🔶 Taking the medication with food reduces GI upset and protects the gastric mucosa.

🔶 This also helps minimize nausea and improves medication tolerance.

🔶 Food decreases direct gastric irritation from the medication.

🔶 This teaching supports adherence and prevents GI complications.

Non-steroidal anti-inflammatory drugs are drug of choice for pain relief —

🔶NSAIDs combined with steroids increase the risk of GI bleeding and ulcer formation.

🔶Pain management should be individualized, and clients should consult the provider before using NSAIDs routinely.

Maintain a low sodium, low protein diet

🔶Sodium moderation may be helpful because steroids can cause fluid retention, but a low-protein diet is not standard teaching.

🔶Adequate protein is often important for healing and maintaining muscle unless another condition requires restriction.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Remove the client from the day room to decrease stimuli and stay with client.

Rationale :

💎 In moderate Alzheimer’s, agitation is often triggered by overstimulation and difficulty processing environmental cues.

💎 The safest, most effective intervention is to reduce stimuli by moving the client to a quieter area.

💎 Staying with the client provides reassurance and safety, helping de-escalate distress without confrontation.

💎 This approach supports person-centered care by meeting the client’s need for calm rather than forcing continued participation.

💎 It also decreases risk of escalation, wandering, or aggressive behaviors.

Orient to reality and continue encouraging participation

💎Reality orientation can increase frustration and agitation in dementia.

💎Continuing the activity may worsen overstimulation.

Stay with client while obtaining a PRN order

💎Medication is not the first response for situational agitation; nonpharmacologic de-escalation is preferred initially.

💎Waiting for an order delays immediate calming strategies.

Stay with client and encourage verbalization

💎Verbal processing may be limited in moderate dementia and can increase frustration.

💎Decreasing stimuli is more directly effective for agitation.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Insertion site has occlusive dressing in place

Rationale :

🔷 A chest tube insertion site should be covered with an occlusive dressing to maintain an airtight seal.

🔷 This prevents air from entering the pleural space and reduces risk of worsening pneumothorax.

🔷 Proper dressing also decreases infection risk and stabilizes the tube.

🔷 An occlusive dressing is a routine expected finding for safe chest tube management.

🔷 This indicates appropriate post-insertion care and secure tube placement.

No fluctuation of water in the water seal chamber

🔷Tidaling may be absent for reasons like lung re-expansion or obstruction, so it is not reliably an “expected” baseline finding.

🔷Nurses typically expect to see tidaling early depending on the condition and ventilation.

Vigorous bubbling in the water seal chamber

🔷Continuous or vigorous bubbling suggests an air leak, which is not expected.

🔷Bubbling should generally be intermittent (e.g., with cough) if present.

Drainage system maintained at chest level

🔷The drainage system should be kept below chest level to promote drainage and prevent backflow.

🔷At chest level increases risk of fluid returning to the pleural space.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

"Symptoms of dementia gradually get worse, so the client will not be independent again."

Rationale :

🔵 Dementia is a progressive neurocognitive disorder with gradual decline in memory, judgment, and functional ability.

🔵 Over time, clients typically require increasing assistance with IADLs and ADLs.

🔵 It is appropriate to provide honest, clear information while remaining supportive to the family caregiver.

🔵 This response helps the adult child plan for long-term needs such as supervision, safety measures, and care support.

🔵 Setting realistic expectations is essential for safe decision-making and caregiver preparation.

“You sound like you aren't ready…”

🔵This is judgmental and shifts focus away from addressing the question.

🔵 Therapeutic communication should provide support and information, not criticism.

“Confusion is temporary…”

🔵Dementia-related confusion is not typically temporary and does not resolve like delirium.

🔵This statement is inaccurate and gives false reassurance.

“Mild dementia can be reversed…”

🔵Dementia is generally not reversible; treatment may slow progression or manage symptoms.

🔵This statement is misleading and inappropriate teaching.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Creatinine 2.0 mg/dl.

Rationale :

✨ Chronic urinary retention from BPH can cause back pressure and obstruct urine outflow over time.

✨ This can lead to hydronephrosis and reduced kidney function, raising serum creatinine.

✨ A creatinine of 2.0 mg/dL indicates impaired renal filtration and possible post-renal injury from obstruction.

✨ Prolonged retention places the client at risk for renal damage, UTIs, and bladder distention.

✨ Therefore, elevated creatinine supports chronic urinary retention with kidney involvement.

Potassium 3.3 mEq/L

✨Hypokalemia is not a typical indicator of chronic urinary retention.

✨Retention-related renal impairment more often raises potassium if severe.

Hypotension

✨Hypotension does not directly indicate chronic urinary retention.

✨Retention is more associated with bladder distention and renal effects.

Hypovolemia

✨Hypovolemia is unrelated to urinary outflow obstruction.

✨ It reflects volume loss rather than retention.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Infuse a unit of packed red blood cells in less than 4 hours

Rationale :

🌟 PRBCs must be infused within a safe time frame to reduce risk of bacterial growth and transfusion complications.

🌟 The standard safety guideline is to complete each unit within 4 hours once started.

🌟 This prevents prolonged exposure of blood products at room temperature, which increases contamination risk.

🌟 Timely infusion also supports safe correction of low hemoglobin contributing to shortness of breath.

🌟 Therefore, infusing each unit in less than 4 hours is a key transfusion safety measure.

Patent IV using at least a 24 gauge

🌟Blood transfusions typically require a larger gauge IV (often 18–20) to prevent hemolysis and allow adequate flow.

🌟A 24 gauge is usually too small for PRBCs.

Take vital signs every 15 minutes while infusing

🌟Vitals are checked at baseline and at set intervals (often 15 min after start, then per policy), but not necessarily every 15 minutes continuously.

🌟Constant q15 monitoring is not the standard safety requirement.

Slow the rate if fever/hypotension/back pain occurs

🌟These can indicate a transfusion reaction, and the correct immediate action is to stop the transfusion and notify the provider.

🌟Slowing the rate can dangerously delay treatment.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Calcium 12 mg/dl

Rationale :

✨ Multiple myeloma causes malignant plasma cells to stimulate bone destruction (osteolytic lesions).

✨ Bone breakdown releases calcium into the bloodstream, leading to hypercalcemia.

✨ A calcium level of 12 mg/dL is elevated and aligns with this disorder.

✨ Hypercalcemia can also worsen dehydration and contribute to renal strain, which is common in myeloma.

✨ Therefore, elevated calcium is an expected lab finding in multiple myeloma.

White blood cells 12,000 c/mm³

✨ Mild leukocytosis may reflect infection or inflammation, not a hallmark lab finding of multiple myeloma.

✨Myeloma is more associated with immune dysfunction and anemia rather than predictable WBC elevation.

Platelets 475,000/mm³

✨Thrombocytosis is not expected in multiple myeloma.

✨Bone marrow involvement more commonly causes decreased blood cell production over time.

BUN 4.7 mg/dL

✨ This BUN is low/normal and does not reflect the renal impairment often seen in multiple myeloma.

✨Myeloma can cause renal damage, which would more likely raise BUN/creatinine.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Sympathectomy

Rationale :

🌟 Palliative procedures are intended to relieve symptoms and improve comfort rather than cure disease.

🌟 A sympathectomy interrupts sympathetic nerve pathways and can be used to reduce severe, refractory pain or ischemic symptoms.

🌟 In advanced cancer, targeted nerve interruption can decrease suffering when other treatments are insufficient.

🌟 This aligns with the goal of palliation: improving quality of life by reducing symptom burden.

🌟 Therefore, sympathectomy is identified as a palliative procedure.

Prophylactic radiation

🌟 Prophylactic radiation is aimed at preventing disease recurrence or progression, not primarily symptom relief.

🌟It is considered preventive/adjunct therapy rather than palliative by intent.

TRAM flap reconstruction

🌟TRAM flap surgery is reconstructive and focused on body image and restoration after mastectomy.

🌟It is not performed to relieve cancer symptoms or suffering.

Mastectomy after a lumpectomy

🌟This is a curative/definitive surgical approach to cancer management.

🌟 It targets disease control rather than comfort-focused symptom relief.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Blood pressure 90/58 mmHg and heart rate a 114 bpm with cool, clammy skin

Rationale :

✅ Hypotension + tachycardia on postoperative day 1 strongly suggests acute hypovolemia/hemorrhage or evolving shock after a major abdominal surgery.

✅ Cool, clammy skin reflects poor perfusion from sympathetic vasoconstriction, which is an urgent red flag for circulatory compromise.

✅ After a Whipple, clients are at risk for postoperative bleeding, third spacing, and fluid shifts, making hemodynamic instability an emergency.

✅ Delayed intervention can quickly progress to organ hypoperfusion (kidney injury, altered mental status, worsening acidosis).

✅ This finding requires immediate provider notification and rapid actions (reassessment, IV fluids/blood products, labs, possible imaging/OR evaluation).

Mild abdominal discomfort and bloating with a feeling of pressure

✅Mild discomfort and bloating can be expected early post-op due to gas, ileus risk, and surgical manipulation.

✅This is monitored and managed, but it is not as immediately life-threatening as shock signs.

Small amount of serous drainage unchanged in 2 hours

✅A small, stable amount of serous drainage is often expected and suggests no rapid bleeding.

✅Concerning drainage would be increasing, bright red, or saturating dressings quickly.

Temperature 99.2°F (37.3°C) with clear lungs and minimal redness

✅A low-grade temperature and minimal incision redness can be a normal inflammatory response in the first 24 hours.

✅This should be monitored for trend, but it is not an emergency finding.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

N201E Spring 26 Exam

No.

2 :
The nurse is providing discharge education to this client who has been on corticosteroid therapy for the last seven (7) days with dexamethasone. What client teaching should the nurse reinforce?

3 :
A nurse is providing care to a client with the diagnosis of Alzheimer's Disease. Which intervention should the nurse identify as the most appropriate for a client with moderate stage: Alzheimer's Disease who becomes agitated while in the day room during an activity?

4 :
What should a nurse recognize as an expected assessment finding?

5 :
A nurse is educating the adult child of a client with dementia on the disease process and medications. The adult child asks if the client will ever be able to live Independently again. Which should be the most appropriate response for the nurse to use?

6 :
The nurse is taking care of a client with benign prostatic hypertrophy (BPH). Which finding suggests that this client has prolonged chronic urinary retention?

7 :
Two units of packed red blood cells (PRBC) have been prescribed for a client with a hemoglobin of 8.2 cells/mm3 experiencing shortness of breath. What safety measure should the nurse perform when administering packed red blood cells?

8 :
The nurse is caring for a client with multiple myeloma. While reviewing the laboratory results in the electronic health record (EHR), which result should the nurse expect to note related to this disorder?

9 :
Different procedures are used palliatively to relieve suffering and minimize symptoms of cancer in a client. Which procedure does the nurse identify as a palliative procedure?

10 :
A client with pancreatic cancer is postoperative day one (1) after undergoing a Whipple procedure (pancreaticoduodenectomy). During nursing assessment, which finding should be immediately reported to the primary healthcare provider?

Connect With Us

N201E Spring 26 Exam

No.

2 : The nurse is providing discharge education to this client who has been on corticosteroid therapy for the last seven (7) days with dexamethasone. What client teaching should the nurse reinforce?

3 : A nurse is providing care to a client with the diagnosis of Alzheimer's Disease. Which intervention should the nurse identify as the most appropriate for a client with moderate stage: Alzheimer's Disease who becomes agitated while in the day room during an activity?

4 : What should a nurse recognize as an expected assessment finding?

5 : A nurse is educating the adult child of a client with dementia on the disease process and medications. The adult child asks if the client will ever be able to live Independently again. Which should be the most appropriate response for the nurse to use?

6 : The nurse is taking care of a client with benign prostatic hypertrophy (BPH). Which finding suggests that this client has prolonged chronic urinary retention?

7 : Two units of packed red blood cells (PRBC) have been prescribed for a client with a hemoglobin of 8.2 cells/mm3 experiencing shortness of breath. What safety measure should the nurse perform when administering packed red blood cells?

8 : The nurse is caring for a client with multiple myeloma. While reviewing the laboratory results in the electronic health record (EHR), which result should the nurse expect to note related to this disorder?

9 : Different procedures are used palliatively to relieve suffering and minimize symptoms of cancer in a client. Which procedure does the nurse identify as a palliative procedure?

10 : A client with pancreatic cancer is postoperative day one (1) after undergoing a Whipple procedure (pancreaticoduodenectomy). During nursing assessment, which finding should be immediately reported to the primary healthcare provider?

2 :
The nurse is providing discharge education to this client who has been on corticosteroid therapy for the last seven (7) days with dexamethasone. What client teaching should the nurse reinforce?

3 :
A nurse is providing care to a client with the diagnosis of Alzheimer's Disease. Which intervention should the nurse identify as the most appropriate for a client with moderate stage: Alzheimer's Disease who becomes agitated while in the day room during an activity?

4 :
What should a nurse recognize as an expected assessment finding?

5 :
A nurse is educating the adult child of a client with dementia on the disease process and medications. The adult child asks if the client will ever be able to live Independently again. Which should be the most appropriate response for the nurse to use?

6 :
The nurse is taking care of a client with benign prostatic hypertrophy (BPH). Which finding suggests that this client has prolonged chronic urinary retention?

7 :
Two units of packed red blood cells (PRBC) have been prescribed for a client with a hemoglobin of 8.2 cells/mm3 experiencing shortness of breath. What safety measure should the nurse perform when administering packed red blood cells?

8 :
The nurse is caring for a client with multiple myeloma. While reviewing the laboratory results in the electronic health record (EHR), which result should the nurse expect to note related to this disorder?

9 :
Different procedures are used palliatively to relieve suffering and minimize symptoms of cancer in a client. Which procedure does the nurse identify as a palliative procedure?

10 :
A client with pancreatic cancer is postoperative day one (1) after undergoing a Whipple procedure (pancreaticoduodenectomy). During nursing assessment, which finding should be immediately reported to the primary healthcare provider?