The nurse is caring for a patient and is monitoring the level of consciousness hourly per hospital mandated policy. The nurse initially assesses the patient be awake with forgetfulness and difficulty following commands without prompting or reminders. 1 hour later, the nurse assesses the patient to be sleepy with slow and delayed responses to stimuli. Describe the two assessments of level of consciousness:

Confusion, Lethargic

Confusion, Stupor

Lethargic, Obtunded

Conscious, Confusion

Answer and Explanation

The Correct Answer is A

A. The initial assessment describes a state of confusion where the patient is awake but experiencing forgetfulness and difficulty following commands. The subsequent assessment indicates lethargy, as the patient is now sleepy and has slow responses, which aligns with the definitions of confusion and lethargy.
B. While confusion is present in the first assessment, stupor describes a state of near-unconsciousness, which does not match the second assessment.
C. Although lethargy is appropriate for the second assessment, obtunded refers to a state where the patient is less aware and has difficulty arousing, which is not accurately described here.
D. The first assessment indicates confusion, but the patient is not fully conscious as described in the second assessment, which does not align with this option.

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Correct Answer is A

Explanation

A. The HPV vaccination is a form of primary prevention as it aims to prevent the initial occurrence of cervical cancer by protecting against the human papillomavirus, which is a major risk factor for this cancer.
B. BRCA1 and BRCA2 testing is a form of genetic testing used for risk assessment rather than prevention; it helps identify individuals at high risk for breast and ovarian cancers but does not prevent cancer itself.
C. Annual mammograms are a secondary prevention measure aimed at early detection of breast cancer rather than preventing the disease from occurring, as they help identify cancer in its early stages.
D. Rehabilitation exercises post-chemotherapy are supportive measures for patients undergoing treatment; they do not constitute primary prevention, which focuses on measures taken before cancer develops.

A. Applies pressure to all injection sites for 5 minutes B. Monitors telemetry every hour during therapy C. Ensures the client has a fluid intake of 3000 to 5000 mL/day D. Assists the client in all ambulatory activities

Correct Answer is C

Explanation

A. Applying pressure to injection sites helps reduce bleeding but does not directly prevent tumor lysis syndrome.
B. Monitoring telemetry is important for patients with potential cardiac issues but is not specifically related to preventing complications from tumor lysis syndrome.
C. Ensuring a high fluid intake of 3000 to 5000 mL/day helps dilute electrolytes and reduce the risk of acute kidney injury and other complications associated with tumor lysis syndrome, making this the most crucial intervention.
D. Assisting the client in ambulatory activities may support their overall well-being but does not address the prevention of tumor lysis syndrome.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is presenting information to the public regarding steps to decrease the risk for cancer development. The nurse includes which information as a form of primary prevention?

Correct Answer is A

Explanation

Which intervention is most important for the nurse to implement to prevent complications from tumor lysis syndrome during chemotherapy?

Correct Answer is C

Explanation

A physician prescribes Vancomycin 20 mg/kg IV. The client weighs 110 lbs. The medication is available in vials which contain 500 mg per 8 mL. What should the nurse withdraw from the vial?

A client was recently diagnosed with lung cancer. The nurse is evaluating discharge teaching with the client. Which statement about lung cancer indicates that teaching was effective?

The client has been diagnosed with a frontal lobe brain tumor and has undergone a craniotomy. What position should the nurse place the client post-operatively?

A client has numerous skin lesions. Which one will the nurse evaluate first?

What statement indicates that the client understands teaching about neutropenia as a result of bone marrow suppression?

A client is to receive a continuous infusion of IV Insulin at 6 units per hour. Pharmacy delivers a concentration of 75 units of regular insulin in 150 mL of NSS. At what rate should the nurse set the IV pump?