NUR 402 EXAM 4 NCLEX QUESTIONS AND CORRECT DETAILED
ANSWERS ,A COMPLETE SOLITION THAT COVERS 2024/2025 BEST
RATED TO SCORE A+
Which item would be most beneficial when providing oral care to a patient with metastatic
cancer who is at risk for oral tissue injury secondary to chemotherapy?
A) Firm-bristle toothbrush
B) Hydrogen peroxide rinse
C) Alcohol-based mouthwash
D) 1 tsp salt in 1 L water mouth rinse - CORRECT ANSWERS D) 1 tsp salt in 1 L water mouth
rinse
A salt-water mouth rinse will not cause further irritation to oral tissue that is fragile because
of mucositis, which is a side effect of chemotherapy. A soft-bristle toothbrush will be used.
One teaspoon of sodium bicarbonate may be added to the salt-water solution to decrease
odor, alleviate pain, and dissolve mucin. Hydrogen peroxide and alcohol-based mouthwash
are not used because they would damage the oral tissue.
Which nursing diagnosis is most appropriate for a patient experiencing myelosuppression
secondary to chemotherapy for cancer treatment?
A) Acute pain
B) Hypothermia
C) Powerlessness
D) Risk for infection - CORRECT ANSWERS D) Risk for infection
Myelosuppression is accompanied by a high risk of infection and sepsis. Hypothermia,
powerlessness, and acute pain are also possible nursing diagnoses for patients undergoing
chemotherapy, but the threat of infection is paramount.
Previous administrations of chemotherapy agents to a cancer patient have resulted in
diarrhea. Which dietary modification should the nurse recommend?
A) A bland, low-fiber diet
B) A high-protein, high-calorie diet
C) A diet high in fresh fruits and vegetables
D) A diet emphasizing whole and organic foods - CORRECT ANSWERS A) A bland, low-fiber
diet
,NUR 402 EXAM 4 NCLEX QUESTIONS AND CORRECT DETAILED
ANSWERS ,A COMPLETE SOLITION THAT COVERS 2024/2025 BEST
RATED TO SCORE A+
Patients experiencing diarrhea secondary to chemotherapy and/or radiation therapy often
benefit from a diet low in seasonings and roughage before the treatment. Foods should be
easy to digest and low in fat. Fresh fruits and vegetables are high in fiber and should be
minimized during treatment. Whole and organic foods do not prevent diarrhea.
A 33-year-old patient has recently been diagnosed with stage II cervical cancer. What should
the nurse understand about the patient's cancer?
A) It is in situ.
B) It has metastasized.
C) It has spread locally.
D) It has spread extensively. - CORRECT ANSWERS C) It has spread locally.
Stage II cancer is associated with limited local spread. Stage 0 denotes cancer in situ; stage I
denotes tumor limited to the tissue of origin with localized tumor growth. Stage III denotes
extensive local and regional spread. Stage IV denotes metastasis.
The nurse is caring for a patient receiving an initial dose of chemotherapy to treat a rapidly
growing metastatic colon cancer. The nurse is aware that this patient is at risk for tumor lysis
syndrome (TLS) and will monitor the patient closely for which abnormality associated with
this oncologic emergency?
A) Hypokalemia
B) Hypouricemia
C) Hypocalcemia
D) Hypophosphatemia - CORRECT ANSWERS C) Hypocalcemia
TLS is a metabolic complication characterized by rapid release of intracellular components in
response to chemotherapy. This can rapidly lead to acute renal injury. The hallmark signs of
TLS are hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcemia.
The nurse is caring for a patient suffering from anorexia secondary to chemotherapy. Which
strategy would be most appropriate for the nurse to use to increase the patient's nutritional
intake?
A) Increase intake of liquids at mealtime to stimulate the appetite.
B) Serve three large meals per day plus snacks between each meal.
,NUR 402 EXAM 4 NCLEX QUESTIONS AND CORRECT DETAILED
ANSWERS ,A COMPLETE SOLITION THAT COVERS 2024/2025 BEST
RATED TO SCORE A+
C) Avoid the use of liquid protein supplements to encourage eating at mealtime.
D) Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods. -
CORRECT ANSWERS D) Add items such as skim milk powder, cheese, honey, or peanut
butter to selected foods.
The nurse can increase the nutritional density of foods by adding items high in protein
and/or calories (such as peanut butter, skim milk powder, cheese, honey, or brown sugar) to
foods the patient will eat. Increasing fluid intake at mealtime fills the stomach with fluid and
decreases the desire to eat. Small frequent meals are best tolerated. Supplements can be
helpful.
Which cellular dysfunction in the process of cancer development allows defective cell
proliferation?
A) Proto-oncogenes
B) Cell differentiation
C) Dynamic equilibrium
D) Activation of oncogenes - CORRECT ANSWERS C) Dynamic equilibrium
Dynamic equilibrium is the regulation of proliferation that usually only occurs to equal cell
degeneration or death or when the body has a physiologic need for more cells. Cell
differentiation is the orderly process that progresses a cell from a state of immaturity to a
state of differentiated maturity. Mutations that alter the expression of proto-oncogenes can
activate them to function as oncogenes, which are tumor-inducing genes and alter their
differentiation.
A patient has been diagnosed with Burkitt's lymphoma. In the initiation stage of cancer, the
cells genetic structure is mutated. Exposure to what may have functioned as a carcinogen for
this patient?
A) Bacteria
B) Sun exposure
C) Most chemicals
D) Epstein-Barr virus - CORRECT ANSWERS D) Epstein-Barr virus
Burkitt's lymphoma consistently shows evidence of the presence of Epstein-Barr virus in
vitro. Bacteria do not initiate cancer. Sun exposure causes cell alterations leading to
, NUR 402 EXAM 4 NCLEX QUESTIONS AND CORRECT DETAILED
ANSWERS ,A COMPLETE SOLITION THAT COVERS 2024/2025 BEST
RATED TO SCORE A+
melanoma and squamous and basal cell skin carcinoma. Long-term exposure to certain
chemicals (e.g., ethylene oxide, chloroform, benzene) is known to initiate cancer.
What can the nurse do to facilitate cancer prevention for the patient in the promotion stage
of cancer development?
A) Teach the patient to exercise daily.
B) Teach the patient promoting factors to avoid.
C) Tell the patient to have the cancer surgically removed now.
D) Teach the patient which vitamins will improve the immune system. - CORRECT ANSWERS
B) Teach the patient promoting factors to avoid.
The promotion stage of cancer is characterized by the reversible proliferation of the altered
cells. Changing the lifestyle to avoid promoting factors (dietary fat, obesity, cigarette
smoking, and alcohol consumption) can reduce the chance of cancer development. Daily
exercise and vitamins alone will not prevent cancer. Surgery at this stage may not be possible
without a critical mass of cells, and this advice would not be the nurse's role.
When caring for the patient with cancer, what does the nurse understand as the response of
the immune system to antigens of the malignant cells?
A) Metastasis
B) Tumor angiogenesis
C) Immunologic escape
D) Immunologic surveillance - CORRECT ANSWERS D) Immunologic surveillance
Immunologic surveillance is the process where lymphocytes check cell surface antigens and
detect and destroy cells with abnormal or altered antigenic determinants to prevent these
cells from developing into clinically detectable tumors. Metastasis is increased growth rate
of the tumor, increased invasiveness, and spread of the cancer to a distant site in the
progression stage of cancer development. Tumor angiogenesis is the process of blood
vessels forming within the tumor itself. Immunologic escape is the cancer cells' evasion of
immunologic surveillance that allows the cancer cells to reproduce.
The patient is told that the adenoma tumor is not encapsulated but has normally
differentiated cells and that surgery will be needed. The patient asks the nurse what this
means. What should the nurse tell the patient?
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