The nurse is reviewing lab results for a client receiving chemotherapy for the treatment of cancer. The nurse notes the carcinoembryonic antigen (CEA) was previously 50 ng/ mL and is now 10 ng/mL (normal range 0-2.5 ng/mL) The nurse is aware this finding indicates the:

treatment plan will need to be changed to achieve the desired effect

cancer treatment is having, the desired effect on killing cancer cells

client is at greater risk for tumor lysis syndrome

cancer has increased size and metastatic sites

Answer and Explanation

The Correct Answer is B

A) Treatment plan will need to be changed to achieve the desired effect:
The decrease in the carcinoembryonic antigen (CEA) levels from 50 ng/mL to 10 ng/mL suggests that the cancer is responding to the current treatment, not that the treatment plan needs to be changed. A drop in CEA levels typically indicates a positive response to treatment, such as chemotherapy, in reducing the number or size of cancer cells.

B) Cancer treatment is having the desired effect on killing cancer cells:
Carcinoembryonic antigen (CEA) is a tumor marker that is often elevated in individuals with certain cancers, particularly colorectal cancer. A decrease in CEA levels, as noted in this case (from 50 ng/mL to 10 ng/mL), usually signifies that the treatment is successfully targeting the cancer and reducing the tumor burden. This drop suggests that the chemotherapy is effectively killing cancer cells and reducing the size or activity of the tumor.

C) Client is at greater risk for tumor lysis syndrome:
Tumor lysis syndrome typically occurs when large numbers of cancer cells die rapidly, releasing their intracellular contents into the bloodstream, which can lead to metabolic disturbances like hyperkalemia, hyperphosphatemia, and renal failure. It is more common in aggressive hematologic cancers, such as leukemia or lymphoma, and typically presents with a rapid rise in tumor marker levels, not a decrease.

D) Cancer has increased size and metastatic sites:
An increase in tumor size or the development of metastatic sites would typically result in an increase in CEA levels, not a decrease. Since CEA levels have dropped, it is more likely that the cancer is shrinking or responding to the current treatment. This finding is more indicative of a positive response rather than disease progression.

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Correct Answer is C

Explanation

A) Prevent the drainage by applying a tight pressure dressing:
Applying a tight pressure dressing is not the appropriate intervention in this case. The presence of fluid draining from the ear, particularly a yellow stain, could indicate cerebrospinal fluid (CSF) leakage, which is a potential sign of a skull fracture or traumatic brain injury (TBI) involving the base of the skull. Applying a tight pressure dressing could potentially increase pressure or cause further injury.

B) Administer antibiotics due to increased risk of infection:
While there is an increased risk of infection with a CSF leak, antibiotics should not be administered immediately unless there is clear evidence of an infection. The priority action is to identify whether the fluid is CSF, as antibiotics alone will not address the underlying issue of a CSF leak. The nurse should allow the fluid to drain, collect a sample, and notify the healthcare provider for further assessment, which may include imaging or testing for the presence of CSF.

C) Allow fluid to drain from the patient's ear onto gauze and notify the healthcare provider:
The yellow stain around the fluid dripping from the patient's ear suggests the possibility of CSF leakage, a sign of a skull base fracture. CSF leakage may occur after a traumatic brain injury and should be handled carefully. The nurse's priority action is to allow the fluid to drain onto gauze to prevent the buildup of pressure and to prevent further leakage into the ear canal. The nurse should also immediately notify the healthcare provider for further evaluation and management.

D) Hang intravenous (IV) fluids to replace fluids lost and prevent dehydration:
While IV fluids may be necessary in some cases for patients with trauma, the priority in this situation is to identify the source and nature of the drainage. If the fluid is CSF, it may be important to manage the leak appropriately rather than focusing solely on replacing fluids. The nurse should first confirm whether the fluid is CSF and notify the healthcare provider for further assessment and management. Replacing fluids may be necessary, but it is not the immediate priority.

A. Equal but sluggishly reactive pupils B. Widening pulse pressure C. Altered level of consciousness D. Tachycardia and hypotension

Correct Answer is C

Explanation

A) Equal but sluggishly reactive pupils:
Pupillary changes, including sluggish or unequal responses, are significant signs of increasing intracranial pressure (ICP) and should be monitored closely. However, altered level of consciousness (LOC) is typically one of the earliest signs of increased ICP. The response of the pupils to light can become abnormal later, once pressure increases within the brain, particularly when brainstem function is impacted.

B) Widening pulse pressure:
A widening pulse pressure is part of Cushing’s triad, which is a late sign of increased ICP. Cushing’s triad consists of hypertension, bradycardia, and irregular respirations (often seen as Cheyne-Stokes). These changes occur in the later stages of elevated ICP as a compensatory mechanism to preserve cerebral perfusion. While this is an important finding, altered LOC would precede the development of Cushing’s triad.

C) Altered level of consciousness:
Altered level of consciousness (LOC) is typically the first and most sensitive indicator of increased ICP. As pressure increases within the skull, it compresses brain tissue and affects the brainstem, which controls basic functions like consciousness. LOC can range from mild confusion and disorientation to full loss of consciousness or coma, depending on the severity of the ICP increase.

D) Tachycardia and hypotension:
Tachycardia and hypotension can be associated with shock or other conditions, but they are not characteristic of early increased ICP. In fact, as ICP rises, the body typically responds with bradycardia (slower heart rate) and hypertension (increased blood pressure), which are part of the compensatory mechanisms.

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The nurse is reviewing lab results for a client receiving chemotherapy for the treatment of cancer. The nurse notes the carcinoembryonic antigen (CEA) was previously 50 ng/ mL and is now 10 ng/mL (normal range 0-2.5 ng/mL) The nurse is aware this finding indicates the:

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Naxlex Comprehensive Predictor Exams

The nurse notices a yellow stain around fluid dripping from a patient’s ear who sustained a traumatic brain injury. The nurse's priority intervention will be as follows:

Correct Answer is C

Explanation

The nurse is caring for a patient with an acute head injury. Which assessment finding would first alert the nurse that the patient is developing an increase in intracranial pressure (ICP)?

Correct Answer is C

Explanation

The nurse is caring for patient with severe, major burns who is receiving fluid resuscitation per protocol. Which of the following assessments indicate positive outcome?

A patient is ordered 1 mg/kg of furosemide IV push. The patient weights 121 lbs. The medication is supplied 40 mg/10 mL. How many mL should the nurse administer? (round to the nearest tenth)

The nurse is reviewing lab results for a client receiving chemotherapy for the treatment of cancer. The nurse notes the carcinoembryonic antigen (CEA) was previously 50 ng/ mL and is now 10 ng/mL (normal range 0-2.5 ng/mL) The nurse is aware this finding indicates the:

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