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. hypoglycemic event often develops B. physical dependency on the drug develops over time. C. a heart block is likely to develop. D. status epileptic us may develop

Correct Answer is D

Explanation

A) Hypoglycemic event often develops:
Phenytoin is an anticonvulsant, and while it can affect glucose metabolism, hypoglycemia is not a typical consequence of abruptly stopping the drug. This is not a primary concern when discontinuing phenytoin therapy. Hypoglycemia is more commonly associated with medications like insulin or sulfonylureas, not anticonvulsants like phenytoin.

B) Physical dependency on the drug develops over time:
Phenytoin does not cause physical dependence in the way that some other substances (e.g., alcohol, opioids) can. While the body can become used to a medication over time, and withdrawal symptoms can occur, the risk of physical dependence is not the main reason why phenytoin should not be stopped suddenly.

C) A heart block is likely to develop:
Phenytoin is known to have effects on cardiac conduction, and it can cause heart rhythm disturbances like bradycardia or a prolonged PR interval, especially with toxicity. However, the risk of a heart block developing due to abrupt discontinuation of phenytoin is not the primary concern.

D) Status epilepticus may develop:
The most serious risk of suddenly stopping phenytoin, or any anticonvulsant, is the potential for status epilepticus. Status epilepticus is a medical emergency where seizures occur continuously without recovery in between, which can be life-threatening. Abruptly discontinuing phenytoin can lead to a rebound increase in seizure activity, which can result in status epilepticus.

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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:

Nursing Test Bank

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

A nurse is teaching a client newly diagnosed with a seizure disorder about phenytoin sodium therapy. What information should the nurse stress regarding the client stopping the drug suddenly? The drug should not be stopped abruptly because:

Correct Answer is D

Explanation

The nurse is evaluating the outcomes for a client diagnosed with disseminated intravascular coagulation (DIC). Which laboratory value reflects a positive outcome?

The nurse is caring for patient with a history of atrial fibrillation who is prescribed warfarin. Sometimes I forget my medication, so l double up doses when I remember " The patient's PT and INR are highly elevated. The nurse anticipates the transfusion of which blood product?

When using an ECG rhythm strip to quickly estimate the ventricular rhythm for a client, the nurse should:

The nurse identifies that which patient with a burn injury most likely require endotracheal intubation or tracheostomy tube? The patient with:

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