Inflammation/Sepsis
A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000/mm3. Which statement by the client indicates a need for additional teaching?
"I floss my teeth every morning."
Which statement indicates that the client needs further teaching about taking medication to control cancer pain?
"I should skip doses periodically so I don't get hooked on my drugs."
The nurse is evaluating if a client with Hodgkin's disease understands the monitoring that needs to be done at home between radiation treatments. Which statement would indicate that the client knows how to detect a major complication?
"I will take my temperature every day."
A client who will have the final chemotherapy cycle in 11 days becomes neutropenic. The client understands the condition by making which statement? Select all that apply.
"I'll monitor my temperature frequently and go to the nearest emergency department if my temperature rises above 100.4° F (38° C)." "I need to avoid going to the movies or eating out while receiving my cancer treatment." "I will carry hand sanitizer with me and use it often.
A client with right lower quadrant pain is admitted to the emergency department with a white blood cell (WBC) count of 17.8/mm3. What should the nurse do next?
Assess vital signs.
The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A stand for?
Asymmetry
In assessing a client in the early stage of chronic lymphocytic leukemia (CLL), the nurse should determine if the client has:
Unintentional weight loss.
A client who's receiving chemotherapy for breast cancer develops myelosuppression. Which instructions would the nurse include in the client's discharge teaching plan? Select all that apply.
Avoid people who have recently received live vaccines. Avoid activities that may cause bleeding. Wash hands frequently. Avoid crowded places such as shopping malls.
A client is undergoing tests for multiple myeloma. Diagnostic study findings in multiple myeloma include
Bence Jones protein in the urine
A nurse is assessing an adult who has been receiving chemotherapy. The client has a platelet count of 22,000 cells/mm3 (22 × 109/L) and has petechiae on the lower extremities. What should the nurse should instruct the client to do?
Consult the health care provider.
A 42-year-old female highway construction worker is concerned about her cancer risks. She has been married for 18 years, has two children, smokes one pack of cigarettes per day, and occasionally drinks one to two beers. She is 30 lb (13.6 kg) overweight, eats fried fast food often, and rarely eats fresh fruits and vegetables. Her mother was diagnosed with breast cancer 2 years ago. Her father and an aunt both died of lung cancer. She had a basal cell carcinoma removed from her cheek 3 years earlier. What behavioral changes should the nurse coach this client to make to decrease her risk of cancer? Select all that apply.
Improve nutrition. Use sunscreen. Stop smoking. Lose weight.
A client is to start chemotherapy to treat lung cancer. A venous access device has been placed to permit administration of chemotherapeutic medications. Three days later at the scheduled appointment to receive chemotherapy, the nurse assesses that the client is dyspneic and the skin is warm and pale. The vital signs are blood pressure 80/30 mm Hg, pulse 132 bpm, respirations 28 breaths/min, temperature 103°F (39.4°C), and oxygen saturation 84%. The central line insertion site is inflamed. After the nurse calls the rapid response team, what should the nurse do next?
Insert a peripheral intravenous fluid line and infuse normal saline.
The nurse is assessing a client's abdominal incision 48 hours after surgery. Which finding indicates that the wound is inflamed?
Localized warmth over the incisional area.
The nurse is developing a care plan for a client who has leukemia. What instructions should the nurse include in the plan? Select all that apply.
Monitor temperature and report elevation. Recognize signs and symptoms of infection. Avoid crowds. Maintain integrity of skin and mucous membranes.
A client receiving chemotherapy for the treatment of lymphoma has a temperature of 103° F (39.4° C). Put the following interventions in the order in which the nurse should perform them.
Obtain blood and urine cultures Administer ampicillin 150 mg/kg intravenously Administer acetaminophen 650 mg orally Obtain a chest X-ray
A client receiving chemotherapy experiences episodes of severe nausea and has vomited more than 1,000 mL of clear fluid in the past 4 hours. The nurse should first:
notify the health care provider.
A nurse is screening participants at a health fair for cancer risk. Which clients will the nurse refer for further evaluation? Select all that apply.
older adult male with a history of smoking older adult female who works as a toll collector middle-aged female with human papillomavirus (HPV)
A client is receiving monthly doses of chemotherapy for treatment of stage III colon cancer. Which laboratory results should the nurse report to the oncologist before the next dose of chemotherapy is administered? Select all that apply.
platelet count of 40,000/mm3 (40 X 109/L) white blood cell count of 2,300/mm3 (2.3 X 109/L) temperature of 101.2° F (38.4° C)
A client who is undergoing radiation therapy develops mucositis. Which action should be included in the client's plan of care?
promoting regular flossing of teeth
Which action is contraindicated for a client who develops a temperature of 102° F (38.9° C)?
providing a low-calorie diet
A nurse is assessing a client 2 days after surgery for infection. Which sign or symptom is most indicative of infection?
red, warm, swollen, tender incision with foul drainage
A client undergoing chemotherapy has a white blood cell count of 2,300/mm3 (2.3 X 109/L); hemoglobin of 9.8 g/dL (98 g/L); platelet count of 80,000/mm3 (80 X 109/L); and potassium of 3.8. Which finding should take priority?
temperature 101° F (38.3° C).
A nurse is administering daunorubicin to a patient with lung cancer. Which situation requires immediate intervention?
the I.V. site is red and swollen.
A client receiving radiation therapy for thyroid cancer reports mouth and throat pain. While inspecting the mouth and throat, the nurse notices white patches and ulcerations in the oral mucosa. The nurse notifies the radiation oncologist, and expects which intervention?
to administer an antifungal agent
A nurse is caring for a client who is undergoing chemotherapy. Current laboratory values are noted on the medical record. Which action would be most appropriate for the nurse to implement?
washing hands before and after entering the room
A nurse uses sterile technique when accessing an implanted venous port. She demonstrates knowledge of basic sterile technique by:
washing her hands before the procedure.
A nurse is assessing a client with lymphoma who reports distress 9 days after chemotherapy. Because of the risk for septic shock, the nurse should assess the client for which cluster of symptoms?
low-grade fever, chills, tachycardia
Which nursing intervention is most important in preventing septic shock?
maintaining asepsis of indwelling urinary catheters
When assessing a client for early sepsis, which assessment finding would most concern the nurse?
mean arterial pressure less than 70 mmHg
The nurse is reviewing the lab report for a client in hospice care with breast cancer and brain metastasis. According to the information in the chart, what should the nurse do next?
Report the elevated calcium level immediately.
After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should assign highest priority to which intervention?
administering metoclopramide and dexamethasone as ordered
A client with a family history of cancer asks the nurse what the single most important risk factor is for cancer. Which risk factor should the nurse discuss?
age
When planning care for a group of clients, the nurse notes that which client is most susceptible to infection?
an 86-year-old with burns from using a heating pad
The nurse is speaking to a group of women about early detection of breast cancer. Which screening does the nurse recommend to women age 50 and older?
annual mammogram
A client with bladder cancer has gross hematuria. The client's hemoglobin is 8.0 g/dL (80 g/L), and the health care provider (HCP) prescribes a unit of packed blood cells. The client has an existing intravenous infusion of normal saline using a 19-gauge needle. To administer the packed red blood cells, the nurse should:
attach the packed cells to the existing 19G IV of normal saline solution using Y tubing.
The nurse has reinforced a pressure dressing on a client who is postoperative mastectomy and notes there is considerable sanguineous drainage in the Hemovac. Which assessments should the nurse report to the physician? Select all that apply.
blood pressure 86/50 mm Hg; pulse weak and thready at 120 bpm fever of 102 degrees F, no urine output for 2 hours
The client who is receiving chemotherapy is not eating well but otherwise feels healthy. What should the nurse suggest the client eat?
broiled chicken, green beans, and cottage cheese
A home care nurse assesses for disease complications in a client with bone cancer. Which laboratory value may indicate the presence of a disease complication?
calcium level of 11.6 mg/dl (2.9 mmol/L)
A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of [12.0 mg/dl (3.0 mmol/L)], a serum potassium level of [3.9 mEq/L (3.9 mmol/L)], a serum chloride level of [101 mEq/L (11 mmol/L)], and a serum sodium level of [140 mEq/L (140 mmol/L)]. Based on this information, the nurse determines that the client will likely need which intervention?
mithramycin 25 mcg/kg/day
A nurse is administering daunorubicin through a peripheral I.V. line when the client complains of burning at the insertion site. The nurse notes no blood return from the catheter and redness at the I.V. site. The client is most likely experiencing which complication?
extravasation
The nurse is assessing a middle-aged client with cancer who has lost 1 lb (0.5 kg) in 4 weeks. The client is taking ondansetron for nausea and now has a temperature of 101°F (38.3°C). The nurse judges that the fever is a sign of what?
infection
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan?
inspecting the skin for petechiae once every shift
Which assessment is most supportive of the nursing diagnosis, impaired skin integrity related to purulent inflammation of dermal layers as evidenced by purulent drainage and erythema?
oral temperature of 101° F (38.3° C)
Hydromorphone 3 mg IV has been prescribed for a client who is experiencing severe pain. The dosage available is 3 mg/mL. The nurse dilutes the hydromorphone in 5 mL of normal saline solution and prepares to administer the medication via IV push over 5 minutes. How many milliliters will the nurse need to administer per minute to administer the drug over 5 minutes? Record your answer using one decimal place.
1.2
A nurse is caring for a client who's experiencing septic arthritis. This client has a history of immunosuppressive therapy and the client's immune system is currently depressed. Which assignment is the most appropriate for the nurse caring for this client?
The nurse is caring for this client on the intensive care unit.
A client with breast cancer received chemotherapy approximately 10 days ago. The complete blood count today is below. Which teaching is appropriate based on these laboratory results? white blood cells 5000/mm3 neutrophils 75% hemoglobin 13 g/dL, hematocrit 40% platelets 45,000/mm3
Use an electric razor to shave.
Which information should be included in the teaching plan for a client with cancer who is experiencing thrombocytopenia? Select all that apply.
Use an electric razor. Use a soft-bristle toothbrush. Avoid frequent flossing for oral care. Report bleeding, such as nosebleed, petechiae, or melena, to a health care provider (HCP).
A few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing which problem?
a hemolytic allergic reaction caused by an antigen reaction
The client is admitted in septic shock. Which assessment data warrants immediate intervention by the nurse?
a urinary output of 50 mL in the past 3 hours
When collaborating with the health care provider in the development of a plan to manage pain for a client with cancer, the nurse should question the use of:
meperidine.
The nurse is planning care with a client with acute leukemia who has mucositis. What should the nurse advise the client to use for mouth care?
normal saline