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"I have this ringing in my ears that just won't go away."

.A nurse is working with a client with rheumatic disease who is being treated with salicylate therapy. What statement would indicate that the client is experiencing adverse effects of this drug?

requests that her family bring her makeup and wig.

A 16-year-old female client experiences alopecia resulting from chemotherapy, prompting the nursing diagnoses of disturbed body image and situational low self- esteem. The nurse should determine that the client is meeting the goal of improved body image and self-esteem when the client

Tofu

A client admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely the best choice for this client?

Visual changes

A nurse is planning client education for a client being discharged home with a diagnosis of rheumatoid arthritis. The client has been prescribed antimalarials for treatment, so the nurse knows to teach the client to self-monitor for what adverse effect?

The family's ability to provide emotional support

A nurse is planning discharge teaching for a 21-year-old client with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the client's coping after discharge?

Methotrexate

A nurse is providing care for a client who has just been diagnosed as being in the early stage of rheumatoid arthritis. The nurse should anticipate the administration of what medication?

Liver function tests (LFTs)

A nurse who works in an oncology clinic is assessing a client who has arrived for a 2- month follow-up appointment following chemotherapy. The nurse notes that the client's skin appears yellow. Which blood tests should be done to further explore this clinical sign?

Preserve or increase range of motion while limiting joint stress

A nurse's plan of care for a client with rheumatoid arthritis includes several exercise-based interventions. What goal should the nurse prioritize?

explain the pain management plan, including the use of a pain rating scale.

A priority nursing intervention to assist a preoperative patient in coping with fear of postoperative pain would be to

coordinating activities occurring in the operating room.

Activities that the nurse might NOT perform in the role of a scrub nurse during surgery include

Paralytic ileus

Five days after an exploratory laparotomy, the nurse assesses that the client has a distended abdomen, abdominal pain, absence of flatus, and absent bowel sounds. The nurse notifies the HCP concerned that the client could be experiencing which typical complication?

accumulation of immune complexes in the glomeruli.

Glomerulonephritis is characterized by glomerular damage caused by

The client has atelectasis.

On the client's second postoperative day, the nurse assesses that the client has diminished breath sounds in both lung bases, is taking shallow breaths, and achieves only 500 mL on an 18. The client smoked cigarettes for the past 30 years- Which is the nurse's best interpretation of these findings?

Assess the client's temperature and lung sounds.

The client diagnosed with a solid tissue tumor scheduled to receive chemotherapy has a WBC count of 5.9 (103 ) with 12% neutrophils. Which intervention should the nurse implement first?

An immunosuppressant, such as cyclosporine

The client diagnosed with acute myeloid leukemia receives a bone marrow transplant. Which medication to prevent graft-versus-host disease (GVHD) should the nurse plan to administer?

Utilize the unit's common film badge that indicates the cumulative radiation exposure while caring for the client.

The client hospitalized with cervical cancer is receiving radiation therapy via a temporary radioactive cervical implant. Which nursing actions would be inappropriate for this client?

"I should shave the skin in the surgical area the evening prior to surgery."

The client is scheduled for a 3-hour surgery under general anesthesia. Which statement indicates that the client needs further teaching?

Inform the client that food and fluids have been with- held to prevent vomiting and potential complications

The client, who is to receive general anesthesia, reports having a dry mouth because food and fluids have been withheld for 8 hours. Which action by the nurse is most appropriate?

"Come to the clinic. We need to complete a urine culture and sensitivity."

The female client, being treated for stress incontinence with vaginal cone therapy, calls a clinic to report that she is experiencing burning on urination, chills, and fever. Which is the best instruction by the nurse?

The client with new-onset neutropenia of unknown etiology

The nurse is performing presurgical assessment of multiple clients. The nurse determines that which client has the greatest risk for developing an infection postoperatively?

Antidiarrheal medications 30 minutes before a meal

The nurse is providing care for a client whose inflammatory bowel disease has necessitated hospital treatment. Which of the following would most likely be included in the client's medication regimen?

Risk for infection related to altered immunologic response

The nurse on a bone marrow transplant unit is caring for a client with cancer who has just begun hematopoietic stem cell transplantation (HSCT). What is the priority nursing diagnosis for this client?

developing an individualized plan of nursing care for the patient.

The nurse's primary responsibility for the care of the patient undergoing surgery is

Elevated blood urea nitrogen (BUN)

What manifestation in the patient will indicate the need for restriction of dietary protein in management of acute poststreptococcal glomerulonephritis (APSGN)?

Teaching clients to wear sunscreen

What nursing action best demonstrates primary cancer prevention?

Decreased plasma oncotic pressure

What results in the edema associated with nephrotic syndrome?

"The TNM system is used to classify solid tumors by size and degree of spread."

When reviewing the client's medical record, the experienced nurse discovers that the client's breast cancer is staged as T4 N3 M1. Which comment made by the experienced nurse to the new nurse is correct?

1.002

Which urine specific gravity value would indicate to the nurse that the patient is receiving excessive IV fluid therapy?

Calcium

A client develops recurrent urolithiasis. What mineral will most likely be restricted in the client's diet?

Bone marrow suppression

A client has a diagnosis of rheumatoid arthritis and the primary provider has now prescribed cyclophosphamide. The nurse's subsequent assessments should address what potential adverse effect?

Assess airway for patency.

A client has just arrived at the postanesthesia unit from surgery. The priority assessment is to

pH

A client is diagnosed with cystitis. The nurse recommends the client drink cranberry juice. What assessment parameter should the nurse consider to determine if this recommendation has been effective?

Arthrocentesis

A client is suspected of having rheumatoid arthritis and her diagnostic regimen includes aspiration of synovial fluid from the knee for a definitive diagnosis. The nurse knows that which procedure will be involved?

Nausea and vomiting

A client newly diagnosed with cancer is scheduled to begin chemotherapy treatment and the nurse is providing anticipatory guidance about potential adverse effects. When addressing the most common adverse effect, what should the nurse describe?

Epistaxis

A client on the oncology unit is receiving carmustine, a chemotherapy agent, and the nurse is aware that a significant side effect of this medication is thrombocytopenia. Which symptom should the nurse assess for in clients at risk for thrombocytopenia?

Fatigue Related to Anemia

A client who has been newly diagnosed with systemic lupus erythematosus (SLE) has been admitted to the medical unit. Which nursing diagnosis is most likely to apply?

Limit the time that visitors spend at the client's bedside.

A client with a diagnosis of prostate cancer is scheduled to have an interstitial implant for high-dose radiation (HDR). What safety measure should the nurse include in this client's plan of care?

"I'll make sure to monitor my body temperature on a regular basis."

A client with systemic lupus erythematosus (SLE) is preparing for discharge. The nurse knows that the client has understood health education when the client makes what statement?

Rheumatoid arthritis (RA)

A client's decreased mobility has been attributed to an autoimmune reaction originating in the synovial tissue, which caused the formation of pannus. This client has been diagnosed with what health problem?

An absence of blood in stool

A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn's disease, rather that ulcerative colitis, as the cause of the client's signs and symptoms?

Lymphatic circulation

A client's most recent diagnostic imaging has revealed that his lung cancer has metastasized to his bones and liver. What is the most likely mechanism by which the client's cancer cells spread?

The drug should be used for as short a time as possible.

A client's rheumatoid arthritis (RA) has failed to respond appreciably to first-line treatments and the primary provider has added prednisone to the client's drug regimen. What principle will guide this aspect of the client's treatment?

Joint stiffness, especially in the morning

A nurse is performing the health history and physical assessment of a client who has a diagnosis of rheumatoid arthritis (RA). What assessment finding is most consistent with the clinical presentation of RA?

Butterfly rash

A nurse is performing the initial assessment of a client who has a recent diagnosis of systemic lupus erythematosus (SLE). What skin manifestation should the nurse expect to observe on inspection?

Watery with blood and mucus

A nurse is preparing to provide care for a client whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would anticipate that the client's stools will have what characteristics?

Systemic lupus erythematosus (SLE)

A nurse is providing care for a client who has a rheumatic disorder. The nurse's comprehensive assessment includes the client's mood, behavior, LOC, and neurologic status. What is this client's most likely diagnosis?

Do not visit if you've had a recent infection."

A nurse provides care on a bone marrow transplant unit and is preparing a female client for hematopoietic stem cell transplantation (HSCT) the following day. What information should the nurse emphasize to the client's family and friends?

Administer an antiemetic.

An adult client with leukemia will soon begin chemotherapy. What would the nurse do to combat the most common adverse effects of chemotherapy?

Avoid rubbing or scratching the affected area

An oncology client has begun to experience skin reactions to radiation therapy, prompting the nurse to make the diagnosis Impaired Skin Integrity: erythematous reaction to radiation therapy. What intervention best addresses this nursing diagnosis?

Avoid using soap on the treatment area.

An oncology nurse is caring for a client who has developed erythema following radiation therapy. What should the nurse instruct the client to do?

Chocolate

Laboratory analysis reveals that the client passed a calcium oxalate stone. To prevent the formation of future stones, the nurse should instruct the client to avoid consuming which food?

Stress incontinence

The patient complains of "wetting when she sneezes." How should the nurse document this information?

Ask additional questions to assess for a possible latex allergy.

The patient tells the nurse in the preoperative setting that she has noticed she has a reaction when wearing rubber gloves. What is the most appropriate intervention?

Bright red blood in the stool

The client is admitted with a diagnosis of colon cancer. Which finding in the client's admission information should prompt the nurse to consider that the cancer may be located in the client's descending colon?

Premedicate the client before each meal.

The client receiving IV chemotherapy was nauseated and vomited twice the day before. Which intervention should the nurse implement?

Left-sided flank pain

The client with acute pyelonephritis of the left kidney is hospitalized. The nurse should monitor for which most frequently occurring symptom?

The incision is inflamed and may indicate that it is infected.

The nurse assesses redness, swelling, and warmth at the client's leg incision 48 hours after femoral popliteal bypass surgery. Which is the nurse's best interpretation of the findings?

Eat a low-residue diet and take sitz baths twice daily.

The nurse assesses that the client who is receiving radiation for cervical cancer continues to have diarrhea. Which nursing advice is most appropriate for this client?

Apply skin products immediately after radiation treatment.

The nurse discusses the self-care guidelines to minimize the side effects of radiation on the skin. Which actions to reduce radiation skin reactions should the nurse NOT explain to the client?

Cleaning the perineal area and urinary meatus twice a day and as needed.

The nurse inserts an indwelling urinary catheter in a client. Which nursing intervention is most likely to prevent a urinary tract infection?

Check the IV pump and alarm for indications of an infiltration of the medication.

The nurse is administering vesicant chemotherapy medications such as doxorubicin hydrochloride to clients. Which nursing actions should the nurse NOT implement to prevent extravasation?

Assess the location and the severity of the client's pain.

The nurse is admitting a hospitalized client who has a renal calculi. Which should be the nurse's priority?

Impaired nutritional status

The nurse is caring for a client who is to begin receiving external radiation for a malignant tumor of the neck. While providing client education, what potential adverse effects should the nurse discuss with the client?

Absence of colicky pain in the left lateral flank and groin

The nurse is caring for the client diagnosed with obstructing left ureterolithiasis. The nurse evaluates that the client may have passed the calculi in the urine when which outcome has been achieved?

Obtain a urine specimen for culture and sensitivity.

The nurse is caring for the client experiencing a possible hospital-acquired bladder infection. Which nursing action should the nurse perform first?

Neurotoxicities and diarrhea

The nurse is caring for the client receiving combination chemotherapy ofoxaliplatin, fluorouracil, and leucovorin. The nurse should assess the client for which common side effects of this chemotherapy regimen?

Turn on the water or flush the toilet to assist the client to void.

The nurse is caring for the female client experiencing new-onset urge urinary incontinence. Which interventions should the nurse implement?

"Eliminate caffeine and tea from your diet."

The nurse is caring for the female client experiencing recurrent UTIs. Which statement would best help the client reduce her risk for another UTI?

Lung sounds are audible and clear on auscultation.

The nurse is caring for the postsurgical client. Which outcome should indicate to the nurse that the client's coughing and deep breathing (C&DB) are most effective?

"Have you had a history of chronic urinary tract infections?"

The nurse is completing an admission assessment of the client with a possible obstructing struvite calculus of the right ureter. Which is the best question for the nurse to ask?

baked apricot chicken and steamed broccoli

The nurse is conducting a health education about cancer prevention to a group of adults. What menu best demonstrates dietary choices for potentially reducing the risks of cancer?

"I took all my meds including warfarin and atenolol with a sip of water this morning."

The nurse is performing a presurgical admission assessment of the client. Which client statement needs the most immediate follow-up?

Position the client flat in bed

The postoperative client who received a spinal anesthetic is experiencing a headache, photophobia, and double vision. What should be the nurse's initial intervention?

Explain the medications prescribed for pain control, availability, and treatment goals.

The preoperative client verbalizes fear of postoperative pain. Which nursing action would be best?

Escherichia coli.

Which aerobic gram-negative bacillus is the most common pathogen for all manifestations of urinary tract infection in all groups of clients?

Fever

Which characteristic is more likely with acute pyelonephritis than with a lower UTI?

azotemia

Which of the following should you document to indicate that the patient's blood is loaded with excessive nitrogenous waste materials?

Stopping the administration of the drug immediately

While a client is receiving IV doxorubicin hydrochloride for the treatment of cancer, the nurse observes swelling and pain at the IV site. The nurse should prioritize what action?