Page 1368 - Saunders Comprehensive Review For NCLEX-RN

Think about the actions that will cause further damage. Note that options 3 and 6 are
comparable or alike and can cause further damage.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Complex Care: Emergency Situations/Management
Health Problem: Adult Health: Integumentary: Inflammations/Infections
Priority Concepts: Clinical Judgment; Tissue Integrity
Reference: Ignatavicius, Workman, Rebar (2018), pp. 217, 392-393.

483. Answer: 3

Rationale: Hyperuricemia is especially common following treatment for
leukemias and lymphomas, because chemotherapy results in massive cell kill.
Although options 1, 2, and 4 also may be noted, an increased uric acid level is related
specifically to cell destruction.
Test-Taking Strategy: Focus on the subject, the laboratory value that reflects
massive cell destruction. Remember that uric acid is released when cells are
destroyed. This will direct you to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Oncology
Health Problem: Adult Health: Cancer: Leukemia
Priority Concepts: Cellular Regulation; Clinical Judgment
Reference: Lewis et al. (2017), p. 252.

484. Answer: 2

Rationale: Hemorrhagic cystitis is an adverse effect that can occur with the use of
cyclophosphamide. The client needs to be instructed to drink copious amounts of
fluid during the administration of this medication. Clients also should monitor urine
output for hematuria. The medication should be taken on an empty stomach, unless
gastrointestinal upset occurs. Hyperkalemia can result from the use of the
medication; therefore, the client would not be told to increase potassium intake. The
client would not be instructed to alter sodium intake.
Test-Taking Strategy: Focus on the subject, client teaching about
cyclophosphamide. Recalling that cyclophosphamide can cause hemorrhagic cystitis
will direct you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pharmacology: Oncology Medications: Alkylating
Health Problem: Adult Health: Cancer: Breast
Priority Concepts: Cellular Regulation; Client Education
Reference: Lewis et al. (2017), p. 1522.

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