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In caring for a patient with a diagnosis of acute myeloid leukemia (AML) receiving induction therapy on the oncology unit, what nursing action should be prioritized in the patient's care plan?
- A. Protective isolation and vigilant use of standard precautions
- B. Provision of a high-calorie, low-texture diet and appropriate oral hygiene
- C. Including the family in planning the patient's activities of daily living
- D. Monitoring and treating the patient's pain
Correct Answer: A
Rationale: The correct answer is A: Protective isolation and vigilant use of standard precautions. Induction therapy for acute myeloid leukemia (AML) can lead to neutropenia, significantly increasing the risk of infections. Therefore, the priority is to protect the patient from potential pathogens by implementing protective isolation measures and adhering to strict standard precautions. This action is crucial for the patient's survival. Choice B is incorrect as nutritional support and oral hygiene are important but not the priority in this situation. Choice C, involving the family in planning activities, is a valuable aspect of care but not the priority during induction therapy. Choice D, monitoring and treating pain, is essential but ensuring protection against infection takes precedence due to the high risk of neutropenia.
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Nurse Joy is caring for a client with cancer who has been receiving cisplatin (Platinol-AQ). Which laboratory result requires an intervention by the nurse?
- A. White blood cell count of 6000 cells/microL
- B. Serum potassium level of 3.5 mEq/L
- C. Blood urea nitrogen (BUN) of 18 mg/dL
- D. Platelet count of 150,000 cells/microL
Correct Answer: C
Rationale: The correct answer is C. A BUN level of 18 mg/dL is within the normal range; however, since cisplatin is nephrotoxic, it requires close monitoring. Elevated BUN levels can indicate impaired kidney function. Choices A, B, and D are within normal ranges and do not directly relate to cisplatin therapy or require immediate intervention.
The home health nurse is performing a home visit for an oncology patient discharged 3 days ago after completing treatment for non-Hodgkin lymphoma. The nurse's assessment should include examination for the signs and symptoms of what complication?
- A. Tumor lysis syndrome (TLS)
- B. Syndrome of inappropriate antidiuretic hormone (SIADH)
- C. Disseminated intravascular coagulation (DIC)
- D. Hypercalcemia
Correct Answer: A
Rationale: The correct answer is A: Tumor lysis syndrome (TLS). Tumor lysis syndrome is a potential complication after treatment for certain cancers, including non-Hodgkin lymphoma. The rapid breakdown of cancer cells in response to treatment can lead to metabolic abnormalities, such as hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia, which can be life-threatening. Choice B, Syndrome of inappropriate antidiuretic hormone (SIADH), is not typically associated with non-Hodgkin lymphoma treatment. Choice C, Disseminated intravascular coagulation (DIC), is more commonly seen in conditions such as sepsis or trauma, not directly related to non-Hodgkin lymphoma treatment. Choice D, Hypercalcemia, is not a common complication following treatment for non-Hodgkin lymphoma.
A nursing student is caring for a patient with acute myeloid leukemia who is preparing to undergo induction therapy. In preparing a plan of care for this patient, the student should assign the highest priority to which nursing diagnosis?
- A. Activity Intolerance
- B. Risk for Infection
- C. Acute Confusion
- D. Risk for Spiritual Distress
Correct Answer: B
Rationale: The correct answer is B: Risk for Infection. Induction therapy for acute myeloid leukemia suppresses the immune system, making the patient highly susceptible to infections due to neutropenia. Preventing infections is crucial in these patients to avoid complications. Activity Intolerance (Choice A) may be a concern, but infection prevention is of higher priority. Acute Confusion (Choice C) and Risk for Spiritual Distress (Choice D) are not the immediate priorities in this situation.
Which of the following management strategies is not included for a patient taking chemotherapeutic drugs?
- A. Limit exposure of pregnant visitors
- B. Protect client from infection
- C. Allow client to use makeup and wig
- D. Administer IV fluids as ordered
Correct Answer: C
Rationale: The correct answer is C. Chemotherapy can lead to hair loss, and while using wigs is common, it is not a primary management strategy. The focus should be on limiting exposure to pregnant visitors to prevent harm to the fetus, protecting the client from infections due to a compromised immune system, and administering IV fluids as ordered to maintain hydration levels. Allowing the client to use makeup and wigs is not a primary concern when managing a patient taking chemotherapeutic drugs.
A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which condition?
- A. Rupture of the bladder
- B. The development of a vesicovaginal fistula
- C. Extreme stress caused by the diagnosis of cancer
- D. Altered perineal sensation as a side effect of radiation therapy
Correct Answer: B
Rationale: The correct answer is B. A vesicovaginal fistula is an abnormal connection between the bladder and the vagina, leading to the passage of urine through the vagina. This condition can occur due to various reasons, including radiation therapy. Choice A, rupture of the bladder, is incorrect because a rupture would present with more severe symptoms and is not consistent with the client's description. Choice C, extreme stress, is incorrect as it does not explain the physical symptom of voiding through the vagina. Choice D, altered perineal sensation, is incorrect as it does not involve a direct connection between the bladder and the vagina.