Nokea
A nurse is caring for a patient who has been diagnosed with leukemia. The nurses most recent assessment reveals the presence of ecchymoses on the patients sacral area and petechiae in her forearms. In addition to informing the patients primary care provider, the nurse should perform what action?
- A. Initiate measures to prevent venous thromboembolism (VTE).
- B. Check the patients most recent platelet level.
- C. Place the patient on protective isolation.
- D. Ambulate the patient to promote circulatory function.
Correct Answer: B
Rationale: The patients signs are suggestive of thrombocytopenia, thus the nurse should check the patients most recent platelet level. VTE is not a risk and this does not constitute a need for isolation. Ambulation and activity may be contraindicated due to the risk of bleeding.
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A nurse at a long-term care facility is amending the care plan of a resident who has just been diagnosed with essential thrombocythemia (ET). The nurse should anticipate the administration of what medication?
- A. Dalteparin
- B. Allopurinol
- C. Hydroxyurea
- D. Hydrochlorothiazide
Correct Answer: C
Rationale: Hydroxyurea is effective in lowering the platelet count for patients with ET. Dalteparin, allopurinol, and HCTZ do not have this therapeutic effect.
Diagnostic testing has resulted in a diagnosis of acute myeloid leukemia (AML) in an adult patient who is otherwise healthy. The patient and the care team have collaborated and the patient will soon begin induction therapy. The nurse should prepare the patient for which of the following?
- A. Daily treatment with targeted therapy medications
- B. Radiation therapy on a daily basis
- C. Hematopoietic stem cell transplantation
- D. An aggressive course of chemotherapy
Correct Answer: D
Rationale: Attempts are made to achieve remission of AML by the aggressive administration of chemotherapy, called induction therapy, which usually requires hospitalization for several weeks. Induction therapy is not synonymous with radiation, stem cell transplantation, or targeted therapies.
A nurse recognizes a patients risk for fluid imbalance while the patient is undergoing treatment for leukemia. What relevant assessments should the nurse include in the patients plan of care? Select all that apply.
- A. Monitoring the patients electrolyte levels
- B. Monitoring the patients hepatic function
- C. Measuring the patients weight on a daily basis
- D. Measuring and recording the patients intake and output
- E. Auscultating the patients lungs frequently
Correct Answer: A,C,D,E
Rationale: Assessments that relate to fluid balance include monitoring the patients electrolytes, auscultating the patients chest for adventitious sounds, weighing the patient daily, and closely monitoring intake and output. Liver function is not directly relevant to the patients fluid status in most cases.
A nurse is planning the care of a patient who has been diagnosed with essential thrombocythemia (ET). What nursing diagnosis should the nurse prioritize when choosing interventions?
- A. Risk for Ineffective Tissue Perfusion
- B. Risk for Imbalanced Fluid Volume
- C. Risk for Ineffective Breathing Pattern
- D. Risk for Ineffective Thermoregulation
Correct Answer: A
Rationale: Patients with ET are at risk for hypercoagulation and consequent ineffective tissue perfusion. Fluid volume, breathing, and thermoregulation are not normally affected.
A patient with advanced leukemia is responding poorly to treatment. The nurse finds the patient tearful and trying to express his feelings, but he is clearly having difficulty. What is the nurses most appropriate action?
- A. Tell him that you will give him privacy and leave the room.
- B. Offer to call pastoral care.
- C. Ask if he would like you to sit with him while he collects his thoughts.
- D. Tell him that you can understand how hes feeling.
Correct Answer: C
Rationale: Providing emotional support and discussing the uncertain future are crucial. Leaving is incorrect because leaving the patient doesnt show acceptance of his feelings. Offering to call pastoral care may be helpful for some patients but should be done after the nurse has spent time with the patient. Telling the patient that you understand how hes feeling is inappropriate because it doesnt help him express his feelings.