Nokea
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.
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Nurse Cecilia is caring for a client who has undergone a vaginal hysterectomy. The nurse avoids which of the following in the care of this client?
- A. Elevating the knee gatch on the bed
- B. Assisting with range-of-motion leg exercises
- C. Removal of antiembolism stockings twice daily
- D. Checking placement of pneumatic compression boots
Correct Answer: A
Rationale: The correct answer is A. Elevating the knee gatch on the bed should be avoided in the care of a client who has undergone a vaginal hysterectomy. This action can inhibit venous return, increasing the risk of deep vein thrombosis or thrombophlebitis. Choices B, C, and D are appropriate nursing interventions for postoperative care to prevent complications and promote circulation.
All of the following are warning signs of cancer except:
- A. Patient palpates a bump on the side of the breast
- B. Bruises are found on the body that the client cannot explain
- C. Patient often complains of impaired digestion
- D. Patient has blood-tinged sputum
Correct Answer: D
Rationale: The correct answer is D. Blood-tinged sputum is not a typical warning sign of cancer but rather a symptom that can indicate other serious conditions like respiratory issues or infections. Choices A, B, and C are common warning signs of cancer: palpable lumps or bumps, unexplained bruises, and persistent digestive issues are often associated with cancer and should be evaluated by a healthcare professional for further assessment and diagnosis.
Nurse Ben is reviewing the laboratory results of a client undergoing chemotherapy. Which of the following values would require immediate intervention?
- A. Platelet count of 150,000/mm3
- B. White blood cell count of 6,000/mm3
- C. Hemoglobin level of 14 g/dL
- D. Absolute neutrophil count of 500/mm3
Correct Answer: D
Rationale: An absolute neutrophil count of 500/mm3 indicates severe neutropenia, putting the client at high risk for infection. Neutrophils are crucial in fighting off infections; a low count increases susceptibility to infections. Platelet count, white blood cell count, and hemoglobin levels are within normal ranges and do not require immediate intervention in this scenario.
Which of the following is a correct statement by the nurse to a patient under radiation therapy?
- A. Brachytherapy can be performed by a pregnant nurse.
- B. Teletherapy makes the patient radioactive.
- C. Brachytherapy is an internal radiation therapy.
- D. Teletherapy requires proper disposal of feces since it can be a source of radiation.
Correct Answer: C
Rationale: The correct answer is C: 'Brachytherapy is an internal radiation therapy.' Brachytherapy involves the placement of radioactive sources inside or next to the area requiring treatment. This differs from teletherapy, which is external radiation therapy. Choice A is incorrect as pregnant individuals should avoid exposure to radiation. Choice B is incorrect because teletherapy does not make the patient radioactive; the radiation source is external. Choice D is incorrect as feces is not a significant source of radiation during teletherapy.
A patient with non-Hodgkin's lymphoma is receiving information from the oncology nurse. The patient asks the nurse why she should stop drinking and smoking and stay out of the sun. What would be the nurse's best response?
- A. Everyone should do these things because they are health promotion activities that apply to everyone.
- B. You don't want to develop a second cancer, do you?
- C. You need to do this just to be on the safe side.
- D. It's important to reduce other factors that increase the risk of second cancers.
Correct Answer: D
Rationale: The nurse should encourage patients to reduce other factors that increase the risk of developing second cancers, such as the use of tobacco and alcohol and exposure to environmental carcinogens and excessive sunlight. Choice A is too general and does not address the specific concerns of a cancer patient. Choice B uses fear tactics, which may not be the most effective approach. Choice C is vague and does not provide a clear rationale for the behavior change, unlike Choice D which specifically links the behaviors to reducing the risk of second cancers.