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A patient with multiple myeloma has developed hypercalcemia. What symptoms should the nurse monitor for in this patient?
- A. Increased heart rate
- B. Decreased urine output
- C. Muscle weakness
- D. Hypertension
Correct Answer: C
Rationale: The correct answer is C: Muscle weakness. In patients with multiple myeloma who have developed hypercalcemia, monitoring for muscle weakness is crucial. Hypercalcemia can lead to muscle weakness due to its effects on neuromuscular function. Choice A, increased heart rate, is more commonly associated with conditions like dehydration or anxiety rather than hypercalcemia. Choice B, decreased urine output, is commonly seen in conditions leading to acute kidney injury rather than hypercalcemia. Choice D, hypertension, is not a typical symptom of hypercalcemia and is more commonly associated with other conditions like uncontrolled high blood pressure.
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A client is receiving rituximab. What assessment by the nurse takes priority?
- A. Blood pressure.
- B. Temperature.
- C. Oral mucous membranes.
- D. Pain.
Correct Answer: A
Rationale: When a client is receiving rituximab, the nurse's priority assessment should be monitoring the blood pressure. Rituximab can lead to infusion-related reactions, such as hypotension. Therefore, assessing the client's blood pressure is crucial to detect and manage any potential adverse reactions promptly. While monitoring temperature, oral mucous membranes, and pain are essential aspects of care, they are not the priority when a client is receiving rituximab.
A nurse is caring for a patient diagnosed with chronic myeloid leukemia (CML) who is receiving the drug imatinib (Gleevec). What should the nurse monitor in this patient to assess for side effects of this therapy?
- A. Cardiac function
- B. Renal function
- C. Liver function
- D. Pulmonary function
Correct Answer: A
Rationale: The correct answer is A: Cardiac function. Imatinib can cause fluid retention and heart failure, so cardiac function should be closely monitored. Renal function (choice B) is not typically affected by imatinib. Liver function (choice C) is not the primary concern with this medication. Pulmonary function (choice D) is not directly impacted by imatinib therapy.
A nurse provides care on a bone marrow transplant unit and is preparing a female patient for a hematopoietic stem cell transplantation (HSCT) the following day. What information should the nurse emphasize to the patient's family and friends?
- A. Your family should gather at the bedside in case there is a negative outcome.
- B. Ensure she abstains from eating any food 24 hours before the procedure.
- C. Wear a hospital gown when entering the patient's room.
- D. Avoid visiting if you've had a recent infection.
Correct Answer: D
Rationale: The correct answer is D: 'Avoid visiting if you've had a recent infection.' Before a hematopoietic stem cell transplantation, it is essential for visitors to refrain from visiting if they have had a recent illness or vaccination to minimize the risk of infection to the patient. Choice A is incorrect because emphasizing a negative outcome is not beneficial to the patient or their family. Choice B is incorrect as it is not necessary to abstain from food for a hematopoietic stem cell transplantation. Choice C is irrelevant to the situation as wearing a hospital gown is not the key information for family and friends to be aware of.
The nurse is caring for a client who is postoperative following a pelvic exenteration, and the health care provider changes the client's diet from NPO status to clear liquids. The nurse should check which priority item before administering the diet?
- A. Bowel sounds
- B. Ability to ambulate
- C. Incision appearance
- D. Urine specific gravity
Correct Answer: A
Rationale: The correct answer is A: Bowel sounds. Checking for bowel sounds is crucial before administering any diet to ensure the gastrointestinal tract is functioning properly following surgery. This assessment helps prevent complications such as paralytic ileus. Choices B, C, and D are not the priority in this situation. While the ability to ambulate, incision appearance, and urine specific gravity are important assessments, ensuring bowel function takes precedence in this postoperative scenario.
A patient with Hodgkin lymphoma is receiving chemotherapy. Which side effect is the nurse most concerned about?
- A. Nausea and vomiting
- B. Alopecia
- C. Fatigue
- D. Peripheral neuropathy
Correct Answer: D
Rationale: The correct answer is D, Peripheral neuropathy. This can be a serious and dose-limiting side effect of chemotherapy for Hodgkin lymphoma. Peripheral neuropathy can cause tingling, numbness, and pain in the hands and feet due to nerve damage. While nausea and vomiting, alopecia, and fatigue are common side effects of chemotherapy, they are not typically as concerning or dose-limiting as peripheral neuropathy in the context of Hodgkin lymphoma treatment.