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An oncology nurse recognizes a patient's risk for fluid imbalance while the patient is undergoing treatment for leukemia. What relevant assessments should the nurse include in the patient's plan of care? Select all that apply.
- A. Monitoring the patient's electrolyte levels
- B. Monitoring the patient's hepatic function
- C. Measuring the patient's weight on a daily basis
- D. Measuring and recording the patient's intake and output
Correct Answer: B
Rationale: The correct answer is B: Monitoring the patient's hepatic function. In leukemia treatment, chemotherapy drugs can affect liver function, leading to fluid imbalance. By monitoring hepatic function, the nurse can assess the liver's ability to regulate fluid balance.
A: Monitoring electrolyte levels is important but not directly related to fluid imbalance in leukemia treatment.
C: Measuring weight daily is important for fluid status assessment but does not target hepatic function specifically.
D: Measuring and recording intake and output is crucial for fluid balance monitoring but does not focus on hepatic function assessment.
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A 9-month-old boy has been referred to you for the evaluation of an enlarged abdomen. Imaging studies show a large liver mass (PRETEXT III). Alfa-fetoprotein is 98 ng/mL, and a CT scan of the lungs show bilateral lung metastases. A needle biopsy is performed, and you are planning to review the specimen with the pathologist. Which of the following diagnoses are you suspecting?
- A. Pure fetal histology hepatoblastoma
- B. Embryonal sarcoma of the liver
- C. Fibrolamellar hepatocellular carcinoma
- D. Small cell undifferentiated hepatoblastoma
Correct Answer: D
Rationale: The correct answer is D: Small cell undifferentiated hepatoblastoma. In this case, the key features to consider are the patient's age (9 months old), large liver mass with lung metastases, and elevated alpha-fetoprotein level. Small cell undifferentiated hepatoblastoma is commonly seen in infants, presents as a large liver mass, and frequently metastasizes to the lungs. The alpha-fetoprotein level in this case is also elevated, which is typical for hepatoblastoma. Pure fetal histology hepatoblastoma (A) is less common in older infants, and the presence of lung metastases is not typical. Embryonal sarcoma (B) typically presents as a solitary mass without metastases. Fibrolamellar hepatocellular carcinoma (C) is rare in infants and does not typically present with elevated alpha-fetoprotein levels. Thus, based on the clinical presentation and imaging findings, small cell undifferentiated hepatob
A nurse is caring for a client who is scheduled for an outpatient surgical procedure and reports taking aspirin 81 mg daily, including this morning. The nurse should identify that this places the client at risk for which of the following complications?
- A. Uncontrolled bleeding
- B. Myocardial infarction
- C. Respiratory depression
- D. Decreased renal perfusion
Correct Answer: A
Rationale: Rationale: Aspirin is an antiplatelet medication that inhibits platelet aggregation, increasing the risk of uncontrolled bleeding during surgical procedures. By taking aspirin, the client's blood clotting ability is impaired, leading to potential excessive bleeding during and after surgery. This can result in complications such as prolonged bleeding, hematoma formation, and delayed wound healing. Therefore, the correct answer is A: Uncontrolled bleeding.
Summary:
- B: Myocardial infarction is not directly related to taking aspirin; it is actually used to prevent heart attacks.
- C: Respiratory depression is not a common complication associated with aspirin use.
- D: Decreased renal perfusion is not a typical risk of taking aspirin; it primarily affects the cardiovascular system.
A nurse is caring for a patient with Hodgkin lymphoma at the oncology clinic. The nurse should be aware of what main goal of care?
- A. Cure of the disease
- B. Enhancing quality of life
- C. Controlling symptoms
- D. Palliation
Correct Answer: A
Rationale: The correct answer is A: Cure of the disease. The main goal of care for a patient with Hodgkin lymphoma is to achieve a cure whenever possible. This is because Hodgkin lymphoma is a potentially curable cancer with appropriate treatment. Achieving a cure means eradicating the cancer cells completely and preventing its recurrence in the future. This is the most desirable outcome for the patient's long-term health and well-being.
Incorrect choices:
B: Enhancing quality of life - While improving the patient's quality of life is important, the primary goal in treating Hodgkin lymphoma is to cure the disease.
C: Controlling symptoms - Symptom management is important in providing comfort to the patient, but the main goal is to cure the disease.
D: Palliation - Palliative care focuses on relieving symptoms and improving quality of life in patients with advanced or incurable diseases. For Hodgkin lymphoma, the main goal is to aim for a cure rather than palliation.
A hospitalized client has a platelet count of 58,000/mm³. What action by the nurse is best?
- A. Encourage high-protein foods.
- B. Institute neutropenic precautions.
- C. Limit visitors to healthy adults.
- D. Place the client on safety precautions.
Correct Answer: D
Rationale: The correct answer is D: Place the client on safety precautions. A platelet count of 58,000/mm³ indicates thrombocytopenia, increasing the risk of bleeding. Placing the client on safety precautions will minimize the risk of injury and bleeding. Encouraging high-protein foods (choice A) is not directly related to managing thrombocytopenia. Neutropenic precautions (choice B) are for clients with low neutrophil counts, not low platelet counts. Limiting visitors to healthy adults (choice C) is important for infection control, not addressing the risk of bleeding.
An older client asks the nurse why 'people my age' have weaker immune systems than younger people. What responses by the nurse are best? (Select all that apply.)
- A. Bone marrow produces more blood cells as you age.'
- B. You may have decreased levels of circulating platelets.'
- C. You have lower levels of plasma proteins in the blood.'
- D. Lymphocytes become more reactive to antigens.'
Correct Answer: C
Rationale: The correct answer is C: 'You have lower levels of plasma proteins in the blood.' As we age, there is a decline in the production of plasma proteins, which play a crucial role in immune function. These proteins help fight infections and regulate immune responses. Lower levels can weaken the immune system's ability to respond effectively to pathogens.
Choice A is incorrect because while bone marrow does produce blood cells, it does not directly relate to the weakening of the immune system with age. Choice B is incorrect as decreased platelet levels primarily affect blood clotting, not immune function. Choice D is incorrect because lymphocytes becoming more reactive to antigens is not a characteristic of aging immune systems.