Nokea
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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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.
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.
When reviewing the safe administration of antineoplastic agents, what action should the nurse emphasize?
- A. Adjust the dose based on the patient's present symptoms.
- B. Wash hands with an alcohol-based cleanser before and after administration.
- C. Use gloves and a lab coat when preparing and administering the medication.
- D. Dispose of the antineoplastic wastes in the hazardous waste receptacle.
Correct Answer: D
Rationale: The correct answer is to dispose of the antineoplastic wastes in the hazardous waste receptacle. Antineoplastic agents are hazardous materials, and proper disposal is crucial to prevent harm to individuals and the environment. Option A is incorrect because adjusting the dose based on the patient's present symptoms may not be safe without proper authorization. Option B is incorrect as hand hygiene should be performed both before and after administering medications. Option C is incorrect as gloves and a lab coat should be worn primarily during handling and administration, not just during preparation.
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.