Nokea
Nurse Mike is providing care to a client with chronic myelogenous leukemia (CML). The nurse knows that the client is at risk for tumor lysis syndrome. Which of the following laboratory values requires immediate intervention?
- A. Increased uric acid level
- B. Increased serum potassium level
- C. Increased serum sodium level
- D. Increased fibrinogen level
Correct Answer: A
Rationale: The correct answer is A: Increased uric acid level. In tumor lysis syndrome, rapid cell destruction releases large amounts of potassium, phosphate, and nucleic acids into the bloodstream. Uric acid can accumulate rapidly, leading to hyperuricemia, which can result in kidney damage due to urate crystal deposition. Immediate intervention is necessary to prevent renal complications. Choices B, C, and D are incorrect because while electrolyte imbalances are common in tumor lysis syndrome, hyperuricemia with potential kidney damage is the priority concern that requires immediate attention.
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A patient with multiple myeloma is receiving chemotherapy and is at risk for bone fractures. What intervention should the nurse prioritize to reduce this risk?
- A. Encouraging bed rest
- B. Promoting bed rest to avoid injury
- C. Encouraging weight-bearing exercises
- D. Ensuring adequate hydration
Correct Answer: B
Rationale: The correct answer is B: 'Promoting bed rest to avoid injury.' In patients with multiple myeloma undergoing chemotherapy, encouraging bed rest can lead to muscle weakness and bone loss, increasing the risk of fractures. Promoting bed rest to avoid injury means advising the patient on safe movement and activities to prevent fractures. Encouraging weight-bearing exercises (choice C) would be more beneficial than bed rest as it helps in maintaining bone density and strength. Ensuring adequate hydration (choice D) is essential for overall health but does not directly address the risk of bone fractures associated with multiple myeloma and chemotherapy. Choice A, 'Encouraging bed rest,' is incorrect as it may worsen the risk of fractures rather than reduce it.
A client receiving chemotherapy is experiencing severe nausea and vomiting. Which intervention should the nurse implement first?
- A. Administer antiemetics 30 minutes before chemotherapy.
- B. Offer small, frequent meals that are bland and easy to digest.
- C. Encourage the client to rest after meals to reduce nausea.
- D. Instruct the client to use relaxation techniques.
Correct Answer: A
Rationale: The correct answer is A: Administer antiemetics 30 minutes before chemotherapy. Administering antiemetics before chemotherapy is crucial to prevent nausea rather than treating it after it occurs. This proactive approach helps in minimizing the side effects. Choice B, offering small, frequent meals, can be beneficial but is not the first intervention for severe nausea and vomiting. Choice C, encouraging rest after meals, may help but is not the priority when the client is experiencing severe symptoms. Choice D, instructing the client to use relaxation techniques, is not the first-line intervention for severe nausea and vomiting in a client receiving chemotherapy.
As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement?
- A. I should avoid blowing my nose.
- B. I may need a platelet transfusion if my platelet count is too low.
- C. I should take aspirin for my headache as soon as I get home.
- D. I will count the number of pads and tampons I use when menstruating.
Correct Answer: C
Rationale: The correct answer is C. Taking aspirin is not recommended during periods of bone marrow suppression as it can increase the risk of bleeding. Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can impair platelet function, further exacerbating the risk of bleeding. Choices A, B, and D are all appropriate statements for a client at risk for bleeding and undergoing chemotherapy. Blowing the nose gently, being prepared for a platelet transfusion if needed, and monitoring menstrual bleeding are all important aspects of self-care during this period.
The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor?
- A. Age younger than 50 years
- B. History of colorectal polyps
- C. Family history of colorectal cancer
- D. Chronic inflammatory bowel disease
Correct Answer: A
Rationale: The correct answer is A: Age younger than 50 years. Colorectal cancer is more commonly diagnosed in individuals over the age of 50, so being younger than 50 is not typically considered a significant risk factor. Choice B, history of colorectal polyps, is a known risk factor as polyps can develop into cancer over time. Choice C, family history of colorectal cancer, is a well-established risk factor due to genetic predisposition. Choice D, chronic inflammatory bowel disease, such as Crohn's disease or ulcerative colitis, increases the risk of developing colorectal cancer. Therefore, the incorrect choice is A as age younger than 50 years is not a common risk factor for colorectal cancer.
A client with cancer has anorexia and mucositis, and is losing weight. The client's family members continually bring favorite foods to the client and are distressed when the client won't eat them. What action by the nurse is best?
- A. Explain the pathophysiologic reasons behind the client not eating.
- B. Help the family show other ways to demonstrate love and caring.
- C. Suggest foods and liquids the client might be willing to try to eat.
- D. Tell the family the client isn't able to eat now no matter what they bring.
Correct Answer: B
Rationale: The best action for the nurse in this situation is to help the family show other ways to demonstrate love and caring. When a client with cancer is experiencing anorexia and mucositis, it can be challenging for them to eat even their favorite foods. By assisting the family in finding alternative ways to provide comfort and care, the nurse can help create a supportive environment for the client. Option A is not the best choice as explaining the pathophysiologic reasons may not address the emotional needs of the client and family. Option C, suggesting foods and liquids, might not be helpful if the client is unable to tolerate them due to their condition. Option D, telling the family that the client can't eat, may come across as dismissive and not supportive of the family's concerns.