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The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?
- A. The passage of flatus
- B. Absent bowel sounds
- C. The client¢â‚¬â„¢s ability to tolerate food
- D. Bloody drainage from the colostomy
Correct Answer: A
Rationale: The passage of flatus (gas) from the colostomy is an early sign that the bowel is beginning to function after surgery. This indicates that peristalsis, or the movement of the intestines, has resumed and that the digestive system is actively moving gas and eventually stool through the bowel and out of the colostomy. It's a positive sign that the bowel is recovering from the surgery and starting to work as intended.
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A 35-year-old male is admitted to the hospital complaining of severe headaches, vomiting, and testicular pain. His blood work shows reduced numbers of platelets, leukocytes, and erythrocytes, with a high proportion of immature cells. The nurse caring for this patient suspects a diagnosis of what?
- A. AML
- B. CML
- C. MDS
- D. ALL
Correct Answer: D
Rationale: Acute Lymphocytic Leukemia (ALL) is a type of cancer where immature lymphocytes (a type of white blood cell) proliferate uncontrollably in the bone marrow. This leads to a reduction in the production of platelets, leukocytes, and erythrocytes, causing symptoms such as fatigue, anemia, bleeding tendencies, and increased susceptibility to infection. In ALL, leukemic cell infiltration into other organs is common, which can manifest as severe headaches (due to central nervous system involvement), vomiting, and testicular pain (due to infiltration of leukemic cells into the testes). These are hallmark signs of ALL, especially in younger patients.
The nurse is caring for a client who is at risk for tumor lysis syndrome. Which laboratory value requires the nurse to intervene?
- A. Decreased blood urea nitrogen (BUN)
- B. Increased serum calcium
- C. Increased creatinine level
- D. Increased blood glucose level
Correct Answer: C
Rationale: Tumor lysis syndrome (TLS) is a potentially life-threatening condition that occurs when large numbers of cancer cells die rapidly, releasing their contents into the bloodstream. This can overwhelm the kidneys and lead to acute kidney injury. Creatinine is a waste product filtered out of the blood by the kidneys, and an elevated creatinine level is a sign of kidney dysfunction or damage. In TLS, increased creatinine levels indicate that the kidneys are struggling to filter out the excess waste products from cell breakdown, requiring immediate intervention to prevent further complications, such as acute renal failure.
A nurse is caring for a patient with myelodysplastic syndrome (MDS) who is at risk for anemia. What is the most appropriate intervention to address this risk?
- A. Administering iron supplements
- B. Administering blood transfusions
- C. Providing a high-iron diet
- D. Administering erythropoietin
Correct Answer: D
Rationale: In myelodysplastic syndrome (MDS), the bone marrow does not produce enough healthy blood cells, leading to conditions such as anemia. Administering erythropoietin is an effective intervention to manage anemia in MDS patients because it stimulates the production of red blood cells. This can help improve the patient's hemoglobin levels, reducing symptoms such as fatigue and weakness associated with anemia. Erythropoietin is commonly used in MDS to enhance red blood cell production and reduce the need for frequent blood transfusions.
A client has been prescribed epoetin alfa for anemia related to chemotherapy. What lab value should the nurse monitor to determine the effectiveness of this medication?
- A. Hemoglobin level.
- B. Hematocrit level.
- C. White blood cell count.
- D. Platelet count.
Correct Answer: A
Rationale: Epoetin alfa is a medication used to treat anemia, particularly anemia related to chemotherapy or chronic kidney disease. It stimulates the bone marrow to produce more red blood cells, which increases the hemoglobin level. Monitoring hemoglobin is the best way to assess the effectiveness of epoetin alfa, as an increase in hemoglobin indicates that the body is producing more red blood cells and the anemia is improving.
A nurse practitioner is assessing a patient who has a fever, malaise, and a white blood cell count that is elevated. Which of the following principles should guide the nurses management of the patients care?
- A. There is a need for the patient to be assessed for lymphoma.
- B. Infection is the most likely cause of the patients change in health status.
- C. The patient is exhibiting signs and symptoms of leukemia.
- D. The patient should undergo diagnostic testing for multiple myeloma.
Correct Answer: B
Rationale: An elevated white blood cell (WBC) count, also known as leukocytosis, is most commonly a response to infection. When the body detects an infection, the immune system responds by increasing the production of white blood cells to fight off the invading pathogens. The accompanying symptoms of fever and malaise are typical signs of infection, supporting the likelihood that this patient's health status is related to an infectious process rather than a more serious hematologic condition like lymphoma or leukemia.