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The nurse is caring for a patient with non-Hodgkin's lymphoma who develops a platelet count of 38 x 10^9/L during chemotherapy. Which of the following actions should the nurse implement based on this finding?
- A. Provide oral hygiene every 2 hours.
- B. Check all stools for occult blood.
- C. Assess temperature every 4 hours.
- D. Encourage fluids to 3000 mL/day.
Correct Answer: B
Rationale: Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.
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After receiving change-of-shift report for the following four patients with neutropenia, which patient should the nurse assess first?
- A. 66-year-old who has white pharyngeal lesions
- B. 35-year-old who has a fever of 38.2°C (100.8°F)
- C. 36-year-old who has frequent explosive diarrhea
- D. 23-year old who is complaining of severe fatigue
Correct Answer: B
Rationale: Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not exhibit symptoms of potentially life-threatening problems.
The hemophilia clinic nurse receives a call from a patient with hemophilia to discuss all of these problems. Which of the following problems is most important to communicate to the health care provider?
- A. Joint swelling
- B. Painful hematuria
- C. Multiple bruises
- D. Dark tarry stools
Correct Answer: D
Rationale: Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury, but are not indicators of possible serious blood loss.
All of these patients are waiting to be admitted by the emergency department nurse. Which one of the following requires the most rapid assessment and care by the nurse?
- A. The patient with hemochromatosis who has symptoms of abdominal pain
- B. The patient with thrombocytopenia who has blood oozing after having a tooth extracted
- C. The patient with chemotherapy-induced neutropenia who has a temperature of 38.2°C (100.8°F)
- D. The patient with a history of sickle cell anemia who has had nausea and diarrhea for 24 hours
Correct Answer: C
Rationale: A neutropenic patient with a fever is assumed to have an infection and developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient.
The nurse is caring for a patient with neutropenia who is started on a cephalosporin. Which of the following common adverse effects should the nurse observe for in the patient?
- A. Nephrotoxicity
- B. Rash
- C. Ototoxicity
- D. Fever
- E. Pruritus
Correct Answer: B,D,E
Rationale: Adverse effects common to cephalosporins include rashes, fever, and pruritus. Adverse effects common to aminoglycosides include nephrotoxicity and ototoxicity.
The nurse is planning discharge teaching for a patient who was admitted with neutropenia. Which of the following instructions should the nurse include?
- A. Limit fluids to 2-3 litres a day.
- B. Include eggs and fish in the diet.
- C. Avoid exposure to crowds as much as possible.
- D. Drink only one or two caffeinated beverages daily.
Correct Answer: C
Rationale: Exposure to crowds increases the risk of infection in neutropenic patients. Limiting fluids or caffeinated beverages is not necessary, and eggs and fish are acceptable in the diet unless otherwise contraindicated.