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The nurse is caring for the client experiencing superior vena cava syndrome secondary to lung cancer. Which problem should be the nurse’s priority?
- A. Ineffective breathing pattern
- B. Ineffective tissue perfusion
- C. Risk for infection
- D. Impaired skin integrity
Correct Answer: A
Rationale: A. Ineffective breathing pattern occurs with superior vena cava syndrome because the superior vena cava is located next to the main stem bronchus and causes compression of the intrathoracic structures. B. Ineffective tissue perfusion may occur with superior vena cava syndrome, but ineffective breathing pattern is priority. C. Risk for infection occurs with chemotherapy treatment and not from superior vena cava syndrome. D. Impaired skin integrity occurs with malignant skin conditions and usually not from lung cancer.
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A toddler has been treated for sickle cell crisis. The crisis subsides, and the child improves. Which statement is essential for the nurse to include in the discharge teaching?
- A. Your child will bruise easily. Do not let your child bump into things.
- B. Notify the physician immediately if your child develops a fever.
- C. Your child will need special help with feeding.
- D. Observe your child frequently for difficulty breathing.
Correct Answer: B
Rationale: Fevers can cause dehydration and trigger sickling, leading to a crisis, making it essential to notify the physician immediately.
The nurse is caring for a client diagnosed with acute myeloid leukemia. Which assessment data warrant immediate intervention?
- A. T 99, P 102, R 22, and BP 132/68.
- B. Hyperplasia of the gums.
- C. Weakness and fatigue.
- D. Pain in the left upper quadrant.
Correct Answer: D
Rationale: Left upper quadrant pain (D) suggests splenic rupture, a life-threatening AML complication. Vitals (A) are stable, gum hyperplasia (B) is expected, and fatigue (C) is common.
A child is being evaluated for possible leukemia. Which assessment finding is most likely to be present?
- A. Numerous bruises on the child's body
- B. Ruddy complexion
- C. Diarrhea and vomiting
- D. Chest pain
Correct Answer: A
Rationale: Numerous bruises are common in leukemia due to decreased platelets from bone marrow failure.
The client is diagnosed with hemophilia. Which safety precaution should the nurse encourage?
- A. Wear helmets and pads during contact sports.
- B. Take antibiotics prior to any dental work.
- C. Keep clotting factor VIII on hand at all times.
- D. Use ibuprofen, an NSAID, for mild pain.
Correct Answer: C
Rationale: Hemophilia requires factor VIII availability (C) for bleeding emergencies. Contact sports (A) are risky, antibiotics (B) are for endocarditis, and ibuprofen (D) increases bleeding.
The nurse has identified the concept of cellular deviation for a client diagnosed with chronic myelogenous leukemia. Which intervention should the nurse implement? Select all that apply.
- A. Screen visitors for infection before allowing them to enter the room.
- B. Assess the client’s vital signs every four (4) hours.
- C. Do not allow fresh fruits and vegetables on diet trays.
- D. Monitor the client’s white blood cell count.
- E. Place the client on droplet isolation.
- F. Check the client’s bone marrow results daily.
Correct Answer: A,C,D
Rationale: Screening visitors (A), avoiding fresh produce (C), and monitoring WBCs (D) reduce infection risk in CML. Vitals (B) are routine, droplet isolation (E) is excessive, and daily bone marrow (F) is impractical.