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The nurse receives orders after notifying an HCP about the client who has tachycardia, diaphoresis, and an elevated temperature after treatments for ALL. Which order should be the nurse’s priority?
- A. Portable chest x-ray in the client’s room
- B. Urine culture, and blood cultures x 2
- C. Vancomycin 500 mg IV q6h
- D. Filgrastim 0.3 mg subcut daily
Correct Answer: B
Rationale: A. The results of the portable CXR will help determine if the cause is a respiratory infection. It will not change the treatment. B. Urine and blood cultures are priority; these should be obtained before antibiotics are administered. C. National recommendations are to administer broad-spectrum antibiotics such as vancomycin (Vancocin) within 1 hour of a suspected infection diagnosis. The antibiotics may be changed after culture and sensitivity reports are available (usually 24 to 48 hours). D. It takes 4 days for filgrastim (Neupogen) to return the neutrophil count to baseline, so this is not priority. Filgrastim should not be given within 24 hours of cytotoxic chemotherapy.
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The client who was recently admitted with gastric cancer appears pale and weak and states feeling fatigued. In reviewing the client’s laboratory results, which component of the CBC should the nurse most associate with the client’s gastric cancer and identify as the causative factor for the fatigue?
- A. White blood cell 12,200/mm3
- B. Hemoglobin 7.9 g/dL
- C. Serum protein 5.9 g/dL
- D. Blood urea nitrogen 22 mg/dL
Correct Answer: B
Rationale: A. The elevation in the WBC (normal is 4500–10,000/mm3 or microL) is concerning because it could indicate an infection, but the elevation would not necessarily be related to the gastric cancer. B. The presenting symptoms are indicative of anemia, which is common in gastric cancer due to chronic blood loss, or as a result of pernicious anemia (due to loss of intrinsic factor). The low Hgb (normal is 12–15 g/dL) may be the causative factor for the fatigue. C. The serum protein is slightly low (normal is 6.0–8.0 g/dL) and could be indicative of nutritional problems associated with the gastric cancer, but it is not specific to the signs and symptoms described in the question, and it is not part of a CBC. D. The BUN (normal is 5–25 mg/dL) is within normal parameters and is measuring kidney function or hydration status. It is not part of the CBC.
The client diagnosed with leukemia has central nervous system involvement. Which instruction should the nurse teach?
- A. Sleep with the HOB elevated to prevent increased intracranial pressure.
- B. Take an analgesic medication for pain only when the pain becomes severe.
- C. Explain radiation therapy to the head may result in permanent hair loss.
- D. Discuss end-of-life decisions prior to cognitive deterioration.
Correct Answer: D
Rationale: CNS leukemia risks cognitive decline; discussing end-of-life decisions (D) is critical before deterioration. HOB elevation (A) is for ICP, not routine, analgesics (B) should be proactive, and hair loss (C) is secondary.
Which concepts could the nurse identify for a client diagnosed with lymphoma? Select all that apply.
- A. Coping.
- B. Hematologic regulation.
- C. Tissue perfusion.
- D. Clotting.
- E. Clinical judgment.
Correct Answer: A,B,C,D
Rationale: Lymphoma involves coping (A) with diagnosis, hematologic regulation (B) via lymph dysfunction, perfusion (C) due to node obstruction, and clotting (D) from thrombocytopenia. Clinical judgment (E) is a nursing process, not a patient concept.
The nurse administers iron using the Z track technique. What is the primary reason for administering iron via Z track?
- A. To prevent adverse reactions
- B. To prevent staining of the skin
- C. To improve the absorption rate
- D. To increase the speed of onset of action
Correct Answer: B
Rationale: The Z track technique prevents iron from leaking into subcutaneous tissue, reducing skin staining.
The nurse writes a diagnosis of altered tissue perfusion for a client diagnosed with anemia. Which interventions should be included in the plan of care? Select all that apply.
- A. Monitor the client’s hemoglobin and hematocrit.
- B. Move the client to a room near the nurse’s desk.
- C. Limit the client’s dietary intake of green vegetables.
- D. Assess the client for numbness and tingling.
- E. Allow for rest periods during the day for the client.
Correct Answer: A,D,E
Rationale: Monitoring Hb/Hct (A), assessing numbness/tingling (D), and rest periods (E) address perfusion in anemia. Proximity to desk (B) is nonspecific, and limiting greens (C) is for anticoagulation, not anemia.