Nokea
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.
You may also like to solve these questions
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 is working in a blood bank facility procuring units of blood from donors. Which client would not be a candidate to donate blood?
- A. The client who had wisdom teeth removed a week ago.
- B. The nursing student who received a measles immunization two (2) months ago.
- C. The mother with a six (6)-week-old newborn.
- D. The client who developed an allergy to aspirin in childhood.
Correct Answer: C
Rationale: Recent childbirth (C) (within 6 months) disqualifies blood donation due to anemia risk. Wisdom teeth (A), immunization (B), and aspirin allergy (D) are not contraindications.
The client has undergone a lymph node biopsy to differentiate between Hodgkin’s and non-Hodgkin’s lymphoma. After reviewing the client’s lymph node biopsy results, which revealed that the client has Hodgkin’s lymphoma, the nurse should obtain which educational brochure?
- A. The brochure that includes an explanation of an elevated reticulocyte count
- B. The brochure that includes an explanation of CA-125 tumor markers
- C. The brochure that includes an explanation of an elevated WBC count
- D. The brochure that includes an explanation about Reed-Sternberg cells
Correct Answer: D
Rationale: A. Reticulocytes are found in a CBC, not from a lymph node biopsy, and are not indicative of either Hodgkin’s or non-Hodgkin’s lymphoma. B. CA-125 tumor markers are sometimes used in the management of ovarian cancer. C. WBCs are collected from a complete blood panel, not a lymph node biopsy, and could be indicative of other lymphomas and/or leukemia. D. The nurse should obtain the brochure that explains about Reed-Sternberg cells. The main diagnostic feature of Hodgkin’s lymphoma is the presence of Reed-Sternberg cells in a lymph node biopsy.
The client diagnosed with anemia begins to complain of dyspnea when ambulating in the hall. Which intervention should the nurse implement first?
- A. Apply oxygen via nasal cannula.
- B. Get a wheelchair for the client.
- C. Assess the client’s lung fields.
- D. Assist the client when ambulating in the hall.
Correct Answer: B
Rationale: Dyspnea in anemia suggests low oxygen-carrying capacity; a wheelchair (B) prevents exertion while further assessment occurs. Oxygen (A), lung assessment (C), and assistance (D) follow.
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.