Nokea
The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy?
- A. Restrict all visitors.
- B. Restrict fluid intake.
- C. Teach the client and family about the need for hand hygiene.
- D. Insert an indwelling urinary catheter to prevent skin breakdown.
Correct Answer: C
Rationale: In clients experiencing neutropenia, particularly due to chemotherapy, the immune system is significantly compromised, increasing the risk of infections. Hand hygiene is one of the most effective methods for preventing the spread of pathogens that can lead to infections. Teaching both the client and their family about the importance of frequent and proper handwashing helps create a safer environment and reduces the risk of infections, which can be critical in neutropenic patients.
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The nurse is reviewing the medication record for a client receiving chemotherapy and notes that the client is receiving epoetin alfa (Epogen). The nurse determines that this medication has been prescribed to:
- A. Increase white blood cell production
- B. Treat anemia
- C. Reduce pain
- D. Prevent infection
Correct Answer: B
Rationale: Epoetin alfa (Epogen) is a synthetic form of erythropoietin, a hormone that stimulates the production of red blood cells in the bone marrow. Chemotherapy often leads to anemia due to its effects on rapidly dividing cells, including those in the bone marrow responsible for red blood cell production. By administering epoetin alfa, the healthcare provider aims to increase the red blood cell count and improve hemoglobin levels, thereby alleviating symptoms associated with anemia, such as fatigue and weakness.
A nurse knows that the patient with stage 3 based on Ann-arber staging has:
- A. 2 or more lymph node involvement and outside the lymph nodes
- B. 2 or more lymph node involvement on one side of the body
- C. 2 or more lymph nodes on the breasts
- D. 2 or more lymph node involvement on both sides of the body
Correct Answer: D
Rationale: In the Ann Arbor staging system for lymphomas, Stage 3 indicates that the disease has spread beyond the initial lymph node region to involve lymph nodes on both sides of the diaphragm (i.e., the areas above and below the diaphragm). This includes lymphatic involvement in both the thoracic and abdominal regions, signifying a more advanced disease state.
The nurse on a bone marrow transplant unit is caring for a patient with cancer who is preparing for HSCT. What is a priority nursing diagnosis for this patient?
- A. Fatigue related to altered metabolic processes
- B. Altered nutrition: less than body requirements related to anorexia
- C. Risk for infection related to altered immunologic response
- D. Body image disturbance related to weight loss and anorexia
Correct Answer: C
Rationale: Patients preparing for hematopoietic stem cell transplantation (HSCT) undergo intensive chemotherapy and/or radiation, which significantly suppresses their immune system. This immunosuppression leads to a heightened risk for infection, making it the most critical nursing diagnosis for these patients. As the body's ability to fight off pathogens is compromised, close monitoring and interventions aimed at preventing infections are essential for their safety and recovery.
A patient with acute lymphocytic leukemia (ALL) is undergoing chemotherapy and develops neutropenia. What is the most important nursing intervention for this patient?
- A. Administering antipyretics
- B. Restricting visitors
- C. Maintaining a sterile environment
- D. Administering prophylactic antibiotics
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the client's oral chemotherapy medications. What action by the nurse is most appropriate?
- A. Crush the medications if the client cannot swallow them.
- B. Give one medication at a time with a full glass of water.
- C. No special precautions are needed for these medications.
- D. Wear personal protective equipment when handling the medications.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.