Nokea
The nurse writes a nursing problem of 'altered nutrition' for a client diagnosed with leukemia who has received a treatment regimen of chemotherapy and radiation. Which nursing intervention should be implemented?
- A. Administer an antidiarrheal medication prior to meals.
- B. Monitor the client's serum albumin levels.
- C. Assess for signs and symptoms of infection.
- D. Provide skin care to irradiated areas.
Correct Answer: B
Rationale: Altered nutrition requires monitoring serum albumin (B) to assess protein status. Antidiarrheals (A) are symptom-specific, infection (C) is unrelated, and skin care (D) addresses radiation effects.
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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 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.
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 nurse has been teaching the parents of a child with hemophilia about the care he will need. Which statement by the parents indicates a need for more instruction?
- A. If my child needs something for pain or a fever, I will give him acetaminophen instead of aspirin.'
- B. I will take my child to the dentist for regular checkups.'
- C. I will keep my child in the house most of the time.'
- D. My son's Medic Alert Bracelet arrived.'
Correct Answer: C
Rationale: Overprotecting the child by keeping him indoors most of the time prevents normal development. Acetaminophen, dental care, and a Medic Alert bracelet are appropriate.
The nurse is preparing to administer epoetin alfa to the client who has chemotherapy-associated anemia. The nurse recognizes the need to consult with the HCP before administration when the client makes which statements?
- A. “I spend most of my days lying on the couch.”
- B. “I usually eat a lot of salads for my main meals.”
- C. “I seem to have an aversion to eating eggs right now.”
- D. “I developed a blood clot in my leg on my last admission.”
- E. “I hope this helps so I don’t have to have a blood transfusion.”
Correct Answer: A, D
Rationale: Erythropoiesis-stimulating agents, such as epoetin alfa (Epogen), can cause thromboembolic events. It would be concerning if the client had limited activity because this could further increase the client’s risk of a thromboembolic event. B. Dark green, leafy vegetables are high in iron and help with Hgb synthesis and therefore would be beneficial. C. Eggs are high in iron, but there are other food sources high in iron that the client can consume if an aversion exists. D. A history of a thromboembolic event and use of epoetin alfa increase the client’s risk for another thromboembolic event. E. The use of epoetin alfa is recommended as a treatment option for clients with chemotherapy-associated anemia and an Hgb concentration that is approaching, or has fallen below, 10 g/dL, to increase the Hgb level and decrease the need for a transfusion.