Nokea
Which of the following nursing actions should the nurse include in the plan of care for a patient admitted with multiple myeloma?
- A. Monitor fluid intake and output.
- B. Administer calcium supplements.
- C. Assess lymph nodes for enlargement.
- D. Limit weight bearing and ambulation.
Correct Answer: A
Rationale: A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient's calcium level and are not used.
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The nurse is caring for a patient with acute myelogenous leukemia (AML) who has induction therapy prescribed and the patient asks the nurse whether the planned chemotherapy will be worth undergoing. Which of the following responses by the nurse is best?
- A. If you do not want to have chemotherapy, there are other options for treatment such as stem cell transplantation.
- B. The decision about chemotherapy is one that you and the doctor need to make rather than asking what I would do.
- C. You don't need to make a decision about treatment right now since leukemias in adults tend to progress quite slowly.
- D. The adverse effects of the chemotherapy are difficult, but AML frequently does go into remission with chemotherapy.
Correct Answer: D
Rationale: This response uses therapeutic communication by addressing the patient's question and giving accurate information. The other responses either give inaccurate information or fail to address the patient's question, which will discourage the patient from asking the nurse for information.
The nurse is caring for a patient with septicemia who develops prolonged bleeding from venipuncture sites and blood in the stools. Which of the following actions is most important for the nurse to take?
- A. Notify the patient's health care provider.
- B. Give the ordered dose of warfarin.
- C. Avoid unnecessary venipunctures.
- D. Give prescribed proton-pump inhibitors.
Correct Answer: A
Rationale: The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions also are appropriate, but the most important action should be to notify the physician so that DIC treatment can be initiated rapidly.
The nurse is caring for a patient who is receiving methotrexate and develops a megaloblastic anemia. Which of the following nutrients should the nurse include in the teaching plan?
- A. Iron
- B. Folic acid
- C. Cobalamin (vitamin B12)
- D. Ascorbic acid (vitamin C)
Correct Answer: B
Rationale: Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.
Which of the following newly admitted patients should the nurse assign as a roommate for a patient who has aplastic anemia?
- A. A patient with severe heart failure
- B. A patient who has viral pneumonia
- C. A patient who has right leg cellulitis
- D. A patient with multiple abdominal drains
Correct Answer: A
Rationale: Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.
The nurse is caring for a patient with non-Hodgkin's lymphoma who develops a platelet count of 38 x 10^9/L during chemotherapy. Which of the following actions should the nurse implement based on this finding?
- A. Provide oral hygiene every 2 hours.
- B. Check all stools for occult blood.
- C. Assess temperature every 4 hours.
- D. Encourage fluids to 3000 mL/day.
Correct Answer: B
Rationale: Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.