A client with leukemia is receiving intravenous (IV) chemotherapy. Which assessment finding should the nurse report to the healthcare provider immediately?
Mild redness and tenderness at the IV site
Temperature of 99.8°F (37.7°C)
A small amount of blood in the IV tubing
Crackles and decreased breath sounds on auscultation
The Correct Answer is D
A) This choice is incorrect because mild redness and tenderness at the IV site are common findings and may indicate a local inflammatory response to the IV infusion.
B) This choice is incorrect because a temperature of 99.8°F (37.7°C) is slightly elevated but not a critical finding. The client's healthcare provider should be notified if the temperature is significantly elevated or if other symptoms are present.
C) This choice is incorrect because a small amount of blood in the IV tubing may be due to a minor infiltration or a common occurrence during IV administration. However, the nurse should monitor the IV site and flow rate closely.
D) This choice is correct. Crackles and decreased breath sounds on auscultation may indicate fluid overload or pulmonary edema, which could be a severe complication of IV chemotherapy. The healthcare provider should be notified immediately to assess the client's respiratory status and provide appropriate intervention.
Questions
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) This choice is incorrect because leukemia is not always caused by inherited genetic mutations. While genetic factors can contribute to the development of some types of leukemia, it is not the only cause.
B) This choice is incorrect because there are known genetic links to certain types of leukemia. For example, some forms of leukemia, such as chronic myeloid leukemia (CML), are associated with specific genetic mutations.
C) This choice is incorrect because genetic factors and environmental factors can both play a role in the development of leukemia. Some cases may be influenced more by genetic factors, while others may be influenced more by environmental factors.
D) This choice is correct. Leukemia can have various causes, including genetic mutations, exposure to certain environmental factors (e.g., radiation, certain chemicals), and viral infections. While some cases may have a genetic basis, others may be triggered by environmental factors or have an unknown cause.
Correct Answer is C
Explanation
A) This choice is incorrect because AML is not characterized by the overproduction of immature lymphocytes. It involves the uncontrolled proliferation of abnormal myeloid cells in the bone marrow.
B) This choice is incorrect because AML does not cause abnormal proliferation of red blood cells. Anemia may occur as a result of AML due to the displacement of normal blood-forming cells in the bone marrow.
C) This choice is correct. AML is a type of leukemia that arises from genetic mutations in the myeloid stem cells. These mutations lead to uncontrolled growth and accumulation of abnormal myeloid cells, including granulocytes, monocytes, and platelets.
D) This choice is incorrect because the abnormal growth of plasma cells leading to the production of abnormal antibodies is characteristic of multiple myeloma, not AML.
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