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 a bone marrow biopsy is not performed to remove a tumor mass. The purpose of the procedure is to obtain a sample of bone marrow tissue for diagnostic evaluation.
B) This choice is incorrect because assessing the presence of circulating cancer cells in the bloodstream is typically done through a blood test, not a bone marrow biopsy. The biopsy provides direct information about the condition of the bone marrow.
C) This choice is incorrect because evaluating the overall blood cell count and differential is typically done through a complete blood count (CBC) test, not a bone marrow biopsy. The biopsy provides more detailed information about the bone marrow and its cellular composition.
D) This choice is correct. The primary purpose of a bone marrow biopsy is to obtain a sample of bone marrow tissue for examination under a microscope. This allows healthcare professionals to assess the presence of abnormal cells, determine the type and extent of leukemia, and guide treatment decisions.
Correct Answer is C
Explanation
A) This choice is incorrect because increased platelet production would not lead to easy bruising and petechiae. It would, in fact, improve clotting abilities.
B) This choice is incorrect because overproduction of red blood cells would not directly cause easy bruising and petechiae. It may lead to symptoms like fatigue and pallor.
C) This choice is correct. Easy bruising and petechiae are common in leukemia due to a deficiency of platelets and impaired clotting factors in the blood. Leukemia can lead to decreased platelet production and clotting abnormalities, resulting in easy bleeding and bruising.
D) This choice is incorrect because a deficiency of white blood cells would not directly cause easy bruising and petechiae. It might lead to an increased risk of infections.
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