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.
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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) This choice is incorrect because red blood cells are not directly involved in the body's immune response. Decreased red blood cells may cause anemia, but they are not responsible for frequent infections and recurrent fevers.
B) This choice is incorrect because platelets are involved in clotting and do not directly impact the body's immune response.
C) This choice is correct. Neutrophils are a type of white blood cell responsible for fighting infections. In leukemia, particularly when neutrophils are affected, the body's ability to fight infections becomes compromised, leading to frequent infections and recurrent fevers.
D) This choice is incorrect because lymphocytes, specifically B-lymphocytes, are affected in chronic lymphocytic leukemia (CLL). While CLL can lead to increased susceptibility to infections, neutrophil dysfunction is more commonly associated with recurrent infections in leukemia.
Correct Answer is B
Explanation
A) This choice is incorrect because an elevated red blood cell count is not a typical finding in leukemia. Leukemia is characterized by the overproduction of white blood cells, not red blood cells.
B) This choice is correct. Leukemia is associated with an elevated white blood cell count, particularly an abnormal increase in blast cells, which are immature cells indicative of leukemia.
C) This choice is incorrect because an elevated platelet count is not a typical finding in leukemia. Leukemia is more commonly associated with thrombocytopenia, which is a decreased platelet count.
D) This choice is incorrect because the laboratory report indicating elevated levels of blast cells in the peripheral blood supports the suspicion of leukemia, not the blast cells' presence in the bone marrow.
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