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 B
Explanation
A) This choice is incorrect because a complete blood count (CBC) provides information about the number of blood cells, but it does not directly assess the bone marrow for leukemia.
B) This choice is correct. Bone marrow aspiration and biopsy involve the collection of bone marrow samples from the sternum or hip bone. These samples are then analyzed to determine the presence of leukemia cells, assess cell morphology, and determine the type of leukemia.
C) This choice is incorrect because flow cytometry analysis is used to identify specific markers on the surface of cells and can aid in diagnosing and classifying leukemia. However, it is not the primary test used to assess the bone marrow directly.
D) This choice is incorrect because magnetic resonance imaging (MRI) is not commonly used to assess bone marrow in the diagnostic evaluation of leukemia.
Correct Answer is C
Explanation
A) This choice is incorrect because leukemia does not result from an overproduction of platelets. Leukemia involves an overproduction of abnormal white blood cells.
B) This choice is incorrect because leukemia is not caused by the body's immune system attacking healthy white blood cells. Instead, it involves the uncontrolled growth of abnormal white blood cells.
C) This choice is correct. Leukemia is characterized by genetic mutations in the bone marrow cells, particularly in the stem cells that produce white blood cells. These mutations lead to uncontrolled growth and proliferation of abnormal white blood cells, interfering with the normal production of other blood cells.
D) This choice is incorrect because an imbalance of red blood cells would not trigger the overproduction of white blood cells. Leukemia is specifically a disorder of white blood cell proliferation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.