A nurse is assessing a client 1 week after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as an indication of which of the following complications?
Failure to engraft
Veno-occlusive disease
Graft-versus-host disease
Pancytopenia
The Correct Answer is B
A. Failure to engraft typically presents with symptoms such as persistent neutropenia, thrombocytopenia, and anemia, rather than skin peeling.
B. Veno-occlusive disease, also known as sinusoidal obstruction syndrome, can lead to liver dysfunction and subsequent skin manifestations such as peeling, especially on the palms and soles.
C. Graft-versus-host disease (GVHD) typically presents with symptoms such as skin rash, diarrhea, and liver dysfunction, but peeling skin is not a hallmark manifestation.
D. Pancytopenia refers to a deficiency of all types of blood cells (red blood cells, white blood cells, and platelets) and is not typically associated with skin peeling as a primary symptom.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Vancomycin is not typically associated with hepatotoxicity.
B. Ototoxicity, which can manifest as hearing loss or tinnitus, is a potential adverse reaction of vancomycin therapy, especially with prolonged or high-dose therapy. Monitoring for signs of hearing impairment is essential.
C. Hypercalcemia is not a common adverse reaction associated with vancomycin therapy.
D. Hypertension is not a common adverse reaction associated with vancomycin therapy.
Correct Answer is D
Explanation
A. Sputum culture is used to diagnose active tuberculosis but is not typically used for routine screening of asymptomatic individuals.
B. Chest x-ray can detect active tuberculosis or its complications but is not typically used for routine screening of asymptomatic individuals.
C. QuantiFERON-TB Gold blood analysis is a blood test that detects the presence of tuberculosis infection but is not typically used for routine screening of asymptomatic individuals.
D. The Mantoux test, also known as the tuberculin skin test (TST), is commonly used for routine screening of tuberculosis infection in asymptomatic individuals, including new employees in healthcare settings.
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