A nurse is assessing a toddler who has leukemia and is receiving his first round of chemotherapy. Which of the following is the priority for the nurse to report to the provider?
Urticaria
Fatigue
Anorexia
Vomiting
The Correct Answer is A
A. Urticaria (hives) could indicate an allergic reaction or hypersensitivity to the chemotherapy, which needs to be addressed immediately to prevent more severe reactions, such as anaphylaxis.
B. Fatigue is a common side effect of chemotherapy and not usually an immediate concern unless accompanied by signs of more serious complications.
C. Anorexia can occur during chemotherapy but is typically managed with dietary adjustments and does not usually require urgent attention unless it leads to dehydration or significant weight loss.
D. Vomiting is a common side effect of chemotherapy, but it is usually managed with antiemetic medication and is not as immediately concerning as an allergic reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Orthostatic hypotension (a significant drop in blood pressure when standing) could indicate a problem such as dehydration, hemorrhage, or shock and should be reported immediately.
B. Crying due to pain is common with burn injuries but does not indicate a life-threatening problem.
C. A pain increase after ambulation is expected in some cases but is not an emergency.
D. A mild temperature (99.5°F) postoperatively is not a cause for immediate concern.
Correct Answer is B
Explanation
A. A urinary output of 100 mL/hr is within the expected range for a 10-year-old and does not indicate septic shock. In early septic shock, urinary output is often preserved or mildly decreased.
B. An elevated temperature (fever) is a hallmark of early septic shock as the body mounts an inflammatory response to infection. Fever often accompanies early sepsis in pediatric patients.
C. Blood pressure may remain normal or slightly elevated in early septic shock due to compensatory mechanisms. A BP of 130/90 mm Hg is not a defining feature.
D. A heart rate of 60/min is abnormally low for a 10-year-old and could indicate late-stage shock or other complications. In early septic shock, tachycardia (elevated heart rate) is typically observed.
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