A nurse is caring for a client on the oncology unit who is experiencing multiple symptoms and requiring close monitoring.
The client appears fatigued and has recently experienced significant weight loss.
Nurse's Notes: 1030- Client reports increased fatigue and shortness of breath when ambulating.
Weight has decreased by 10 lbs over the past month.
Lung sounds are diminished bilaterally, and slight cyanosis is noted around the lips.
Vital Signs at 1000: Temperature 36.7 C (98.1 F), Heart Rate 110/min, Respiratory Rate 22/min, Blood Pressure 110/70 mmHg, Oxygen Saturation 94 Vital Signs at 1400: Temperature 37.2 C (99 F), Heart Rate 95/min, Respiratory Rate 24/min, Blood Pressure 100/65 mmHg, Oxygen Saturation 92 Laboratory Results at 1400: Hgb 9.3 gm/dL, Platelets 70,000 mcL, WBC 8,000 mcL, BUN 24 mg/dL. 1430- Client expresses concern about swelling in the abdomen and has not had a bowel movement in three days.
Abdomen is distended and tender to palpation, with hypoactive bowel sounds.
Based on the given scenario, which nursing action is the priority for the client's current status?
Administering a prescribed stimulant laxative for constipation.
Increasing the frequency of vital sign monitoring to every 15 minutes.
Applying supplemental oxygen via nasal cannula as prescribed.
Encouraging high-calorie oral nutritional supplements.
The Correct Answer is C
Choice A rationale
While the client reports abdominal distension, tenderness, and a lack of bowel movements, administering a stimulant laxative is not the most urgent priority compared to respiratory compromise. Constipation and hypoactive bowel sounds indicate a potential paralytic ileus or obstruction, which requires further diagnostic evaluation before stimulating peristalsis. While important for comfort and gastrointestinal function, this intervention does not address the immediate life-threatening issues of hypoxemia or potential respiratory failure noted in the assessment.
Choice B rationale
Increasing the frequency of vital sign monitoring to every 15 minutes provides more data but does not directly treat the client's current physiological distress. The client's blood pressure is dropping and their oxygen saturation has decreased from 94 to 92. While frequent monitoring is necessary in an unstable patient, the priority nursing action must be an intervention that stabilizes the patient's condition. Observation alone cannot correct the worsening oxygenation or the underlying cause of the client's respiratory and circulatory decline.
Choice C rationale
The client is demonstrating signs of respiratory distress, including a respiratory rate of 24, decreased oxygen saturation of 92, cyanosis, and diminished lung sounds. The hemoglobin level is also low at 9.3 gm/dL, which reduces the oxygen-carrying capacity of the blood. Normal hemoglobin for an adult is generally 12 to 18 gm/dL. Applying supplemental oxygen is the priority to ensure adequate tissue perfusion and prevent further cellular hypoxia, especially given the client's oncology status and recent clinical deterioration.
Choice D rationale
Significant weight loss and fatigue suggest that the client is in a catabolic state or experiencing cancer-related cachexia, making nutritional support essential for long-term recovery. However, nutritional interventions are considered a secondary priority when a client is experiencing acute physiological instability such as worsening oxygenation and potential shock. The immediate focus must remain on the ABCs of nursing care. Once the respiratory and hemodynamic status is stabilized, the nurse can then implement strategies to improve the client's caloric and protein intake. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While maintaining hydration is generally important for oncology patients to prevent complications like tumor lysis syndrome, it does not address the acute mechanical compression of the spinal cord. Spinal cord compression is a structural emergency where a tumor mass or vertebral collapse puts direct pressure on the neural elements. Fluid intake has no effect on reducing this pressure or preventing the permanent paralysis that can occur if the compression is not relieved by medical interventions.
Choice B rationale
Bisphosphonates are used to treat hypercalcemia of malignancy by inhibiting osteoclast activity, but they are not the primary treatment for spinal cord compression. Although some patients with bone metastases may have concurrent hypercalcemia, the immediate threat in spinal cord compression is neurological deficit due to edema and ischemia of the spinal cord. Therefore, bone stabilizing agents are secondary to interventions that directly reduce the inflammatory response and the physical size of the compressive mass.
Choice C rationale
Positioning a client in a semi-Fowler position may help with respiratory effort if the compression is high in the cervical or thoracic spine, but it is not a curative or primary intervention for the oncologic emergency itself. Proper alignment and stabilization of the spine are often more critical to prevent further mechanical injury to the cord. While comfort and ventilation are important, they do not provide the necessary medical treatment to reverse the neural compression.
Choice D rationale
High dose intravenous corticosteroids, such as dexamethasone, are the gold standard initial treatment for malignant spinal cord compression. They work by rapidly reducing vasogenic edema around the spinal cord and the tumor site, which relieves pressure and helps preserve neurological function. This intervention is often followed by radiation therapy or surgery. Prompt administration is essential because the duration of symptoms before treatment is a major predictor of the final functional and neurological outcome.
Correct Answer is C
Explanation
Choice A rationale
This statement is incorrect because hyperacute rejection occurs almost immediately, usually within minutes to hours after the graft is vascularized. It does not take several days to develop; that timeframe is more characteristic of acute rejection, which typically occurs within the first few weeks or months. Hyperacute rejection is a rapid and violent immune response that happens while the patient is still in the operating room or very shortly after the surgical procedure is completed.
Choice B rationale
This statement is false because hyperacute rejection is generally irreversible. Once the process begins, the damage to the transplanted organ is so severe and rapid that increasing immunosuppressive medications like corticosteroids or monoclonal antibodies will not save the graft. The only effective treatment for hyperacute rejection is the immediate surgical removal of the transplanted organ to prevent a systemic inflammatory response and further complications for the recipient, who must then return to dialysis.
Choice C rationale
This is the correct statement. Hyperacute rejection is caused by pre-existing recipient antibodies that react against the donor's antigens, specifically the ABO blood group or human leukocyte antigens. This binding triggers the complement system and a massive inflammatory cascade. This leads to widespread endothelial damage, platelet aggregation, and capillary thrombosis within the new organ. The resulting ischemia and necrosis cause the organ to turn blue or mottled almost immediately after blood flow is restored.
Choice D rationale
This statement is inaccurate because the symptoms of hyperacute rejection are immediate rather than occurring within two weeks. While fever and pain at the transplant site can occur, they happen immediately. The two-week timeframe is much more common for acute rejection, which is mediated by T-cells rather than pre-existing antibodies. Hyperacute rejection is now rare due to improved cross-matching techniques that identify these pre-formed antibodies before the transplant surgery is ever performed.
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