A nurse is caring for a client receiving chemotherapy for breast cancer. Which finding is the priority to report to the healthcare provider?

Fever of 101°F (38.3°C)

Mild nausea and vomiting

Fatigue

Hair loss

Answer and Explanation

The Correct Answer is A

Rationale:

A. Fever of 101°F (38.3°C) in a client receiving chemotherapy is the highest-priority finding. Chemotherapy often causes myelosuppression, particularly neutropenia, which diminishes the body’s immune response. Even a mild fever can signal a potentially life-threatening infection, as the client may not exhibit other typical signs of infection due to immunosuppression. Prompt reporting allows for immediate assessment, laboratory testing (including CBC), and initiation of empiric broad-spectrum antibiotics to prevent progression to sepsis or septic shock.

B. Mild nausea and vomiting are common expected side effects of chemotherapy, caused by the emetic effects of cytotoxic drugs on the gastrointestinal tract and chemoreceptor trigger zone. While they require management with antiemetics and supportive care, they are generally non-emergent and do not pose an immediate threat to life.

C. Fatigue is frequently experienced by chemotherapy clients due to anemia, metabolic changes, disrupted sleep, or treatment-related catabolism. Although it affects quality of life and functional status, it is not acutely dangerous. Fatigue is managed through energy conservation, rest, and nutritional support rather than urgent intervention.

D. Hair loss (alopecia) is an expected and non-life-threatening side effect of many chemotherapeutic agents. While it can have significant psychosocial impact, it does not require emergency intervention and is considered a normal part of treatment planning and patient education.

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Correct Answer is C

Explanation

Rationale:

A. Encouraging ambulation is contraindicated in a patient with sudden severe abdominal pain and a rigid abdomen. These symptoms suggest a surgical emergency, such as bowel perforation or ischemia, and movement could worsen the condition.

B. Administering analgesics may provide pain relief, but pain management is secondary to identifying and addressing the life-threatening cause. Masking symptoms could delay recognition of perforation or peritonitis.

C. Notifying the healthcare provider immediately is the priority action. Sudden severe pain and abdominal rigidity in a patient with SBO indicate a potential bowel perforation, peritonitis, or strangulation, all of which are medical emergencies requiring urgent surgical evaluation and intervention. Prompt notification ensures rapid assessment, imaging, and preparation for possible surgery.

D. Increasing IV fluid rate is important for maintaining hydration and supporting circulation, but it does not address the emergent cause of acute pain and rigidity. While IV access should be maintained, contacting the provider takes precedence.

A. Nutritional deficiency B. Perforation of the bowel C. Dehydration due to fluid loss D. Electrolyte imbalance

Correct Answer is B

Explanation

Rationale:

A. Nutritional deficiency can develop with a small bowel obstruction if it persists for a prolonged period, but it is not the immediate life-threatening concern. Early in the course, other complications take priority.

B. Perforation of the bowel is the most serious and urgent complication of small bowel obstruction. Increased intraluminal pressure from accumulated gas and fluid can weaken the intestinal wall, leading to perforation, peritonitis, sepsis, and potentially death. Assessing for rigid abdomen, severe worsening pain, fever, and signs of peritoneal irritation is critical. This is a surgical emergency, and prompt recognition and intervention are essential.

C. Dehydration due to vomiting and fluid shifts is a common complication, but it is secondary to the acute risk of perforation. Fluid resuscitation is important but comes after prioritizing identification and management of life-threatening conditions.

D. Electrolyte imbalance (e.g., hypokalemia, hyponatremia) can result from vomiting and nasogastric suctioning, but like dehydration, it is not immediately life-threatening compared to perforation. It should be corrected as part of ongoing management.

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A nurse is caring for a client receiving chemotherapy for breast cancer. Which finding is the priority to report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient diagnosed with small bowel obstruction (SBO) develops sudden severe abdominal pain and a rigid abdomen. What is the nurse's priority action?

Correct Answer is C

Explanation

A patient with a known small bowel obstruction is admitted with severe abdominal pain and vomiting. Which complication should the nurse assess for as a priority?

Correct Answer is B

Explanation

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