A nurse is caring for a client who is receiving cisplatin for the treatment of ovarian cancer. The client's most recent complete blood count (CBC) is shown in the table below. It is important for the nurse to consider which of the following for the client?

- WBC: 1,400/mm³

- RBC: 4.3 x 10¹²/L

- Hgb: 12.1 g/dL

- Hct: 36.5%

- Platelets: 170,000/mm³

- Albumin: 4.5 g/dL

Given the options:

The client should receive an erythropoiesis-stimulating agent.

The client should receive a diet with increased protein.

The client has an increased risk of infection.

The client has an increased risk for bleeding.

Answer and Explanation

The Correct Answer is C

Choice A reason: The use of erythropoiesis-stimulating agents (ESAs) is indicated for anemia due to chemotherapy¹. However, the client's hemoglobin (Hgb) level is 12.1 g/dL, which is within the normal range (normal: 12-15.5 g/dL for women). Therefore, administering an ESA is not indicated based on the Hgb level provided.

Choice B reason: A diet with increased protein can be beneficial for patients undergoing chemotherapy as it helps in tissue repair and immune system function. However, the client's albumin level is 4.5 g/dL, which falls within the normal range (normal: 3.4-5.4 g/dL), suggesting adequate protein intake. Thus, there is no indication that the client requires an increased protein diet based on the albumin level provided.

Choice C reason: The client's white blood cell (WBC) count is 1,400/mm³, which is below the normal range (normal: 4,500-11,000/mm³). This condition, known as leukopenia, significantly increases the risk of infection³. Therefore, the nurse should prioritize monitoring for signs of infection and implementing infection control measures.

Choice D reason: The client's platelet count is 170,000/mm³, which is within the normal range (normal: 150,000-450,000/mm³). Although cisplatin can cause thrombocytopenia, the current platelet count does not indicate an increased risk for bleeding⁴. Therefore, this choice is not correct based on the platelet count provided.

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Correct Answer is A

Explanation

Choice A reason:
Phenytoin is an antiepileptic drug that can be used to treat and prevent seizures. Headache and restlessness could be signs of neurological irritation or an impending seizure, which phenytoin can help to manage. It is important to monitor the client's neurological status closely following hemodialysis, as changes in electrolyte balance can affect neuronal activity.

Choice B reason:
Decreased blood pressure and rapid pulse are not typical indications for administering phenytoin. These symptoms could indicate hypovolemia or other cardiovascular issues that may occur after hemodialysis, which would require different interventions.

Choice C reason:
Muscle cramps and chest heaviness are not indications for phenytoin administration. Muscle cramps can be a common side effect of hemodialysis due to electrolyte shifts, and chest heaviness may indicate cardiovascular strain or other complications.

Choice D reason:
Pain and tingling at the access site are typically related to the vascular access itself and are not treated with phenytoin. These symptoms may require assessment for potential complications such as infection or thrombosis at the access site.

A. Bowel sounds B. Oxygen saturation C. Surgical dressing D. Temperature

Correct Answer is B

Explanation

Choice A reason:
Bowel sounds are an important assessment to determine the return of gastrointestinal function after surgery. However, they are not the immediate priority following a cholecystectomy. The nurse will monitor bowel sounds to assess for ileus or obstruction, but this comes after ensuring that the patient's vital signs are stable.

Choice B reason:
Oxygen saturation is the priority assessment for a client being admitted from the PACU following a cholecystectomy. Ensuring adequate oxygenation is crucial after anesthesia, as respiratory function can be compromised. Monitoring oxygen saturation helps to detect hypoxemia early and prevent respiratory complications.

Choice C reason:
Inspecting the surgical dressing is necessary to check for signs of bleeding or infection at the surgical site. However, this is not the first priority upon admission from the PACU. The nurse will assess the dressing after vital signs and oxygen saturation have been addressed.

Choice D reason:
Temperature is an important vital sign that can indicate infection or other postoperative complications. However, the immediate priority is to ensure the client's airway and breathing are adequate, which includes assessing oxygen saturation before temperature.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client immediately following a hemodialysis treatment. For which of the following manifestations will the nurse administer a PRN dose of phenytoin?

Correct Answer is A

Explanation

A nurse is admitting a client to the surgical unit from the Post-Anesthesia Care Unit (PACU) following a cholecystectomy. Which of the following assessments is the nurse's priority?

Correct Answer is B

Explanation

A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make?

A nurse is preparing a client for surgery. Which of the following is a priority when completing an assessment preoperatively?

A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4+ T-cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions?

A nurse is caring for a client who is taking aspirin for arthritis. The nurse should identify which of the following findings as an adverse effect of this medication?

A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client?

A nurse is assessing a client who has a cast in place for a fractured tibia. Which of the following actions should the nurse take first?

A nurse is caring for a middle adult client who has just received the diagnosis of endometrial cancer. In taking a nursing history, which of the following manifestations is likely to be reported by this client?

A nurse in an allergy clinic is caring for a client who has a history of seasonal allergy symptoms. The client had a radioallergosorbent test (RAST) completed on a previous visit. The nurse should recognize that an elevation in which of the following immunoglobulins indicates a positive result?