A nurse is caring for a client who is receiving cisplatin to treat bladder cancer.
After several treatments, the client reports fatigue.
Which of the following actions should the nurse take?
Examine the client for hepatomegaly.
Assess the client for a hypersensitivity reaction.
Check the results of the client's most recent CBC.
Evaluate the client for hypercalcemia.
The Correct Answer is C
Choice A rationale
Examining the client for hepatomegaly can be part of a broader assessment but does not directly address the fatigue related to chemotherapy, particularly cisplatin, which is known to cause bone marrow suppression.
Choice B rationale
Assessing for a hypersensitivity reaction is important during chemotherapy, but it does not specifically address the issue of fatigue, which is often related to blood cell counts.
Choice C rationale
Checking the results of the client's most recent CBC (complete blood count) is crucial because cisplatin can cause anemia, leukopenia, and thrombocytopenia, all of which can lead to significant fatigue.
Choice D rationale
Evaluating for hypercalcemia is not typically associated with cisplatin treatment; it is more relevant in malignancies associated with bone metastasis or overproduction of parathyroid hormone-related protein.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The Papanicolaou test (Pap smear) is the primary screening tool for cervical cancer. It detects precancerous or cancerous cells on the cervix and is recommended regularly for women.
Choice B rationale
A vaginal ultrasound is not used for initial cervical cancer screening. It may be used to evaluate abnormalities found by other means, but not as a primary screening test.
Choice C rationale
Serum prolactin level testing is not related to cervical cancer screening. Elevated prolactin levels are associated with other conditions like prolactinomas or hypothyroidism.
Choice D rationale
An endometrial biopsy is used to diagnose endometrial cancer or other uterine conditions, not for screening cervical cancer. It examines the tissue lining the uterus.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Choice A rationale:
The client's low platelet count (90 x 10⁹/L) is a significant risk factor for developing Disseminated Intravascular Coagulation (DIC), a condition characterized by abnormal blood clotting and bleeding. The client's history of cancer and symptoms such as unexplained bruising and fatigue further support this risk.
Choice B rationale:
Hyperkalemia is characterized by high potassium levels, but the client's potassium level is within the normal range (4.1 mmol/L), so this is not a risk factor.
Choice C rationale:
Hyponatremia is a condition of low sodium levels in the blood. The client's sodium level is normal (137 mmol/L), so this is not a risk factor.
Choice D rationale:
Pneumonia is a lung infection, and the client's oxygen saturation is normal (98% on room air), indicating no immediate risk of pneumonia.
Choice E rationale:
Acute nephritic syndrome is a kidney disorder that can cause elevated blood urea nitrogen (BUN) and creatinine levels. The client's BUN is slightly elevated (22 mg/dL), but her creatinine level is normal (1.0 mg/dL), making this less likely.
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