A nurse is promoting fluid and electrolyte balance in a patient with lymphoma.
What interventions are appropriate for this purpose?
"Administer intravenous fluids as prescribed.”
"Encourage the patient to consume caffeine and alcohol.”
"Teach the patient to report signs of imbalance.”
"Administer diuretics as prescribed.”
The Correct Answer is A
Choice A rationale:
Administer intravenous fluids as prescribed.
Lymphoma patients may experience fluid and electrolyte imbalances due to factors such as nausea, vomiting, and treatment-related side effects.
Administering intravenous fluids as prescribed can help maintain hydration and electrolyte balance, especially if the patient is unable to tolerate oral intake.
Choice B rationale:
Encourage the patient to consume caffeine and alcohol.
Encouraging the consumption of caffeine and alcohol is not appropriate for a patient with lymphoma who needs to maintain fluid and electrolyte balance.
Both caffeine and alcohol can have diuretic effects and may worsen dehydration and electrolyte imbalances.
Choice C rationale:
Teach the patient to report signs of imbalance.
Educating the patient to report signs of fluid and electrolyte imbalance is important for early detection and intervention.
However, this alone is not sufficient as an intervention.
Actual measures to address the imbalance, such as administering fluids or adjusting the treatment plan, should be implemented based on the patient's condition.
Choice D rationale:
Administer diuretics as prescribed.
Administering diuretics should not be the first-line intervention for a patient with lymphoma who is at risk of fluid and electrolyte imbalance.
Diuretics can exacerbate these imbalances and should only be used when medically necessary and under the guidance of a healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Lymphoma is characterized by the abnormal proliferation of lymphocytes, not their apoptosis.
In lymphoma, lymphocytes become altered and undergo uncontrolled growth, leading to the formation of a tumor mass.
Choice B rationale:
This is the correct answer.
In lymphoma, altered lymphocytes proliferate and form a tumor mass.
This abnormal proliferation of lymphocytes is a key process in the development of lymphoma.
Choice C rationale:
The tumor mass in lymphoma does not inhibit angiogenesis.
In fact, it may induce angiogenesis to supply nutrients to the growing tumor.
Angiogenesis is the process of forming new blood vessels, and it is often seen in tumors to ensure their blood supply.
Choice D rationale:
Lymphoma tumor cells can spread beyond the lymphatic system to other parts of the body.
This spread is a significant concern in lymphoma, as it can lead to metastasis.
Therefore, this statement is not accurate.
Correct Answer is B
Explanation
Choice B rationale:
Providing comfort measures, such as cool compresses and lotion application, is an appropriate nursing intervention to address pain and itching in a client with lymphoma.
Itching is a common symptom in some lymphomas, and these measures can help soothe the skin and alleviate discomfort.
Administering analgesics (as mentioned in choice A) may be necessary for pain relief, but it is not the primary intervention for itching.
Choice A rationale:
"I will administer analgesics and antipyretics as prescribed." Administering analgesics (pain relievers) can be a helpful intervention if the client is experiencing pain, but it may not effectively address itching.
Antipyretics (fever-reducing medications) are not relevant to addressing pain and itching in lymphoma patients unless they have a fever as well.
Choice C rationale:
"I will recommend avoiding all physical activity." While it may be necessary for some patients to limit physical activity during certain phases of lymphoma treatment, recommending complete avoidance of physical activity is not a standard intervention for addressing pain and itching associated with lymphoma.
In fact, gentle movement and exercises may be beneficial for maintaining mobility and overall well-being.
Choice D rationale:
"I will perform surgery to alleviate the pain and itching." Surgical intervention is not a primary or standard approach for addressing pain and itching in lymphoma patients.
Surgery is typically reserved for specific cases, such as lymph node biopsy or removal, and would not be the first-line treatment for these symptoms.
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