The nurse is caring for a client diagnosed with acute myelocytic leukemia (AML). A nursing diagnosis of Risk for Infection has been made. What nursing intervention(s) should the nurse employ in the care of this client? (Select all that apply)

Administer a Flu and Pneumovax immunization IM.

Restrict visitation of family and friends who have colds, flu, or infections.

Assist the client with appropriate hygiene measures.

Report neutrophil levels of 2000 mm3-2500 mm3 to the PCP

Obtain vital signs including temperature and pulse oximetry every & hours

Answer and Explanation

Correct Answer : B,C,E

A. Administer a Flu and Pneumovax immunization IM: In acute myelocytic leukemia, where the immune system is compromised, administering live vaccines or vaccines during active treatment is not recommended as their immune system may not be able to mount an adequate response.

B. Restrict visitation of family and friends who have colds, flu, or infections: Limiting exposure to people who have infections is crucial. Their immune system is often suppressed due to both the disease and treatment, making the client highly susceptible to infections.

C. Assist the client with appropriate hygiene measures: Proper hygiene is essential for reducing the risk of infections in immunocompromised clients. This includes handwashing and maintaining cleanliness to minimize the risk of infections.

D. Report neutrophil levels of 2000/mm3-2500/mm3 to the PCP: Neutrophil levels of 2000–2500/mm3 are within acceptable range, so there is no immediate need to report this to the healthcare provider. A critical neutrophil count is <1000/mm3, where infection risk is high.

E. Obtain vital signs including temperature and pulse oximetry every 4 hours: Monitoring vital signs, especially temperature, is essential in clients with AML due to their heightened risk of infection. Fever can indicate the onset of infection, so regular monitoring is critical.

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Correct Answer is C

Explanation

A. Nasal congestion: Nasal congestion is a symptom commonly associated with respiratory infections, allergies, or other conditions affecting the nasal passages. It has no relevance to testicular torsion.

B. Difficulty breathing: Difficulty breathing is not related to testicular torsion. It is typically associated with respiratory or cardiac issues, not testicular problems.

C. Sudden severe testicular pain: Sudden, severe testicular pain is the hallmark symptom of testicular torsion. It occurs when the spermatic cord twists, cutting off blood flow to the testicle, which can lead to tissue damage if not treated promptly.

D. Blurred vision: Blurred vision is a symptom associated with eye conditions, neurological issues, or systemic diseases like diabetes. It is not a symptom of testicular torsion.

A. angiogenesis. B. allergic reaction. C. tumour lysis. D. apheresis.

Correct Answer is A

Explanation

A. Angiogenesis: Angiogenesis is the process by which new blood vessels form from existing ones. In the case of malignant plasma cells, they secrete substances that stimulate angiogenesis to increase blood supply to the tumor, facilitating its growth and spread.

B. Allergic reaction: An allergic reaction involves the immune system's response to an allergen, not the creation of blood vessels. It is unrelated to the process of tumor growth and angiogenesis.

C. Tumor lysis: Tumor lysis refers to the breakdown of tumor cells, often resulting in the release of intracellular contents into the bloodstream, which can cause complications. It is not related to the process of stimulating new blood vessel formation.

D. Apheresis: Apheresis is a medical procedure used to remove certain components of blood, such as plasma or platelets. It is a therapeutic or donor procedure, not a biological process involved in cancer growth or blood vessel formation.

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The nurse is caring for a client diagnosed with acute myelocytic leukemia (AML). A nursing diagnosis of Risk for Infection has been made. What nursing intervention(s) should the nurse employ in the care of this client? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is a common symptom of testicular torsion?

Correct Answer is C

Explanation

Malignant plasma cells secrete substances to stimulate the creation of new blood vessels to enhance the growth of the clusters of plasma cells. This is the process of

Correct Answer is A

Explanation

The nurse is analyzing a client's arterial blood gas (ABG) values with the following results: pH 7.44, PaCO2 30 mmHg, Pa02 90 mmHg, and HCO3 18 mEq/L. Which acid base imbalance should the nurse associate with these results? PH 7.35-7.45 PCO2 35-45mm Hg HCO3 22-26 m/l

The nurse is caring for a client diagnosed with Acute Myelocytic Leukemia (AML). A nursing diagnosis/client problem of Risk for Infection has been made. What nursing intervention(s) should the nurse employ in the care of this client? (Select all that apply)

What safety practice should a nurse ensure a client undergoing brachytherapy follows to limit the risk of exposure to others?

The nurse receives an order to administer ranitidine 300 mg IVPB over one hour. Ranitidine is available 300 mg in 100 mL NS. The drip factor of the piggyback tubing is 15 gtts/mL. How should the nurse adjust the IV tubing?

The nurse should educate clients who are HIV positive on proper nutrition, exercise and stress reduction because these factors will: (Select all that apply)

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