The nurse is caring for a client diagnosed with leukemia who has just completed a course of radiation therapy and chemotherapy in preparation for a bone marrow transplant. The nurse notices that the client is febrile, has foul smelling urine, and is complaining of urinary frequency and dysuria. What is the priority nursing action?

Request medical prescription for an antibiotic such as gentamicin

Obtain a full set of vital signs and have the client void in a specimen cup

Increase intake of oral fluids such as cranberry juice

Place the client in protective isolation

Answer and Explanation

The Correct Answer is B

A.   While antibiotics may be necessary if a UTI is confirmed, requesting a prescription would not be the immediate nursing action. The nurse must first assess the situation thoroughly and obtain necessary diagnostic information before medications can be prescribed.
B.   This option is the most appropriate immediate action. Obtaining a full set of vital signs helps assess
the client’s overall condition, including the degree of fever and any signs of systemic infection. Collecting

a urine specimen will facilitate further evaluation, such as a urinalysis and culture, to confirm a UTI and identify the appropriate antibiotic treatment.
C.   While increasing fluid intake can help with urinary tract health and dilute the urine, it is not an immediate priority in this situation. The client may need more urgent assessment and possible medical intervention rather than just dietary changes.
D.   Although protective isolation may be warranted given the client’s immunocompromised state due to chemotherapy and radiation, it is not the immediate priority based on the current symptoms. The focus should first be on assessing and addressing the potential UTI.

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Correct Answer is D

Explanation

A. This statement is not advisable. While it is essential to avoid strenuous activity initially, gentle arm exercises and range-of-motion activities are generally encouraged as soon as possible to promote circulation and help prevent lymphedema. Immobilization can actually increase the risk of lymphedema.
B. This intervention is not recommended for preventing lymphedema. Sleeping on the side of the surgery (in this case, the left side) can put pressure on the affected arm and may not promote proper lymphatic drainage. Clients are often advised to sleep on their back or to position themselves in a way that does not compress the affected arm.
C. This intervention can provide temporary relief if there is swelling or discomfort, but it does not effectively prevent lymphedema. While cool compresses might help reduce inflammation, they are not a primary measure for lymphedema prevention.
D. This is the most effective intervention for preventing lymphedema. Elevating the affected arm helps facilitate lymphatic drainage and reduces the risk of fluid accumulation. Keeping the arm elevated above heart level encourages proper circulation and helps manage swelling.

A. Postmenopausal bleeding B. Green, malodorous vaginal discharge C. Extreme abdominal pain with intercourse D. Swelling on the posterior of the vulva

Correct Answer is A

Explanation

A. One of the most common and concerning symptoms of uterine (endometrial) cancer is abnormal vaginal bleeding, particularly postmenopausal bleeding. Any bleeding after menopause is considered abnormal and can be an indicator of uterine cancer, warranting further investigation.
B. While a malodorous vaginal discharge can occur due to infections or other gynecological issues, it is not a primary symptom of uterine cancer. Uterine cancer more commonly presents with bleeding rather than discharge.
C. While some women with advanced uterine cancer may experience pelvic pain or pain during intercourse (dyspareunia), this symptom is not as characteristic or early in the disease process. It is more associated with conditions like endometriosis or pelvic inflammatory disease.
D. This is not a typical manifestation of uterine cancer. While vulvar swelling may be seen in cases of vulvar cancer or infections, it is not a common symptom associated with uterine cancer specifically. Symptoms related to uterine cancer primarily focus on abnormal bleeding.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client that has undergone a modified left radical mastectomy with lymph node removal. Which intervention would assist in preventing lymphedema?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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