The nurse is caring for a patient with acute leukemia who has been in the hospital for treatment for three weeks.
The patient states, "I am so tired, I feel too exhausted and breathe fast when I try to get out of bed and do anything.” What is the best intervention for the nurse to implement for this patient?
Refer the patient to the psychiatrist for anti-depressant medications.
Provide portable oxygen therapy via nasal cannula during physical activity.
Instruct the patient to increase their oral iron supplement dose until fatigue subsides.
Encourage the patient to perform light exercises daily.
The Correct Answer is B
Choice A rationale
Referring the patient to a psychiatrist for anti-depressant medications may not address the immediate issue of fatigue and breathlessness related to acute leukemia. While psychological support is important, the primary focus should be on managing the patient's physical symptoms and improving oxygenation during activities.
Choice B rationale
Providing portable oxygen therapy via nasal cannula during physical activity is the best intervention for this patient. Oxygen therapy can help alleviate the patient's symptoms of breathlessness and fatigue by ensuring adequate oxygen levels during physical exertion. This intervention allows the patient to engage in activities with less discomfort and prevents further complications related to hypoxia.
Choice C rationale
Instructing the patient to increase their oral iron supplement dose until fatigue subsides is not appropriate without medical supervision. Iron supplementation should be based on the patient's iron levels and hematologic status. Over-supplementation can lead to adverse effects and may not address the underlying cause of fatigue in patients with acute leukemia.
Choice D rationale
Encouraging the patient to perform light exercises daily can be beneficial for overall health, but it may not be practical for someone experiencing severe fatigue and breathlessness. The patient's immediate need for oxygen support during activities takes precedence, and physical activity should be tailored to their current capabilities and medical condition. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Administering filgrastim (G-CSF) as ordered is crucial for patients with a low ANC. Filgrastim stimulates the production of neutrophils in the bone marrow, helping to reduce the risk of infections. For a patient with an ANC of 500/mm³, which indicates severe neutropenia, this intervention can significantly enhance the immune response and decrease susceptibility to infections.
Choice B rationale
Keeping the patient's central line insertion site clean and open to air is incorrect and could increase the risk of infection. Central line sites must be covered with a sterile dressing to prevent bacterial contamination and infection. Open exposure to air can introduce pathogens, especially in a patient with neutropenia.
Choice C rationale
Educating the patient and family about food safety and hygiene is essential for preventing infections in patients with neutropenia. Proper food handling and hygiene practices reduce the risk of bacterial and other infections. This education can help patients and their families implement measures to protect the patient from potential sources of infection.
Choice D rationale
Providing a high-protein, high-calorie diet is appropriate for supporting the patient's overall health and recovery. High-protein and high-calorie foods support the body's immune function, repair tissues, and maintain energy levels. Proper nutrition is vital for patients with leukemia to help them cope with the demands of their illness and treatment.
Correct Answer is A
Explanation
Choice A rationale
Prevent graft versus host disease (GVHD) is a common complication following an allogeneic stem cell transplant. Immunosuppressant medications are given to prevent the donor immune cells from attacking the recipient's body tissues, which is GVHD. This prevention is crucial for the success of the transplant and the patient's overall recovery.
Choice B rationale
Prevent graft rejection is more commonly associated with solid organ transplants like kidney or liver transplants. In the context of stem cell transplants, preventing GVHD is the primary concern rather than preventing graft rejection.
Choice C rationale
Preventing hospital-acquired infections is important for all patients, especially those with compromised immune systems. However, this is not the primary indication for immunosuppressant medications following an allogeneic stem cell transplant. Other measures, such as infection control protocols, are more directly related to this.
Choice D rationale
Preventing a relapse of leukemia is a key goal of the overall treatment plan for leukemia patients. However, immunosuppressant medications do not directly prevent a relapse; instead, they help manage complications like GVHD that can arise from the transplant process.
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