The nurse is caring for a patient with leukemia who has an absolute neutrophil count (ANC) of 500/mm³. What interventions will the nurse include in the plan of care for this patient related to this finding? Select All That Apply.

Administer filgrastim (granulocyte colony stimulating factor (G-CSF)) as ordered.

Keep the patient's central line insertion site clean and open to air.

Educate the patient and family about food safety and hygiene.

Provide a high-protein, high-calorie diet.

Answer and Explanation

Correct Answer : A,C,D

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.

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Correct Answer is D

Explanation

Choice A rationale

Tumor lysis syndrome (TLS) results from the rapid breakdown of cancer cells, leading to metabolic imbalances such as hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia. Symptoms can include nausea, vomiting, diarrhea, muscle cramps, and arrhythmias. TLS is a metabolic emergency seen in high-turnover cancers like leukemia or lymphoma and is not associated with symptoms like jugular venous distention or edema in the face, neck, and arms.

Choice B rationale

Hypercalcemia, often due to bone metastasis or certain paraneoplastic syndromes, presents with symptoms such as confusion, lethargy, constipation, nausea, polyuria, and polydipsia. It is not related to the symptoms described in the question, which are indicative of a different oncologic emergency.

Choice C rationale

Spinal cord compression occurs when a tumor compresses the spinal cord, leading to symptoms like severe back pain, weakness, sensory changes, and autonomic dysfunction. It does not explain the symptoms of jugular venous distention, facial, neck, and arm edema.

Choice D rationale

Superior vena cava syndrome (SVCS) occurs when a tumor compresses the superior vena cava, leading to decreased venous return from the upper body. Symptoms include shortness of breath, jugular venous distention, and edema of the face, neck, and arms due to impaired blood flow. This is an oncologic emergency requiring prompt intervention to reduce the obstruction.

A. The nurse must wear a dosimeter badge when preparing and administering chemotherapy infusions. B. The patient should wear a lead apron during chemotherapy infusions. C. The nurse must wear personal protective equipment (PPE), including gloves and a gown when handling chemotherapy. D. The nurse must dispose of all chemotherapy waste in the patient's sharps container.

Correct Answer is C

Explanation

Choice A rationale

Wearing a dosimeter badge is essential for healthcare workers handling radioactive materials to monitor exposure, but it is not a standard practice for handling chemotherapy, which is typically not radioactive. Chemotherapy drugs are cytotoxic and require different safety measures, such as PPE.

Choice B rationale

While protecting patients during radiation therapy with a lead apron is necessary, it is not applicable for chemotherapy infusions. Chemotherapy involves the administration of cytotoxic drugs, not ionizing radiation, so protective measures focus on preventing exposure to these chemicals rather than shielding from radiation.

Choice C rationale

The nurse must wear personal protective equipment (PPE), including gloves and a gown, when handling chemotherapy to prevent exposure to these toxic drugs. PPE is crucial to protect healthcare workers from accidental spills, splashes, and skin contact with the chemotherapy agents, which can be harmful.

Choice D rationale

Disposal of chemotherapy waste should follow specific guidelines to prevent contamination and exposure. Sharps containers are for sharp objects like needles and blades, not for all chemotherapy waste. Chemotherapy waste should be disposed of in designated containers that comply with hazardous waste regulations to ensure safe handling and disposal.

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The nurse is caring for a patient with leukemia who has an absolute neutrophil count (ANC) of 500/mm³. What interventions will the nurse include in the plan of care for this patient related to this finding? Select All That Apply.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with lung cancer who suddenly develops shortness of breath, jugular venous distention, and edema in the face, neck, and arms.The nurse promptly notifies the healthcare provider that the patient is exhibiting signs of which oncologic emergency?

Correct Answer is D

Explanation

The nurse manager is orienting a new nurse to the oncology unit.What will the nurse manager teach about best practices for safe handling and administration of chemotherapy?

Correct Answer is C

Explanation

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The nurse is assessing a patient who has received the first dose of chemotherapy for leukemia.Which patient's clinical findings indicate to the nurse that the patient has developed tumor lysis syndrome (TLS)?

The nurse is caring for a woman with a family history of breast cancer who received a positive result on a breast tumor marker test.The patient is requesting a bilateral mastectomy.This is an example of which type of oncologic treatment?

The nurse is caring for a patient with lymphoma who is receiving chemotherapy.The patient's laboratory results are below.What interventions will the nurse implement related to these results? ANC (Absolute neutrophil count): 2400/mm³. Hemoglobin: 8.4 g/dL. Hematocrit: 25.9%. Platelets: 6,000/mm³.

The nurse is caring for a patient who is scheduled for thyroid diagnostic testing.Which information, that may affect the test results, should be documented on the patient's electronic medical record (EMR) and communicated to the personnel conducting the test?

The nurse is caring for a patient who has a new prescription for levothyroxine.The nurse will include in the teaching plan that levothyroxine decreases the action of which medication?