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.
Implement neutropenic precautions and administer broad-spectrum antibiotics.
Implement contact isolation precautions and administer intravenous prednisone.
Implement bleeding precautions and administer platelet transfusion.
Implement bedrest and administer packed red blood cell transfusion.
The Correct Answer is C
Choice A rationale
Neutropenic precautions and broad-spectrum antibiotics are indicated for patients with neutropenia to prevent infections. However, the patient's ANC is within the normal range (2400/mm³), so these measures are not necessary. This choice does not address the low hemoglobin and platelet count.
Choice B rationale
Contact isolation precautions and intravenous prednisone are not relevant to the patient's current condition. Prednisone is an immunosuppressive corticosteroid used for inflammatory and autoimmune conditions, but it does not address the patient's anemia or thrombocytopenia.
Choice C rationale
Bleeding precautions and platelet transfusion are appropriate interventions for the patient. The platelet count is critically low (6,000/mm³), putting the patient at high risk for spontaneous bleeding. Platelet transfusion is needed to increase platelet levels and reduce bleeding risk. Bleeding precautions, such as avoiding invasive procedures and using gentle oral care, help minimize the risk of hemorrhage.
Choice D rationale
Bedrest and packed red blood cell transfusion address the patient's anemia (hemoglobin 8.4 g/dL, hematocrit 25.9%). While these interventions are necessary to improve oxygen-carrying capacity, they do not address the critical issue of thrombocytopenia. Combining interventions C and D would be ideal for comprehensive care, but based on the question, Choice C is most critical for immediate bleeding risk management. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale
Facial swelling and jugular vein distension (JVD) are indicative of superior vena cava syndrome (SVCS), not tumor lysis syndrome (TLS). SVCS occurs when the superior vena cava, which carries blood from the head, neck, upper chest, and arms to the heart, is obstructed. This can lead to facial swelling, cyanosis, and distended neck veins due to increased venous pressure.
Choice B rationale
Muscle weakness, confusion, polyuria, and polydipsia are symptoms of hypercalcemia. Hypercalcemia is characterized by elevated levels of calcium in the blood, which can cause neuromuscular and cognitive symptoms, excessive urination, and increased thirst.
Choice C rationale
Tumor lysis syndrome (TLS) is characterized by rapid destruction of tumor cells, leading to elevated levels of uric acid, potassium, and phosphate. Symptoms include flank pain due to uric acid crystallization in the kidneys, and abnormal heart rhythms due to hyperkalemia.
Choice D rationale
Elevated liver function tests, jaundice, and blistering skin rash are symptoms of liver toxicity or hepatic dysfunction, possibly due to drug-induced liver injury. These symptoms are not related to tumor lysis syndrome (TLS).
Correct Answer is A
Explanation
Choice A rationale
Administering intravenous fluids with glucose is essential for a patient with Addison's disease who has been exposed to stressors like prolonged sun exposure. Patients with Addison's disease may experience an adrenal crisis, characterized by low blood pressure, dehydration, and hypoglycemia. Intravenous fluids with glucose help to rehydrate the patient and restore blood sugar levels, which are critical in preventing shock and other severe complications.
Choice B rationale
Administering 1000 mg of acetaminophen orally is not the priority intervention for this patient. While it may help reduce fever, it does not address the underlying issues of Addison's disease, such as hypoglycemia and dehydration, which are more urgent. The primary concern should be stabilizing the patient's vital signs and electrolyte balance.
Choice C rationale
Educating the patient about ordered hydrocortisone is important for long-term management of Addison's disease, but it is not the immediate priority in an emergency situation. The patient requires prompt medical intervention to address the acute symptoms of adrenal insufficiency, such as lethargy and hypoglycemia.
Choice D rationale
Exploring options to minimize stress is relevant for managing Addison's disease in general, as stress can trigger an adrenal crisis. However, in the emergency department, the nurse's priority should be to stabilize the patient and manage acute symptoms. Stress management can be addressed once the patient's condition is stabilized.
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