The nurse on the oncology unit is caring for a patient receiving chemotherapy for treatment of leukemia.
Which patient finding is the nurse's priority for implementing interventions?

Pain 6/10 from mucositis and oral tissue injury.

Weakness and fatigue with activity.

Blood pressure 90/64 mmHg, pulse 102 beats per minute, oral temperature 38.5 degrees C.

Scattered ecchymosis and petechiae noted on arms.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Pain from mucositis and oral tissue injury is a significant concern for patients undergoing chemotherapy. However, it is not typically life-threatening and can be managed with appropriate pain relief measures and oral care.

Choice B rationale

Weakness and fatigue with activity are common side effects of chemotherapy and the disease process itself. While these symptoms impact the patient's quality of life, they do not usually require urgent intervention.

Choice C rationale

Blood pressure of 90/64 mmHg, pulse of 102 beats per minute, and oral temperature of 38.5 degrees Celsius suggest possible sepsis or severe infection. These vital signs indicate an urgent need for intervention to prevent further deterioration and potentially life-threatening complications.

Choice D rationale

Scattered ecchymosis and petechiae are signs of thrombocytopenia (low platelet count), which is a common complication of leukemia and its treatment. While important to monitor and manage, these findings are not typically as urgent as signs of sepsis or severe infection.

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Correct Answer is ["B","C","E"]

Explanation

Choice A rationale

Levothyroxine should be taken on an empty stomach, typically 30-60 minutes before breakfast, to ensure proper absorption. Taking it with food can interfere with its effectiveness.

Choice B rationale

Monitoring for chest pain or symptoms of angina is crucial as levothyroxine can increase the heart rate and potentially exacerbate pre-existing heart conditions, especially in elderly patients.

Choice C rationale

Monitoring prothrombin time is important for patients taking warfarin because levothyroxine can enhance the anticoagulant effect of warfarin, increasing the risk of bleeding.

Choice D rationale

Stopping levothyroxine abruptly can cause severe hypothyroid symptoms, so it should not be discontinued without consulting a healthcare provider.

Choice E rationale

Hypothyroidism patients are often more sensitive to sedatives, so reducing the dose of any sedative agents can prevent excessive sedation and other adverse effects. .

A. Regular insulin 10 units subcutaneous. B. Chlorothiazide 750 mg intravenous. C. Calcitonin 300 international units subcutaneous. D. Calcitriol 0.75 mcg orally.

Correct Answer is C

Explanation

Choice A rationale

Regular insulin 10 units subcutaneous is used to lower blood glucose levels in hyperkalemia. While insulin can help shift potassium into cells, it is not indicated for hypercalcemia or hyperparathyroidism. Regular insulin would not address the elevated calcium levels in this patient.

Choice B rationale

Chlorothiazide 750 mg intravenous is a diuretic that can increase calcium reabsorption in the kidneys, potentially worsening hypercalcemia. It is contraindicated in hyperparathyroidism because it can exacerbate the high calcium levels and associated symptoms.

Choice C rationale

Calcitonin 300 international units subcutaneous is the correct choice for this patient. Calcitonin inhibits osteoclast activity, reducing bone resorption and lowering serum calcium levels. It provides rapid but short-term control of hypercalcemia, which is crucial for managing acute symptoms of hyperparathyroidism.

Choice D rationale

Calcitriol 0.75 mcg orally is an active form of vitamin D that increases calcium absorption in the gut. It is used to manage hypocalcemia, not hypercalcemia. Administering calcitriol would further elevate the already high calcium levels, worsening the patient's condition.

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The nurse on the oncology unit is caring for a patient receiving chemotherapy for treatment of leukemia.Which patient finding is the nurse's priority for implementing interventions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient newly diagnosed with hypothyroidism who has a new prescription for levothyroxine 50 mcg orally.Which interventions will the nurse include in the plan of care? Select All That Apply.

Correct Answer is ["B","C","E"]

Explanation

Correct Answer is C

Explanation

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The nurse on the oncology unit is caring for a patient receiving chemotherapy for treatment of leukemia.
Which patient finding is the nurse's priority for implementing interventions?