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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

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.

A. Insert nasogastric tube and begin enteral feeding. B. Teach the patient to increase protein intake and to eat five to seven times a day. C. Implement strict NPO status and initiate total parenteral nutrition (TPN). D. Teach the patient to rinse their mouth with alcohol-based mouthwash prior to meals.

Correct Answer is A

Explanation

Choice A rationale

For a client with severe malnutrition, immediate intervention is necessary to address nutritional deficiencies. Inserting a nasogastric tube and beginning enteral feeding is the first step to provide essential nutrients, stabilize the patient's condition, and prevent further complications from malnutrition.

Choice B rationale

Teaching the patient to increase protein intake and to eat more frequently is important but not the immediate priority in a case of severe malnutrition. This can be addressed after initial stabilization and nutritional support.

Choice C rationale

Total parenteral nutrition (TPN) is an option for patients who cannot tolerate enteral feeding, but initiating strict NPO status without first attempting enteral feeding is not the best initial approach. Enteral feeding is generally preferred if the gastrointestinal tract is functional.

Choice D rationale

Rinsing the mouth with alcohol-based mouthwash before meals is not a priority in managing severe malnutrition. It does not address the immediate need for nutritional support and could be harmful if ingested.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 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.

Correct Answer is ["A","C","D"]

Explanation

A client with severe malnutrition is admitted to the hospital.Which intervention should the nurse implement first?

Correct Answer is A

Explanation

The nurse is assessing a patient with metastatic prostate cancer who was admitted with sudden onset of back pain, lower extremity weakness, difficulty walking, and paresthesia in their toes.What intervention will the nurse implement for this patient?

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?

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 was treated for Addisonian crisis.What clinical change indicates to the nurse that the prescribed therapy was effective?

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?

The nurse is assessing a patient with prostate cancer who is receiving chemotherapy.What findings will the nurse identify as potential toxicities of this treatment? Select All That Apply.

The nurse is discussing dietary changes with a patient newly diagnosed with hypoparathyroidism.Which will the nurse encourage the patient to include in their diet?

The nurse is caring for a patient with hypothyroidism who is prescribed levothyroxine.Which assessment data indicates to the nurse that the medication has been effective?

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?