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

Explanation

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. .

A. Administer filgrastim (granulocyte colony stimulating factor (G-CSF)) as ordered. B. Keep the patient's central line insertion site clean and open to air. C. Educate the patient and family about food safety and hygiene. D. Provide a high-protein, high-calorie diet.

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.

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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

Correct Answer is B

Explanation

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

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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?