Which intervention is most important for the nurse to implement to prevent complications from tumor lysis syndrome during chemotherapy?
Applies pressure to all injection sites for 5 minutes
Monitors telemetry every hour during therapy
Ensures the client has a fluid intake of 3000 to 5000 mL/day
Assists the client in all ambulatory activities
The Correct Answer is C
A. Applying pressure to injection sites helps reduce bleeding but does not directly prevent tumor lysis syndrome.
B. Monitoring telemetry is important for patients with potential cardiac issues but is not specifically related to preventing complications from tumor lysis syndrome.
C. Ensuring a high fluid intake of 3000 to 5000 mL/day helps dilute electrolytes and reduce the risk of acute kidney injury and other complications associated with tumor lysis syndrome, making this the most crucial intervention.
D. Assisting the client in ambulatory activities may support their overall well-being but does not address the prevention of tumor lysis syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Washing the skin with water is generally acceptable, but applying scented lotion is not recommended as it may irritate the skin or interfere with treatment; only specific products as advised by the healthcare provider should be used.
B. Skin treatment markings are important for ensuring correct targeting of radiation during therapy and should remain intact for the duration of treatment to avoid misalignment.
C. While some precautions may be necessary, limiting time with others at home is not typically a requirement for external radiation, as it does not make the client radioactive.
D. Skin damage can occur from radiation treatment, and any changes should be reported to the healthcare provider, as monitoring and managing side effects is important for the patient's overall care.
Correct Answer is B
Explanation
A. Requesting antidepressant medication may be appropriate later, but it does not address the immediate need for emotional support and communication.
B. Encouraging the client to verbalize feelings about their diagnosis provides an opportunity for the client to express their concerns and emotions, fostering a therapeutic relationship and aiding in emotional processing.
C. While explaining improved prognosis can provide hope, it may minimize the client’s feelings of fear and uncertainty and could be perceived as dismissive.
D. Allowing time for reflection is important, but it should be balanced with the need for communication and support to prevent isolation.
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