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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. While being alert for non-verbal clues for pain or discomfort is important, it does not directly address the risk for ineffective airway clearance.
B. Answering for the client during rounds with the physician may compromise the client's ability to communicate their needs and concerns, which is not appropriate.
C. Assessment of the ability to cough and swallow is crucial for clients who have undergone oral surgery, as it directly relates to their airway clearance and safety in managing secretions.
D. Providing enough time for the client to respond is important for overall communication and comfort but does not specifically address the risk for ineffective airway clearance, which requires more targeted interventions.

A. Bowel sounds, abdominal girth, and NG tube output B. Vital signs, cardiac rhythm, and peripheral pulses C. Blood Urea Nitrogen, Creatinine, and daily weight D. Respiratory rate, respiratory depth, and pulse oximetry

Correct Answer is B

Explanation

A. Bowel sounds, abdominal girth, and NG tube output provide important information about gastrointestinal function and the potential for complications like ileus or obstruction. However, they do not provide direct information regarding fluid volume status.
B. Vital signs (including blood pressure and heart rate), cardiac rhythm, and peripheral pulses are the first indicators to assess for decreased fluid volume. Hypovolemia often manifests as tachycardia, hypotension, and weak peripheral pulses, which are critical early signs of fluid depletion.
C. Blood Urea Nitrogen (BUN), creatinine, and daily weight are useful in assessing kidney function and long-term fluid status, but they may not be as immediate indicators of acute fluid volume changes in the immediate postoperative period.
D. Respiratory rate, depth, and pulse oximetry are important for assessing respiratory function and oxygenation. While fluid volume imbalances can impact respiratoryfunction, these parameters are not the most direct indicators of fluid volume status.

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Which intervention is most important for the nurse to implement to prevent complications from tumor lysis syndrome during chemotherapy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client problem of Risk for Ineffective Airway Clearance has been made for a client who has undergone surgery for oral cancer. What should the nurse include in the plan of care?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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