Which of the following nursing diagnoses (nursing problem) would be of highest priority for the patient hospitalized for a bone marrow transplant to treat relapse of acute myelocytic leukemia?
Disturbed body image
Anxiety
Ineffective protection
Imbalanced nutrition: less than body requirements
The Correct Answer is C
Choice A reason: While disturbed body image is a concern, it is not the highest priority for a patient undergoing a bone marrow transplant.
Choice B reason: Anxiety is important to address but does not take precedence over physical health concerns in the immediate post-transplant period.
Choice C reason: Ineffective protection is the highest priority because patients undergoing bone marrow transplants have compromised immune systems and are at high risk for infection.
Choice D reason: Imbalanced nutrition is a concern but is secondary to the risk of infection in the immediate care of a patient post bone marrow transplant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["82.5"]
Explanation
The general rule of thumb for urine output is 0.5 mL/kg/hour.
Step 1: Convert the patient's weight from pounds to kilograms.
We know that 1 kg = 2.2 lbs.
So, we have:
363 lbs ÷ 2.2 = 165 kg (rounded to the nearest whole number)
Step 2: Calculate the urine output using the rule of 0.5 mL/kg/hour. So, we have:
165 kg × 0.5 mL/kg/hour = 82.5 mL/hour
Correct Answer is D
Explanation
Choice A reason: While it is useful to know the patient's current pain management strategies, new onset severe back pain could indicate a serious complication such as a spinal fracture or compression, which requires immediate attention.
Choice B reason: Reassuring the patient is not appropriate without further assessment, as new onset severe pain could signify a serious issue that needs to be addressed.
Choice C reason: Suggesting a back brace may be part of the management plan, but it should not precede notifying the healthcare provider of new severe pain.
Choice D reason: Notifying the healthcare provider is the correct action because new onset severe back pain in a patient with multiple myeloma could indicate a serious condition such as a spinal fracture or compression, which requires prompt evaluation and treatment.
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