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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Packed RBCs should be transfused as soon as possible once the nurse has prepared everything necessary for the transfusion.

Choice B reason: Waiting 2 hours after obtaining the blood is not necessary and could delay needed treatment.

Choice C reason: The client's mealtime should not delay the transfusion of blood, which is a time-sensitive medical treatment.

Choice D reason: While the client's readiness is important, it should not unduly delay the transfusion if the client is medically stable and the transfusion is necessary.

A. "It is okay to take aspirin with GERD." B. "You should avoid possible mercury-containing foods such as some seafood because of their risk to GERD." C. "There is no causal link between lying down after eating and increased onset of GERD." D. "You should avoid or cut down on alcohol and caﬀeine which can aggravate GERD."

Correct Answer is D

Explanation

Choice A reason: Aspirin can irritate the stomach lining and increase acid reﬂux, worsening GERD symptoms. It is generally not recommended without consulting a healthcare provider.
Choice B reason : Mercury content in seafood is not directly linked to GERD. This statement is misleading and does not address known risk factors for GERD.
Choice C reason : Lying down after eating can indeed increase the onset of GERD as it allows stomach contents to ﬂow back into the esophagus more easily.
Choice D reason : Alcohol and caﬀeine can relax the lower esophageal sphincter, allowing stomach acid to rise into the esophagus and worsen GERD symptoms. Therefore, it is advisable to avoid or reduce their intake.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 11:30. The nurse should begin the infusion at which of the following times?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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