a client is diagnosed as having a positive reaction to the mantoux test which of the following is the most appropriate nursing action
Logo

Nursing Elites

ATI RN

Oncology Questions

1. A client is diagnosed as having a positive reaction to the Mantoux test. Which of the following is the most appropriate nursing action?

Correct answer: C

Rationale: The correct answer is to schedule the client for a chest x-ray. A positive Mantoux test indicates exposure to TB, but it does not confirm active disease. A chest x-ray is necessary to assess the presence of active TB disease. Isolating the client in a private room (Choice A) is not necessary based solely on a positive Mantoux test result. Administering isoniazid (INH) (Choice B) or beginning a 9-month course of medication therapy (Choice D) is premature without confirming active TB through a chest x-ray.

2. A patient with multiple myeloma is receiving chemotherapy and is at risk for bone fractures. What intervention should the nurse prioritize to reduce this risk?

Correct answer: B

Rationale: The correct answer is B: 'Promoting bed rest to avoid injury.' In patients with multiple myeloma undergoing chemotherapy, encouraging bed rest can lead to muscle weakness and bone loss, increasing the risk of fractures. Promoting bed rest to avoid injury means advising the patient on safe movement and activities to prevent fractures. Encouraging weight-bearing exercises (choice C) would be more beneficial than bed rest as it helps in maintaining bone density and strength. Ensuring adequate hydration (choice D) is essential for overall health but does not directly address the risk of bone fractures associated with multiple myeloma and chemotherapy. Choice A, 'Encouraging bed rest,' is incorrect as it may worsen the risk of fractures rather than reduce it.

3. The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?

Correct answer: A

Rationale: The passage of flatus (gas) from the colostomy is an early sign that the bowel is beginning to function after surgery. This indicates that peristalsis, or the movement of the intestines, has resumed and that the digestive system is actively moving gas and eventually stool through the bowel and out of the colostomy. It’s a positive sign that the bowel is recovering from the surgery and starting to work as intended.

4. A patient who is undergoing consolidation therapy for the treatment of leukemia has been experiencing debilitating fatigue. How can the nurse best meet this patients needs for physical activity?

Correct answer: B

Rationale: For patients undergoing consolidation therapy for leukemia, severe fatigue is a common side effect of treatment due to factors such as anemia, decreased nutritional intake, and the body’s response to chemotherapy. While exercise is beneficial, the patient's fatigue may limit their ability to engage in strenuous activity. Assisting the patient to sit in a chair during awake times is a practical way to encourage some physical activity while respecting their fatigue levels. This intervention helps prevent complications associated with immobility, such as muscle atrophy and venous stasis, without overwhelming the patient. It allows the patient to engage in light activity that is manageable and promotes recovery.

5. A client has been prescribed epoetin alfa for anemia related to chemotherapy. What lab value should the nurse monitor to determine the effectiveness of this medication?

Correct answer: A

Rationale: Epoetin alfa is a medication used to treat anemia, particularly anemia related to chemotherapy or chronic kidney disease. It stimulates the bone marrow to produce more red blood cells, which increases the hemoglobin level. Monitoring hemoglobin is the best way to assess the effectiveness of epoetin alfa, as an increase in hemoglobin indicates that the body is producing more red blood cells and the anemia is improving.

Similar Questions

A home health nurse is caring for a patient with multiple myeloma. Which of the following interventions should the nurse prioritize when addressing the patients severe bone pain?
The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time?
A clinic nurse is working with a patient who has a long-standing diagnosis of polycythemia vera. How can the nurse best gauge the course of the patient's disease?
In caring for a patient with a diagnosis of acute myeloid leukemia (AML) receiving induction therapy on the oncology unit, what nursing action should be prioritized in the patient's care plan?
What is a characteristic of normal cells?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses