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
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Nursing Elites

ATI RN

Oncology Test Bank

1. 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?

Correct answer: D

Rationale: The course of polycythemia vera can be best ascertained by monitoring the patient's hematocrit, which should remain below 45%. Hematocrit levels are a key indicator in assessing the progression of the disease. Choices A, B, and C are not the most appropriate methods for gauging the course of polycythemia vera. Monitoring the color of the patient's palms and face, or their response to erythropoietin injections, may not provide an accurate reflection of the disease's progression. Similarly, while erythrocyte sedimentation rate can be affected in polycythemia vera, it is not the primary marker for monitoring the disease's course.

2. 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?

Correct answer: A

Rationale: The correct answer is A: Protective isolation and vigilant use of standard precautions. Induction therapy for acute myeloid leukemia (AML) can lead to neutropenia, significantly increasing the risk of infections. Therefore, the priority is to protect the patient from potential pathogens by implementing protective isolation measures and adhering to strict standard precautions. This action is crucial for the patient's survival. Choice B is incorrect as nutritional support and oral hygiene are important but not the priority in this situation. Choice C, involving the family in planning activities, is a valuable aspect of care but not the priority during induction therapy. Choice D, monitoring and treating pain, is essential but ensuring protection against infection takes precedence due to the high risk of neutropenia.

3. The nurse is assessing a client with leukemia who is receiving chemotherapy. Which of the following findings would be of most concern?

Correct answer: D

Rationale: The correct answer is D, 'Mouth sores.' Mouth sores (stomatitis) are a common and potentially serious side effect of chemotherapy. They can lead to difficulty eating, increased risk of infection, and overall decreased quality of life for the client. While alopecia, fatigue, and nausea/vomiting are also common side effects of chemotherapy, they are generally manageable and do not pose the same level of immediate concern as the development of mouth sores in a client undergoing chemotherapy.

4. A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate?

Correct answer: B

Rationale: Radiation-induced fatigue can last for months; it’s important to normalize this for the client.

5. The nurse is instructing a client on ways to reduce the risk of lymphedema after a mastectomy. Which of the following should be emphasized?

Correct answer: D

Rationale: After a mastectomy, particularly when lymph nodes are removed, patients are at increased risk for developing lymphedema, which is a buildup of lymph fluid that can cause swelling in the affected arm. Wearing tight clothing can constrict lymphatic flow and increase the risk of developing lymphedema by impeding normal lymphatic drainage. Therefore, it is crucial to advise patients to avoid tight-fitting clothing, especially around the chest and arm areas.

Similar Questions

A 50-year-old man diagnosed with leukemia will begin chemotherapy. What would the nurse do to combat the most common adverse effects of chemotherapy?
A patient with a myelodysplastic syndrome is being treated on the medical unit. What assessment finding should prompt the nurse to contact the patients primary care provider?
A patient’s most recent diagnostic imaging has revealed that his lung cancer has metastasized to his bones and liver. What is the most likely mechanism by which the patient’s cancer cells spread?
Which of the following descriptions of chemotherapy is correct?
A nurse is creating a plan of care for an oncology patient and one of the identified nursing diagnoses is risk for infection related to myelosuppression. What intervention addresses the leading cause of infection-related death in oncology patients?

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