Nursing Elites

1. 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?

• A. Protective isolation and vigilant use of standard precautions
• B. Provision of a high-calorie, low-texture diet and appropriate oral hygiene
• C. Including the family in planning the patient's activities of daily living
• D. Monitoring and treating the patient's pain

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.

2. Mina, who is suspected of an ovarian tumor is scheduled for a pelvic ultrasound. The nurse provides which preprocedure instruction to the client?

• A. Eat a light breakfast only
• B. Maintain an NPO status before the procedure
• C. Wear comfortable clothing and shoes for the procedure
• D. Drink six to eight glasses of water without voiding before the test

Correct answer: D

Rationale: A pelvic ultrasound requires the client to have a full bladder because the bladder acts as a window through which pelvic organs, such as the uterus and ovaries, can be visualized more clearly. The full bladder pushes the intestines out of the way and provides a better acoustic pathway for the ultrasound waves. Without this, the pelvic organs might be obscured, and the images would be less accurate.

3. A patient newly diagnosed with cancer is scheduled to begin chemotherapy treatment and the nurse is providing anticipatory guidance about potential adverse effects. When addressing the most common adverse effect, what should the nurse describe?

• A. Pruritis (itching)
• B. Nausea and vomiting
• C. Altered glucose metabolism
• D. Confusion

Correct answer: B

Rationale: Nausea and vomiting are among the most common and distressing side effects of chemotherapy. Chemotherapy drugs target rapidly dividing cells, including cancer cells, but they also affect healthy cells in the gastrointestinal (GI) tract, triggering the release of chemicals that stimulate the brain’s vomiting center. These side effects can occur immediately (acute), be delayed, or even anticipatory, and often require management with antiemetic (anti-nausea) medications to improve the patient’s comfort and quality of life during treatment.

4. A patient with chronic lymphocytic leukemia (CLL) is at risk for tumor lysis syndrome. What laboratory values should the nurse monitor to detect this complication?

• A. Creatinine and blood urea nitrogen (BUN)
• B. Electrolytes and uric acid levels
• C. Serum glucose and calcium levels
• D. Liver enzymes and bilirubin levels

Correct answer: B

Rationale: Electrolytes and uric acid levels are important to monitor for the development of tumor lysis syndrome.

5. 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. The patient is experiencing a frontal lobe headache.
• B. The patient has an episode of urinary incontinence.
• C. The patient has an oral temperature of 37.5C (99.5F).
• D. The patients SpO2 is 91% on room air.

Correct answer: C

Rationale: Patients with myelodysplastic syndrome (MDS) have a dysfunctional bone marrow that leads to ineffective blood cell production, including white blood cells, which are crucial for fighting infections. As a result, they are at high risk for infections. Even a slight elevation in temperature, such as 37.5°C (99.5°F), could be an early sign of infection in an immunocompromised patient. Early detection and treatment of infections are critical in MDS patients, as infections can quickly become severe or life-threatening due to their compromised immune system.

Similar Questions