a patient with acute lymphocytic leukemia all is undergoing chemotherapy and develops neutropenia what is the most important nursing intervention for
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Nursing Elites

ATI RN

ATI Oncology Quiz

1. A patient with acute lymphocytic leukemia (ALL) is undergoing chemotherapy and develops neutropenia. What is the most important nursing intervention for this patient?

Correct answer: C

Rationale: Maintaining a sterile environment is crucial to prevent infection in neutropenic patients.

2. 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?

Correct answer: B

Rationale: In oncology patients, particularly those undergoing chemotherapy or radiation therapy, myelosuppression (the decrease in bone marrow activity that leads to reduced white blood cells, red blood cells, and platelets) increases the risk of infection. Maintaining skin integrity is crucial because the skin acts as the body's first line of defense against infections. If the skin becomes compromised, such as through radiation burns, rashes, or breakdowns, it provides a potential entry point for pathogens, increasing the risk of infection. Since infections in oncology patients can quickly become severe due to their weakened immune systems, maintaining skin integrity is a critical intervention to reduce infection risk, especially for patients who are immunosuppressed.

3. 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?

Correct answer: D

Rationale: The optimal time for performing a breast self-examination (BSE) is about one week after menstruation begins, as this is when the breasts are least likely to be swollen, tender, or affected by hormonal changes. Hormonal fluctuations during the menstrual cycle can cause temporary changes in breast tissue, such as swelling, lumpiness, or tenderness, which may make it more difficult to detect any unusual lumps or changes. Conducting the examination during this period ensures that the breasts are in their natural state, making it easier to notice any abnormalities.

4. A patient with Hodgkin lymphoma is receiving radiation therapy. What side effect should the nurse monitor for that is most common with this type of treatment?

Correct answer: D

Rationale: Mucositis is a common side effect of radiation therapy that should be closely monitored.

5. 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.

Similar Questions

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When preparing for the patient's subsequent care after completing the full course of treatment for acute lymphocytic leukemia without a significant response, what action should the nurse take?
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