Exam 3 - Leukemia

6. The client diagnosed with leukemia is being admitted for an induction course of chemotherapy. Which laboratory values indicate a diagnosis of leukemia? 1. A left shift in the white blood cell count differential. 2. A large number of WBCs that decreases after the administration of antibiotics. 3. An abnormally low hemoglobin (Hb) and hematocrit (Hct) level. 4. Red blood cells that are larger than normal.

*1. A left shift indicates immature white blood cells are being produced and released into the circulating blood volume. This should be investigated for the malignant process of leukemia.* 2. Leukocytosis (elevated WBCs) is normal in the presence of an infection, but it should decrease as the infection clears. 3. A low hemoglobin and hematocrit level indicates anemia and can be caused by a number of factors. Anemia does occur in leukemia, but it is not diagnostic for leukemia. 4. Red blood cells larger than normal occur in macrocytic anemias (vitamin B12 and folic acid deficiency). They are not characteristic of leukemia. TEST-TAKING HINT: The test taker should recognize elevated WBCs resolve with antibiotics as an infection. Option "3" is not specific enough to be the correct answer.

4. The client diagnosed with leukemia is scheduled for bone marrow transplantation. Which interventions should be implemented to prepare the client for this procedure? *Select all that apply.* 1. Administer high-dose chemotherapy. 2. Teach the client about autologous transfusions. 3. Have the family members HLA typed. 4. Monitor the complete blood cell count daily. 5. Provide central line care per protocol.

*1. All of the bone marrow cells must be destroyed prior to "implanting" the healthy bone marrow. High-dose chemotherapy and full-body irradiation therapy are used to accomplish this.* 2. Autologous transfusions are infusions from the client himself or herself. This client has a cancer involving blood tissue. To reinfuse the client's own tissues would be to purposefully give the client cancer cells. *3. The best bone marrow donor comes from an identical twin; next best comes from a sibling who matches. The most complications occur from a matched unrelated donor (MUD). The client's body recognizes the marrow as foreign and tries to reject it, resulting in graft-versus-host disease (GVHD).* *4. The CBC must be monitored daily to assess for infections, anemia, and thrombocytopenia.* *5. Clients will have at least one multiple-line central venous access. These clients are seriously ill and require multiple transfusions and antibiotics.* TEST-TAKING HINT: If the test taker knows the definition of "autologous," then option "2" could be eliminated.

2. The nurse is assessing a client diagnosed with acute myeloid leukemia. Which assessment data support this diagnosis? 1. Fever and infections. 2. Nausea and vomiting. 3. Excessive energy and high platelet counts. 4. Cervical lymph node enlargement and positive acid-fast bacillus.

*1. Fever and infection are hallmark symptoms of leukemia. They occur because the bone marrow is unable to produce white blood cells of the number and maturity needed to fight infection.* 2. Nausea and vomiting are symptoms related to the treatment of cancer but not to the diagnosis of leukemia. 3. The clients are frequently fatigued and have low platelet counts. The platelet count is low as a result of the inability of the bone marrow to produce the needed cells. In some forms of leukemia, the bone marrow is not producing cells at all, and in others, the bone marrow is stuck producing tens of thousands of immature cells. 4. Cervical lymph node enlargement is associated with Hodgkin's lymphoma, and positive acid-fast bacillus is diagnostic for tuberculosis. TEST-TAKING HINT: Option "3" could be eliminated because of the excessive energy. Illness normally drains energy reserves; it does not increase them.

10. The nurse and the licensed practical nurse (LPN) are caring for clients on an oncology floor. Which client should not be assigned to the LPN? 1. The client newly diagnosed with chronic lymphocytic leukemia. 2. The client who is four (4) hours postprocedure bone marrow biopsy. 3. The client who received two (2) units of PRBCs on the previous shift. 4. The client who is receiving multiple intravenous piggyback medications.

*1. The newly diagnosed client will need to be taught about the disease and about treatment options. The registered nurse cannot delegate teaching to an LPN.* 2. This client is postprocedure and could be cared for by the LPN. 3. This client has already received the blood products; this client requires routine monitoring, which the LPN could perform. 4. The LPN can administer antibiotic medications. TEST-TAKING HINT: The nurse cannot assign assessment, teaching, or evaluation. The clients in options "2," "3," and "4" are stable or have expected situations.

5. The client is diagnosed with chronic lymphocytic leukemia (CLL) after routine laboratory tests during a yearly physical. Which is the scientific rationale for the random nature of discovering the illness? 1. CCL is not serious, and clients die from other causes first. 2. There are no symptoms with this form of leukemia. 3. This is a childhood illness and is self-limiting. 4. In early stages of CLL, the client may be asymptomatic.

1. All types of leukemia are serious and can cause death. The chronic types of leukemia are more insidious in the onset of symptoms and can have a slower progression of the disease. Chronic types of leukemia are more common in the adult population. 2. The symptoms may have a slower onset, but anemia causing fatigue and weakness and thrombocytopenia causing bleeding can be present (usually in the later stages of the disease). Organ enlargement from infiltration may be present. Secondary symptoms of fever, night sweats, and weight loss may also be present. 3. This disease is usually found in adults. *4. In this form of leukemia, the cells seem to escape apoptosis (programmed cell death), which results in many thousands of mature cells clogging the body. Because the cells are mature, the client may be asymptomatic in the early stages.* TEST-TAKING HINT: The test taker can eliminate option "1" on the basis of "not serious"; common sense lets the test taker know this is not true.

7. Which medication is contraindicated for a client diagnosed with leukemia? 1. Bactrim, a sulfa antibiotic. 2. Morphine, a narcotic analgesic. 3. Epogen, a biologic response modifier. 4. Gleevec, a genetic blocking agent.

1. Because of the ineffective or nonexistent WBCs (segmented neutrophils) characteristic of leukemia, the body cannot fight infections, and antibiotics are given to treat infections. 2. Leukemic infiltrations into the organs or the central nervous system cause pain. Morphine is the drug of choice for most clients with cancer. *3. Epogen is a biologic response modifier that stimulates the bone marrow to produce red blood cells. The bone marrow is the area of malignancy in leukemia. Stimulating the bone marrow would be generally ineffective for the desired results and would have the potential to stimulate malignant growth.* 4. Gleevec is a drug that specifically works in leukemic cells to block the expression of the BCR-ABL protein, preventing the cells from growing and dividing. TEST-TAKING HINT: If the test taker were not familiar with the drug mentioned in option "4," then this option would not be a good choice. Options "1" and "2" are common drugs and should not be chosen as the answer unless the test taker knows for sure they are contraindicated.

3. The client diagnosed with leukemia has central nervous system involvement. Which instruction should the nurse teach? 1. Sleep with the head of the bed elevated to prevent increased intracranial pressure. 2. Take an analgesic medication for pain only when the pain becomes severe. 3. Explain radiation therapy to the head may result in permanent hair loss. 4. Discuss end-of-life decisions prior to cognitive deterioration.

1. Sleeping with the head of the bed elevated might relieve some intracranial pressure, but it will not prevent increased intracranial pressure from occurring. 2. Analgesic medications for clients with cancer are given on a scheduled basis with a fast-acting analgesic administered PRN for breakthrough pain. *3. Radiation therapy to the head and scalp area is the treatment of choice for central nervous system involvement of any cancer. Radiation therapy has longer lasting side effects than chemotherapy. If the radiation therapy destroys the hair follicles, the hair will not grow back.* 4. Cognitive deterioration does not usually occur. TEST-TAKING HINT: The test taker must be aware of the treatments used for the disease processes to answer this question but might eliminate option "2" because it violates basic principles of pain management.

8. The laboratory results for a male client diagnosed with leukemia include RBC count 2.1 × 10^6/mm3, WBC count 150 × 10^3/mm3, platelets 22 × 10^3/mm3, K+ 3.8 mEq/L, and Na+ 139 mEq/L. Based on these results, which intervention should the nurse teach the client? 1. Encourage the client to eat foods high in iron. 2. Instruct the client to use an electric razor when shaving. 3. Discuss the importance of limiting sodium in the diet. 4. Instruct the family to limit visits to once a week.

1. The anemia that occurs in leukemia is not related to iron deficiency, and eating foods high in iron will not help. *2. The platelet count of 22 × 103/mm3 indicates a platelet count of 22,000. The definition of thrombocytopenia is a count less than 100,000. This client is at risk for bleeding. Bleeding precautions include decreasing the risk by using soft-bristle toothbrushes and electric razors and holding all venipuncture sites for a minimum of five (5) minutes.* 3. The sodium level is within normal limits. The client is encouraged to eat whatever he or she wants to eat unless some other disease process limits food choices. 4. The client is at risk for infection, but unless the family or significant others are ill, they should be encouraged to visit whenever possible. TEST-TAKING HINT: The test taker could eliminate option "3" on the basis of a normal laboratory value. The RBC, WBC, and platelet values are all not in normal range. The correct answer option must address one of these values.

9. The nurse writes a nursing problem of "altered nutrition" for a client diagnosed with leukemia who has received a treatment regimen of chemotherapy and radiation. Which nursing intervention should be implemented? 1. Administer an antidiarrheal medication prior to meals. 2. Monitor the client's serum albumin levels. 3. Assess for signs and symptoms of infection. 4. Provide skin care to irradiated areas.

1. The nurse should administer an antiemetic prior to meals, not an antidiarrheal medication. *2. Serum albumin is a measure of the protein content in the blood that is derived from the foods eaten; albumin monitors nutritional status.* 3. Assessment of the nutritional status is indicated for this problem, not assessment of the signs and symptoms of infections. 4. This addresses an altered skin integrity problem. TEST-TAKING HINT: The stem of the question asks for interventions for "altered nutrition." Assessment is the first step of the nursing process, but option "3" is not assessing nutrition.

12. The nurse is caring for a client diagnosed with acute myeloid leukemia. Which assessment data warrant immediate intervention? 1. T 99, P 102, R 22, and BP 132/68. 2. Hyperplasia of the gums. 3. Weakness and fatigue. 4. Pain in the left upper quadrant.

1. These vital signs are not alarming. The vital signs are slightly elevated and indicate monitoring at intervals, but they do not indicate an immediate need. 2. Hyperplasia of the gums is a symptom of myeloid leukemia, but it is not an emergency. 3. Weakness and fatigue are symptoms of the disease and are expected. *4. Pain is expected, but it is a priority, and pain control measures should be implemented.* TEST-TAKING HINT: If all the answer options contain expected events, the test taker must decide which is priority—and pain is a priority need.

1. The nurse is caring for clients on an oncology unit. Which neutropenia precautions should be implemented? 1. Hold all venipuncture sites for at least five (5) minutes. 2. Limit fresh fruits and flowers. 3. Place all clients in reverse isolation. 4. Have the clients use a soft-bristle toothbrush.

1. This would be done for thrombocytopenia (low platelets), not neutropenia (low white blood cells). *2. Fresh fruits and flowers may carry bacteria or insects on the skin of the fruit or dirt on the flowers and leaves, so they are restricted around clients with low white blood cell counts.* 3. Clients with severe neutropenia may be placed in reverse isolation, but not all clients with neutropenia will be placed in reverse isolation. Clients are at a greater risk for infecting themselves from endogenous fungi and bacteria than from being exposed to noninfectious individuals. 4. This is an intervention for thrombocytopenia. TEST-TAKING HINT: The test taker must match the problem with the answer option. Options "1" and "4" would probably be implemented for the client with a bleeding disorder. Option "3" has the word "all" in it, which would make the test taker not select this option.

11. The nurse is completing a care plan for a client diagnosed with leukemia. Which independent problem should be addressed? 1. Infection 2. Anemia 3. Nutrition 4. Grieving

1. Treating infections, which require HCP orders for cultures and antibiotics, is a collaborative problem. 2. The treatment of anemia is a collaborative problem. 3. The provision of adequate nutrition requires collaboration between the nurse, HCP, and dietitian. *4. Grieving is an independent problem, and the nurse can assess and treat this problem with or without collaboration.* TEST-TAKING HINT: The stem of the question asks for an independent intervention. If the test taker understands the problem and the treatment needs, options "1," "2," and "3" can be eliminated.