NCLEX Ch 34
A patient with suspected multiple myeloma is complaining of pain in the back. What is the priority nursing action? a) Have the patient rest. b) Have the patient lie on a hard surface. c) Encourage ambulation. d) Send the patient for x-ray study of the spine.
d) Send the patient for x-ray study of the spine. Explanation: The patient with myeloma can have bone pain, especially in the back and ribs. The pain will decrease with rest and increase with activity. Lying on a hard surface will not relieve the pain. The priority action is to make certain the patient does not have a fracture of the spine, as the bone destruction in this disease is sufficiently severe to cause vertebral collapse.
Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets? a) Myeloid stem cell b) Monocyte c) Neutrophil d) Lymphoid stem cell
a) Myeloid stem cell Explanation: The myeloid stem cell is responsible not only for all nonlymphoid white blood cells (WBC), but also for the production of RBCs and platelets. Lymphoid cells produce either T or B lymphocytes. A monocyte is large WBC that becomes a macrophage when is leaves the circulation and moves into body tissues. A neutrophil is a fully mature WBC capable of phagocytosis.
The nurse is teaching a patient about the development of leukemia. What statement should be included in the teaching plan? a) "Chronic leukemia develops slowly." b) "Acute leukemia develops slowly." c) "In acute leukemia there are not many undifferentiated cells." d) "In chronic leukemia, the majority of leukocytes are mature."
a) "Chronic leukemia develops slowly." Explanation: Chronic leukemia develops slowly, and the majority of leukocytes are still maturing. Acute leukemia develops quickly and the majority of leukocytes are undifferentiated cells.
Which assessment findings support the client's diagnosis of AML (acute myeloid leukemia)? Select all that apply. a) Bone pain b) Enlarged lymph nodes c) Enlarged heart d) Weakness and fatigue e) Petechiae
a) Bone pain, b) Enlarged lymph nodes, d) Weakness and fatigue, e) Petechiae Explanation: Clients with AML may present with petechiae, enlarged lymph nodes, weakness, fatigue, and bone pain. An enlarged heart is not a typical finding with this disorder.
The nurse is assessing several patients. Which patient does the nurse determine is most likely to have Hodgkin lymphoma? a) The patent with painful lymph nodes under the arm. b) The patient with enlarged lymph nodes in the neck. c) The patient with painful lymph nodes in the groin. d) The patient with a painful sore throat.
b) The patient with enlarged lymph nodes in the neck. Explanation: Lymph node enlargement in Hodgkin lymphoma is not painful. The patient with enlarged lymph nodes in the neck is most likely to have Hodgkin lymphoma if the enlarged nodes are painless. Sore throat is not a sign for this disorder.
Which of the following nursing interventions should be incorporated into the plan of care to manage the delayed clotting process in a patient with leukemia? a) Eliminate direct contact with others who are infectious. b) Implement neutropenic precautions. c) Apply prolonged pressure to needle sites or other sources of external bleeding. d) Apply prolonged pressure to needle sites or other sources of external bleeding.
c) Apply prolonged pressure to needle sites or other sources of external bleeding. Explanation: For a patient with leukemia, the nurse should apply prolonged pressure to needle sites or other sources of external bleeding. Reduced platelet production results in a delayed clotting process and increases the potential for hemorrhage. Implementing neutropenic precautions and eliminating direct contact with others are interventions to address the risk for infection.
A patient who is undergoing chemotherapy for AML complains of pain in his lower back. What is the nurse's first action? a) Place heating pads on the patient's back. b) Refer the client to a chiropractor. c) Assess renal function. d) Administer pain medication, as ordered.
c) Assess renal function. Explanation: Chemotherapy results in the destruction of cells and tumor lysis syndrome. There is an increase in uric acid and phosphorus levels and the patient is susceptible to renal failure. The nurse should assess renal function if the patient complains of lower back pain as this could be indicative of a kidney stone formation. Heating pads, pain medication, and referrals could be instituted once the cause of the pain is determined. The priority is further assessment to rule out priority problems.
A patient with multiple myeloma is complaining about pain. What instructions will the nurse give the patient to help to reduce pain during activity? a) Do not lift more than 10 pounds. b) Limit activity to once a day. c) Limit fluids to prevent going to the bathroom. d) Stay in bed as much as possible.
a) Do not lift more than 10 pounds. Explanation: The patient with multiple myeloma needs education about activity instructions such as lifting no more than 10 pounds and using proper body mechanics. Braces may be needed. The patient should have activity and would not be instructed to stay in bed or limit activity as he or she would become very stiff. Limiting fluids would be contraindicated. The patient needs to remain well hydrated.
A patient with leukemia has developed a cough and increased fatigue. What is the primary nursing intervention? a) Evaluate the patient for potential infection. b) Place a cooling blanket on the patient. c) Administer an antitussive. d) Medicate the patient for pain.
a) Evaluate the patient for potential infection. Explanation: The patient with leukemia has a lack of mature and normal granulocytes for fighting infection. For this reason, the patient is susceptible to infection. The primary nursing intervention is to evaluate the patient for potential infection if he or she has a cough and increased fatigue. Administering an antitussive would not be appropriate before determining the cause of the cough. A cooling blanket would not be needed if the patient does not have a fever. Medicating the patient for pain would come after the assessment phase.
Which of the following terms refers to a form of white blood cell involved in immune response? a) Lymphocyte b) Spherocyte c) Thrombocyte d) Granulocyte
a) Lymphocyte Explanation: Both B and T lymphocytes respond to exposure to antigens. Granulocytes include basophils, neutrophils, and eosinophils. A spherocyte is a red blood cell without central pallor, seen with hemolysis. A thrombocyte is a platelet.
The nurse is teaching the patient about consolidation. What statement should be included in the teaching plan? a) "Consolidation of the lungs is an expected effect of induction therapy." b) "Consolidation occurs as a side effect of chemotherapy." c) "Consolidation of the lungs is an expected effect of induction therapy." d) "Consolidation therapy is administered to reduce the chance of leukemia recurrence."
d) "Consolidation therapy is administered to reduce the chance of leukemia recurrence." Explanation: Consolidation therapy is administered to eliminate residual leukemia cells that are not clinically detectable and reduce the chance for recurrence. It is also termed post-remission therapy. It is not a side effect of chemotherapy, but the administration of chemotherapy.
After chemotherapy for AML, what interventions will best help to prevent renal complications? Select all that apply. a) Increase hydration. b) Administer allopurinol (Zyloprim). c) Encourage exercise. d) Administer potassium therapy. e) Administer rasburicase (Elitek).
a) Increase hydration., b) Administer allopurinol (Zyloprim)., e) Administer rasburicase (Elitek). Explanation: Increased uric acid and phosphorus levels after chemotherapy for AML can lead to renal calculi formation. Increasing hydration and administering allopurinol (a uricosuric) will help to eliminate the uric acid. Elitek is an enzyme that can also decrease uric acid. Administration of potassium is not indicated as levels are elevated after chemotherapy. Exercise is not initially encouraged because the patient could have weakness and cramping during this time.
For a patient with Hodgkin disease, who is at a risk for an ineffective airway clearance and an impaired gas exchange, the nurse places the patient in a high Fowler's position to do which of the following? a) Increase the lung expansion. b) Anticipate the need for the airway management. c) Reduce the deficits in the blood oxygen level. d) Detect compromised ventilation.
a) Increase the lung expansion. Explanation: For a patient with Hodgkin disease who is at a risk for an ineffective airway clearance and an impaired gas exchange, the nurse keeps the neck in midline and places the patient in a high Fowler's position if respiratory distress develops. Avoiding unnecessary pressure on the trachea and positioning for an increased lung expansion improve the air exchange. The nurse administers oxygen as per the physician's orders to reduce the deficits in the blood oxygen level. The nurse assesses the respiratory status in each shift to detect compromised ventilation. The nurse places an endotracheal tube, a laryngoscope, and a bag-valve mask at the bedside for intubation if the need for the airway management arises.
Which of the following statements best describes the function of stem cells in the bone marrow? a) They defend against bacterial infection. b) They produce antibodies against foreign antigens. c) They produce all blood cells. d) They are active against hypersensitivity reactions.
c) They produce all blood cells. Explanation: All blood cells are produced from undifferentiated precursors called pluripotential stem cells in the bone marrow. Other cells produced from the pluripotential stem cells help defend against bacterial infection, produce antibodies against foreign antigens, and are active against hypersensitivity reactions.
A patient has completed induction therapy and has diarrhea and severe mucositis. What is the appropriate nursing goal? a) Address issues of negative body image. b) Place client in reverse isolation. c) Administer pain medication. d) Maintain nutrition.
d) Maintain nutrition. Explanation: Maintaining nutrition is the most important goal after induction therapy because the patient experiences severe diarrhea and can easily become nutritionally deficient as well as develop fluid and electrolyte imbalance. The patient is most likely not in pain at this point, and this is an intervention not a goal.
A patient who is being treated for AML has bruises on both legs. What is the nurse's most appropriate action? a) Evaluate the patient's platelet count. b) Keep the patient on bed rest. c) Ask the patient if he has been falling recently. d) Evaluate the patient's INR.
a) Evaluate the patient's platelet count. Explanation: Complications of AML include bleeding. The risk of bleeding correlates with the level and duration of platelet deficiency. Major hemorrhages may develop when the platelet count drops to less than 10,000 x mm3. The bleeding is usually unrelated to falling. Keeping the patient on bed rest will not prevent bleeding when the patient has a low platelet count. Assessment for other areas of bleeding is also a priority intervention.
The term that is used to refer to a primitive cell, capable of self-replication and differentiation, is which of the following? a) Stem cell b) Band cell c) Reticulocyte d) Spherocyte
a) Stem cell Explanation: Stem cells may differentiate into myeloid or lymphoid stem cells. A band cell is a slightly immature neutrophil. A spherocyte is a red blood cell without central pallor. A reticulocyte is a slightly immature red blood cell.
A patient with AML has pale mucous membranes and bruises on his legs. What is the primary nursing intervention? a) Assess the patient's skin. b) Check the patient's history. c) Assess the patient's hemoglobin and platelets. d) Assess the patient's pulses and blood pressure.
c) Assess the patient's hemoglobin and platelets. Explanation: Patients with AML may develop pallor from anemia and bleeding tendencies from low platelet counts. Assessing the patient's hemoglobin and platelets will help to determine if this is the cause of the symptoms. This would be the priority above assessing pulses, blood pressure, history, or skin.
What assessment findings best indicate that the patient has recovered from induction therapy? a) Absence of bone pain b) No evidence of edema c) Neutrophil and platelet counts within normal limits d) Neutrophil and platelet counts within normal limits
c) Neutrophil and platelet counts within normal limits Explanation: Recovery from induction therapy is indicated when the neutrophil and platelet counts have returned to normal and any infection has resolved. Stable vital signs, lack of edema, and absence of pain are not indicative of recovery from induction therapy.
Which of the following terms refers to an abnormal decrease in white blood cells, red blood cells, and platelets? a) Thrombocytopenia b) Anemia c) Pancytopenia d) Leukopenia
c) Pancytopenia Explanation: Pancytopenia may be congenital or acquired. Anemia refers to decreased red cell mass. Leukopenia refers to a less-than-normal amount of WBCs in circulation. Thrombocytopenia refers to a lower-than-normal platelet count.
Which statement indicates the patient understands teaching about induction therapy for leukemia? a) "I know I can never be cured." b) "I will start slowly with medication treatment." c) "I will need to come every week for treatment." d) "I will be in the hospital for several weeks."
d) "I will be in the hospital for several weeks." Explanation: Induction therapy involves high doses of several medications and the patient is usually admitted into the hospital for several weeks. The treatment is started quickly and the goal is to cure or put the patient into remission.
The nurse is teaching a patient with acute lymphocytic leukemia (ALL) about therapy. What statements should be included in the plan of care? a) "The goal of therapy is palliation." b) "Side effects are rare with therapy." c) "Treatment is simple and consists of single drug therapy." d) "Intrathecal chemotherapy is used primarily as preventive therapy."
d) "Intrathecal chemotherapy is used primarily as preventive therapy." Explanation: Intrathecal chemotherapy is a key part of the treatment plan to prevent invasion of the central nervous system. The therapy uses multiple drugs, with many side effects. The goal of therapy is remission.
A patient presents with peripheral neuropathy and hypothesia of the feet. What is the best nursing intervention? a) Keep the feet cool. b) Encourage ambulation. c) Have the client elevate his legs. d) Assess for signs of injury.
d) Assess for signs of injury. Explanation: A patient with hypothesia of the feet will have decreased sensation and numbness. The nurse should assess for signs of injury. If the patient has injured himself, he will not be able to feel it and this could lead to the development of infection. Ambulation will not help the patient and elevation of the legs may make the problem worse as blood flow to the feet would be decreased. Keeping the feet cold will also decrease blood flow.
When assessing a female patient with a disorder of the hematopoietic or the lymphatic system, which of the following assessments is most essential? a) Lifestyle assessments, such as exercise routines b) Age and gender c) Menstrual history d) Health history, such as bleeding, fatigue, or fainting
d) Health history, such as bleeding, fatigue, or fainting Explanation: When assessing a patient with a disorder of the hematopoietic or the lymphatic system, it is essential to assess the patient's health history. An assessment of drug history is essential because some antibiotics and cancer drugs contribute to hematopoietic dysfunction. Aspirin and anticoagulants may contribute to bleeding and interfere with clot formation. Because industrial materials, environmental toxins, and household products may affect blood-forming organs, the nurse needs to explore exposure to these agents. Age, gender, menstrual history, or lifestyle assessments, such as exercise routines and habits, do not directly affect the hematopoietic or lymphatic system.
The nurse is interacting with a family that has been caring for a patient with cancer for several months. What are the best interventions to assist in relieving caregiver stress in this family? Select all that apply. a) Suggest the family go to church more often. b) Suggest the prescription of anti-anxiety medications. c) Suggest support for household maintenance. d) Allow family members to express feelings. e) Educate the family about medications and side effects.
c) Suggest support for household maintenance., d) Allow family members to express feelings., e) Educate the family about medications and side effects. Explanation: Family members benefit from increased education on what to expect. Allowing family members to express their feelings has also been shown to relieve stress. Supporting the caregiver and family with help in household duties will also help the over-burdened family. Anti-anxiety medications and church attendance have not been shown to reduce caregiver stress.
