A nurse is assessing a client 1 week after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as an indication of which of the following complications?

Failure to engraft

Veno-occlusive disease

Graft-versus-host disease

Pancytopenia

Answer and Explanation

The Correct Answer is C

A. Failure to engraft is characterized by the absence of new bone marrow cell growth, leading to persistent low blood counts. It does not typically present with skin peeling or desquamation.

B. Veno-occlusive disease primarily affects the liver and presents with symptoms such as weight gain, hepatomegaly, and jaundice. Skin desquamation is not a common manifestation of this complication.

C. Graft-versus-host disease commonly affects the skin, liver, and gastrointestinal tract, with early signs including rash and desquamation of the hands and feet. This finding is a hallmark indication of this complication following a bone marrow transplant.

D. Pancytopenia involves a reduction in red blood cells, white blood cells, and platelets, leading to fatigue, infection risk, and bleeding. It does not typically cause skin peeling.

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Correct Answer is D

Explanation

A. Allowing the infant to suck on a pacifier during tube feedings can lead to aspiration or choking and is not recommended.

B. Placing enough formula for 12 hours in the feeding container may lead to formula spoilage and contamination, as formula should be prepared fresh for each feeding.

C. Changing the tube feeding setup every 36 hours is not typically necessary unless there are signs of contamination or malfunction. The frequency of changing the setup should be based on institutional policies and manufacturer recommendations.

D. Flushing the tube with water before and after feedings helps ensure proper hydration and prevents tube blockage. A volume of 30 mL is commonly recommended for infants.

A. A client who has a history of MRSA will need antibiotics. B. A client who has a history of MRSA can develop immunity to the infection. C. A client who has a history of MRSA requires a protective environment. D. A client who has a history of MRSA can still transmit the infection.

Correct Answer is D

Explanation

A. Not all clients with a history of MRSA will require antibiotics. Treatment depends on the presence of active infection, colonization, and other clinical factors.
B. There is no evidence to suggest that individuals can develop immunity to MRSA. MRSA remains a significant pathogen, and individuals with a history of MRSA remain susceptible to reinfection or colonization.
C. A protective environment is not typically required for clients with a history of MRSA. Standard precautions, including hand hygiene and appropriate use of personal protective equipment, are sufficient to prevent transmission.

D. Clients with a history of MRSA can still carry the bacteria on their skin or in their nasal passages and may transmit the infection to others, especially in healthcare settings. Therefore, it is important to adhere to infection control practices to prevent transmission.

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A nurse is assessing a client 1 week after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as an indication of which of the following complications?

Nursing Test Bank

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