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
The Correct Answer is B
A. Failure to engraft typically presents with symptoms such as persistent neutropenia, thrombocytopenia, and anemia, rather than skin peeling.
B. Veno-occlusive disease, also known as sinusoidal obstruction syndrome, can lead to liver dysfunction and subsequent skin manifestations such as peeling, especially on the palms and soles.
C. Graft-versus-host disease (GVHD) typically presents with symptoms such as skin rash, diarrhea, and liver dysfunction, but peeling skin is not a hallmark manifestation.
D. Pancytopenia refers to a deficiency of all types of blood cells (red blood cells, white blood cells, and platelets) and is not typically associated with skin peeling as a primary symptom.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Wearing an underwire bra between feedings" can compress the breast tissue, potentially leading to milk stasis and increasing the risk of mastitis.
B. "Covering your breasts immediately after feedings" can trap moisture and warmth, creating an environment conducive to bacterial growth and increasing the risk of mastitis.
C. "Applying cold compresses to your breasts before feedings" may provide temporary relief for discomfort, but it is not a primary preventive measure for mastitis.
D. "Trying to have your baby empty your breasts with each feeding" helps ensure thorough milk removal, which can prevent milk stasis and decrease the risk of mastitis. This is the correct choice.
Correct Answer is B
Explanation
A. Serum calcium levels are not directly indicative of hypervolemia.
B. A urine specific gravity of 1.001 indicates dilute urine, which is a common finding in hypervolemia as the kidneys attempt to excrete excess fluid.
C. Serum sodium levels within the normal range (e.g., 138 mEq/L) are not indicative of hypervolemia.
D. Urine pH of 6.1 is within the normal range and does not specifically indicate hypervolemia.
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