A nurse is caring for a 54-year-old male client in the oncology unit who is undergoing chemotherapy for colorectal cancer. The nurse must evaluate the client’s condition based on provided exhibits to determine which assessments indicate an improvement in the client’s condition.
Which of the following assessments indicates an improvement in the client’s condition?
Oral health
Bleeding episodes
Weight change
WBC count
Platelet count
Correct Answer : B,D,E
Choice A rationale: Oral health indicates the absence of mucositis or other oral complications, which is good, but it doesn't necessarily reflect overall improvement in the client's cancer or chemotherapy response.
Choice B rationale: The absence of bleeding episodes is significant. This suggests that the client's platelet count has improved, reducing the risk of bleeding, which is an important indicator of recovery.
Choice C rationale: While weight maintenance or gain can be an indicator of health improvement, the slight decrease in weight from January to February (70.5 kg to 69 kg) does not suggest an improvement.
Choice D rationale: An increase in the WBC count to within the normal range (4.2 x 10⁹/L) is a positive sign. It indicates that the client’s immune system is recovering, which is crucial during chemotherapy.
Choice E rationale: The improvement in platelet count to within the normal range (150 x 10⁹/L) suggests a reduced risk of bleeding and reflects better bone marrow function, which is a positive outcome of the treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Monitoring the client’s hydration status is critical for older adults, especially those on a medical-surgical unit, to prevent dehydration, which can lead to serious complications such as renal impairment, confusion, and electrolyte imbalance.
Choice B rationale
Encouraging physical activities is beneficial but is not always feasible or safe for all older clients, especially those with certain medical conditions or mobility limitations.
Choice C rationale
Administering medications as prescribed is essential but is a standard practice for all clients and not specific to older adults' unique needs.
Choice D rationale
Educating the client on dietary needs is important but secondary to monitoring hydration, which addresses more immediate physiological needs and complications.
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale
Resistance to the flow of IV fluid may indicate infiltration or extravasation, where the medication leaks into surrounding tissues, necessitating stopping the infusion.
Choice B rationale
Burning or pain, swelling, or redness at the site are signs of extravasation, which is a serious complication of vincristine administration and requires immediate action.
Choice C rationale
Reporting anxiety and depression are not directly related to vincristine infusion site complications. These are more systemic effects and do not indicate the need to stop the infusion immediately.
Choice D rationale
Nausea and vomiting are common side effects of vincristine but do not indicate a problem with the IV line itself, so they do not require stopping the infusion.
Choice E rationale
Absence of blood return from the IV catheter may indicate that the catheter is not in the vein properly, which requires stopping the infusion to prevent tissue damage.
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