A nurse is caring for a 63-year-old female client in the emergency department (ED) with a history of colorectal cancer. The client is receiving chemotherapy and radiation. She presents with complaints of fatigue, unexplained bruising, and recurring headaches. The nurse must evaluate the situation based on the exhibits provided to determine the client’s risk factors and findings.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Choice A rationale:
The client's low platelet count (90 x 10⁹/L) is a significant risk factor for developing Disseminated Intravascular Coagulation (DIC), a condition characterized by abnormal blood clotting and bleeding. The client's history of cancer and symptoms such as unexplained bruising and fatigue further support this risk.
Choice B rationale:
Hyperkalemia is characterized by high potassium levels, but the client's potassium level is within the normal range (4.1 mmol/L), so this is not a risk factor.
Choice C rationale:
Hyponatremia is a condition of low sodium levels in the blood. The client's sodium level is normal (137 mmol/L), so this is not a risk factor.
Choice D rationale:
Pneumonia is a lung infection, and the client's oxygen saturation is normal (98% on room air), indicating no immediate risk of pneumonia.
Choice E rationale:
Acute nephritic syndrome is a kidney disorder that can cause elevated blood urea nitrogen (BUN) and creatinine levels. The client's BUN is slightly elevated (22 mg/dL), but her creatinine level is normal (1.0 mg/dL), making this less likely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Dark stools are not a common side effect of chemotherapy; this symptom typically indicates gastrointestinal bleeding or iron supplements.
Choice B rationale
Flossing 4 times daily can cause gum irritation and bleeding, increasing the risk of infection in immunocompromised clients.
Choice C rationale
Administering an antiemetic before chemotherapy helps to prevent nausea and vomiting, improving the client's comfort and compliance with treatment.
Choice D rationale
Swishing with commercial mouthwash can irritate the mucous membranes; instead, using a gentle saline rinse is recommended.
Correct Answer is A
Explanation
Choice A rationale
The Papanicolaou test (Pap smear) is the primary screening tool for cervical cancer. It detects precancerous or cancerous cells on the cervix and is recommended regularly for women.
Choice B rationale
A vaginal ultrasound is not used for initial cervical cancer screening. It may be used to evaluate abnormalities found by other means, but not as a primary screening test.
Choice C rationale
Serum prolactin level testing is not related to cervical cancer screening. Elevated prolactin levels are associated with other conditions like prolactinomas or hypothyroidism.
Choice D rationale
An endometrial biopsy is used to diagnose endometrial cancer or other uterine conditions, not for screening cervical cancer. It examines the tissue lining the uterus.
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