How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a client who has cancer and is undergoing chemotherapy.

Exhibits

Which of the following assessments indicates an improvement in the client's condition?

(Select all that apply.)

A.

WBC count

B.

Platelet count

C.

Bleeding episodes

D.

Oral health

E.

Weight change

Answer and Explanation

Correct Answer : C,D

A.    In January, WBC count was 5,500/mm3. In February, it decreased to 4,500/mm3. A decrease in WBC count indicates worsening in the client's condition since they are prone to infections.
B.    In January, platelet count was 150,000/mm3. In February, it decreased slightly to 140,000/mm3. The slight decrease in platelet count may not necessarily indicate improvement but is relatively stable.
C.    In January, the client reported bleeding episodes from mouth ulcers. In February, the client reports no bleeding episodes. The absence of bleeding episodes indicates improvement in oral mucosal health and potential effectiveness of interventions.
D.    In January, the oral mucosa was inflamed. In February, there is noted improvement with less inflammation. Improved oral health with reduced inflammation indicates a positive response to interventions and potentially better oral hygiene practices.
E.    The client experienced weight loss of 1.5 kg (3.3 lb) from January to February. Weight loss may indicate ongoing challenges with nutrition despite efforts to increase food intake and manage symptoms.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is ["A","B","E","F"]

Explanation

A. Tenderness in the area of the transplant incision can be a sign of inflammation or rejection.
B. Bilateral edema (swelling) in the lower legs can be a sign of fluid retention, which can occur with kidney dysfunction or rejection.
C. While high blood pressure can be a concern, it's not a specific indicator of transplant rejection in this scenario.
D. The sodium level is within normal limits in this case, decreasing the risk of a transplant rejection.
E. An elevated creatinine level can indicate worsening kidney function, which could be a sign of rejection.
F. Hypoactive bowel sounds in all four quadrants can suggest decreased blood flow or intestinal ischemia, which can be a complication of transplant rejection.
G. Normal lung sounds are not necessarily indicative of rejection.

Correct Answer is []

Explanation

Potential Condition:

Hypovolemia: The client shows signs of hypovolemia such as a low blood pressure (94/56 mm Hg), a high heart rate (110/min), and a relatively high urine output (1500 mL in the last hour), which may indicate an over-diuresis or inadequate fluid replacement postoperatively.

Actions to Take:

Obtain prescription for IV bolus: Administering an IV fluid bolus can help restore intravascular volume, thereby increasing blood pressure and improving perfusion to vital organs.

Lower head of bed: This action helps to increase venous return to the heart, which can help improve cardiac output and blood pressure in a hypovolemic patient.

Parameters to Monitor:

Urinary output: This is a key indicator of kidney function and fluid status. Monitoring urine output will help determine if the client is adequately responding to fluid resuscitation and maintaining appropriate kidney function.

Blood pressure: Continuous blood pressure monitoring is essential to evaluate the effectiveness of interventions aimed at correcting hypovolemia and ensuring the client's hemodynamic stability.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register