A nurse is caring for a client who has leukemia. Which of the following findings is the highest priority for the nurse to report to the provider?
Weight loss
Fatigue
Dysuria
Elevated temperature
The Correct Answer is D
Choice A: This is incorrect because weight loss is not the highest priority finding for the nurse to report to the provider. Weight loss can be a common symptom of leukemia due to decreased appetite, increased metabolism, or malabsorption.
Choice B: This is incorrect because fatigue is not the highest priority finding for the nurse to report to the provider. Fatigue can be a common symptom of leukemia due to anemia, infection, or poor nutrition.
Choice C: This is incorrect because dysuria is not the highest priority finding for the nurse to report to the provider. Dysuria can indicate a urinary tract infection, which can be treated with antibiotics and fluids.
Choice D: This is correct because elevated temperature is the highest priority finding for the nurse to report to the provider. Elevated temperature can indicate a serious infection, which can be life-threatening for a client who has leukemia and a compromised immune system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: This is incorrect because sore throat is not a finding that the nurse should report to the provider. Sore throat is a common and expected complication of bronchoscopy due to irritation from the endoscope. The nurse should provide oral care and offer ice chips or lozenges to soothe the throat.
Choice B: This is incorrect because blood pressure 110/78 mm Hg is not a finding that the nurse should report to the provider. Blood pressure 110/78 mm Hg is within the normal range and does not indicate any adverse effects from bronchoscopy. The nurse should monitor the vital signs and oxygen saturation of the client.
Choice C: This is correct because facial edema is a finding that the nurse should report to the provider. Facial edema can indicate an allergic reaction, airway obstruction, or mediastinal emphysema, which are serious and potentially life-threatening complications of bronchoscopy. The nurse should assess the airway, breathing, and circulation of the client and administer oxygen and medications as prescribed.
Choice D: This is incorrect because presence of gag reflex is not a finding that the nurse should report to the provider. Presence of gag reflex is an expected outcome of bronchoscopy, indicating that the anesthesia has worn off and the client can resume oral intake. The nurse should check the gag reflex before offering any food or fluids to the client.
Correct Answer is C
Explanation
Choice a is not correct because providing an alcohol-based mouthwash is an action that the nurse should avoid when caring for a client who has stomatitis. Alcohol can dry and irritate the oral mucosa and worsen the condition.
Choice b is not correct because minimizing the use of gravies and sauces is not an action that the nurse should take to help manage stomatitis. Gravies and sauces can help moisten dry foods and make them easier to swallow for a client who has stomatitis.
Choice d is not correct because discouraging drinking with a straw is not an action that the nurse should take to help manage stomatitis. Drinking with a straw can help prevent contact between fluids and sore areas of the mouth and reduce pain for a client who has stomatitis.
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