A nurse is planning care for a client who is to undergo a stem cell transplant.
Which of the following actions should the nurse plan to take?
Provide the client with 1,000 mL of water to drink every 12 hr.
Keep blood pressure equipment in the client's room.
Place the client in a negative airflow room.
Monitor the client's vital signs once every 8 hr.
The Correct Answer is B
Choice A rationale
Providing 1,000 mL of water every 12 hours is not directly related to preventing infection or other complications post-transplant.
Choice B rationale
Keeping blood pressure equipment in the client's room helps prevent cross-contamination and infection by not sharing equipment with other clients.
Choice C rationale
A negative airflow room is used for clients with airborne infections, not for those undergoing a stem cell transplant.
Choice D rationale
Monitoring vital signs every 8 hours is insufficient; more frequent monitoring is needed post-transplant to detect complications early.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Metabolic acidosis can occur in renal failure but is not directly linked to tumor lysis syndrome.
Choice B rationale
Elevated white blood cell count is not a primary contributor to renal failure in tumor lysis syndrome.
Choice C rationale
Crystallization of uric acid in the renal tubules can obstruct urine flow and cause acute renal failure, which is a direct pathophysiologic event in tumor lysis syndrome.
Choice D rationale
Hypocalcemia is a consequence of tumor lysis syndrome but does not directly cause renal failure.
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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