The next 3 questions relate to this case study:

Exhibits

In the event of a reaction or side effect during Ms. Anderson’s chemotherapy session, select the immediate nursing interventions you would take. Select all that apply.

Notify the oncologist or healthcare provider immediately.

Slow the chemotherapy infusion.

Stop the chemotherapy infusion.

Assess Ms. Anderson’s vital signs and symptoms.

Infuse normal saline at 100 ml/hr.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A reason:

Notifying the oncologist or healthcare provider immediately is crucial in the event of a reaction or side effect during chemotherapy. Prompt communication with the healthcare provider ensures that the patient receives appropriate and timely medical intervention. The oncologist can provide specific instructions on managing the reaction, including any necessary medications or adjustments to the chemotherapy regimen. Immediate notification helps in preventing the escalation of the reaction and ensures patient safety.

Choice B reason:

Slowing the chemotherapy infusion is not typically recommended as an immediate intervention for a severe reaction. While adjusting the infusion rate can be considered for mild reactions, it is not sufficient for managing more serious side effects or hypersensitivity reactions. In cases of significant reactions, stopping the infusion and taking other emergency measures are more appropriate. Slowing the infusion might delay the necessary interventions and could potentially worsen the patient’s condition.

Choice C reason:

Stopping the chemotherapy infusion is a critical step in managing a reaction. Halting the infusion immediately prevents further exposure to the causative agent, which can help in stabilizing the patient’s condition. This action is essential to prevent the reaction from worsening and allows time for the healthcare team to assess the situation and implement appropriate interventions. Stopping the infusion is a standard protocol in managing infusion-related reactions.

Choice D reason:

Assessing Ms. Anderson’s vital signs and symptoms is essential to determine the severity of the reaction and guide further interventions. Monitoring vital signs such as heart rate, blood pressure, respiratory rate, and oxygen saturation provides crucial information about the patient’s physiological status. This assessment helps in identifying any life-threatening changes and ensures that appropriate measures are taken to stabilize the patient. Continuous monitoring is vital for detecting any deterioration in the patient’s condition.

Choice E reason:

Infusing normal saline at 100 ml/hr is an important intervention to maintain intravenous access and provide fluid support. Normal saline helps in stabilizing the patient’s blood pressure and improving circulation, which can be compromised during a severe reaction. It also ensures that the IV line remains patent for the administration of emergency medications if needed. Fluid support is a key component of managing infusion-related reactions and preventing complications.

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Correct Answer is C

Explanation

Choice A Reason:
Monitoring the CXR (chest X-ray) results is not directly related to assessing myelosuppression. A chest X-ray is typically used to evaluate the lungs and heart, and while it can help identify infections or other complications, it does not provide information about bone marrow activity or blood cell counts. Myelosuppression specifically affects the production of blood cells in the bone marrow, which is best assessed through blood tests like the CBC (Complete Blood Count).
Choice B Reason:
Monitoring the BMP (Basic Metabolic Panel), especially the sodium, potassium, and magnesium counts, is important for evaluating electrolyte balance and kidney function. However, it does not directly assess myelosuppression. Myelosuppression involves the suppression of bone marrow activity, leading to decreased production of blood cells, which is not reflected in electrolyte levels.
Choice C Reason:
Monitoring the CBC (Complete Blood Count), especially the neutrophil, platelet, and RBC (red blood cell) counts, is the most appropriate method for assessing myelosuppression. Myelosuppression results in decreased production of blood cells, including neutrophils (a type of white blood cell), platelets, and red blood cells. A CBC provides detailed information about these cell counts and helps identify conditions like neutropenia (low neutrophil count), thrombocytopenia (low platelet count), and anemia (low red blood cell count), which are common consequences of myelosuppression.
Choice D Reason:
Monitoring the spinal fluid analysis is not relevant for assessing myelosuppression. Spinal fluid analysis is typically used to diagnose conditions affecting the central nervous system, such as infections, bleeding, or multiple sclerosis. It does not provide information about bone marrow activity or blood cell counts, which are the primary concerns in myelosuppression.

A. Check the patient’s temperature daily. B. Keep the surgical dressing in place for the first three post-op days. C. Encourage and assist with early ambulation. D. Assess the need for the Foley catheter every shift. E. Teach and encourage the use of an incentive spirometer. F. Monitor laboratory values.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A reason:

Checking the patient’s temperature daily is crucial for early detection of infections. Fever is often one of the first signs of an infection, including Healthcare-Associated Infections (HAIs). Regular monitoring of temperature can help identify infections early, allowing for prompt intervention and treatment. This is particularly important for Mr. Johnson, who is at increased risk due to his recent surgery and the presence of a Foley catheter. Normal body temperature ranges from 97°F to 99°F (36.1°C to 37.2°C).

Choice B reason:

Keeping the surgical dressing in place for the first three post-op days is important for protecting the surgical site from contamination and infection. However, it is not necessarily a strategy to decrease the risk of HAIs beyond the initial postoperative period. The dressing should be changed according to the healthcare provider’s instructions to ensure the wound remains clean and dry. While this is a good practice, it is not as directly related to preventing HAIs as the other interventions.

Choice C reason:

Encouraging and assisting with early ambulation is vital for preventing postoperative complications, including HAIs. Early ambulation helps improve circulation, lung function, and gastrointestinal motility, reducing the risk of complications such as pneumonia and deep vein thrombosis (DVT). It also promotes overall recovery and reduces the length of hospital stay, which in turn decreases the risk of HAIs. Mobilizing patients early can help prevent respiratory infections and other complications associated with prolonged bed rest.

Choice D reason:

Assessing the need for the Foley catheter every shift is essential for preventing catheter-associated urinary tract infections (CAUTIs). Foley catheters are a common source of HAIs, and their use should be minimized whenever possible. Regular assessment of the necessity of the catheter can help ensure it is removed as soon as it is no longer needed, reducing the risk of infection. The CDC recommends removing catheters as soon as they are no longer necessary to prevent CAUTIs.

Choice E reason:

Teaching and encouraging the use of an incentive spirometer is an effective strategy for preventing postoperative respiratory complications, including pneumonia. Incentive spirometry encourages deep breathing and lung expansion, which helps prevent atelectasis and improves oxygenation. This is particularly important for postoperative patients who are at risk of developing respiratory infections due to immobility and the effects of anesthesia. Proper use of an incentive spirometer can significantly reduce the risk of respiratory HAIs.

Choice F reason:

Monitoring laboratory values is important for overall patient care but is not specifically targeted at preventing HAIs. Laboratory values can provide valuable information about the patient’s health status and help guide treatment decisions. However, they do not directly address the prevention of infections. While monitoring lab values is a good practice, it is not as directly related to HAI prevention as the other interventions listed.

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The next 3 questions relate to this case study: Exhibits In the event of a reaction or side effect during Ms. Anderson’s chemotherapy session, select the immediate nursing interventions you would take. Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Myelosuppression is one of the most common effects of chemotherapy. How would the nurse assess for this condition?

Correct Answer is C

Explanation

Exhibits Select 4 interventions, assessments, and patient education strategies you would use to decrease the risk of a Healthcare-Associated Infection (HAI) for Mr. Johnson.

Correct Answer is ["A","C","D","E"]

Explanation

The nurse is assigned to care for a newly admitted patient. Place the steps for using the nursing process in the correct order, starting with the first step.

Chemotherapy drugs cannot selectively distinguish between normal cells and cancer cells.

Select four principles of aseptic technique in the operating room from the list provided.

A patient with alkalosis can develop hyperkalemia.

Which three nursing interventions can be used to prevent the spread of infection?

The next 3 questions relate to this case study: Exhibits Select 4 appropriate interventions for the prevention and management of chemotherapy-induced nausea and vomiting (CINV) in Ms. Anderson.

A person with a blood pH of 7.21 is considered to have which of the following?

The OR nurse gives an SBAR to the PACU nurse. This verbal report should include which four statements?

The next 3 questions relate to this case study:

Exhibits

In the event of a reaction or side effect during Ms. Anderson’s chemotherapy session, select the immediate nursing interventions you would take. Select all that apply.