The nurse is caring for a client diagnosed with leukemia who has just completed a course of radiation therapy and chemotherapy in preparation for a bone marrow transplant. The nurse notices that the client is febrile, has foul smelling urine, and is complaining of urinary frequency and dysuria. What is the priority nursing action?

Request medical prescription for an antibiotic such as gentamicin

Obtain a full set of vital signs and have the client void in a specimen cup

Increase intake of oral fluids such as cranberry juice

Place the client in protective isolation

Answer and Explanation

The Correct Answer is B

A.   While antibiotics may be necessary if a UTI is confirmed, requesting a prescription would not be the immediate nursing action. The nurse must first assess the situation thoroughly and obtain necessary diagnostic information before medications can be prescribed.
B.   This option is the most appropriate immediate action. Obtaining a full set of vital signs helps assess
the client’s overall condition, including the degree of fever and any signs of systemic infection. Collecting

a urine specimen will facilitate further evaluation, such as a urinalysis and culture, to confirm a UTI and identify the appropriate antibiotic treatment.
C.   While increasing fluid intake can help with urinary tract health and dilute the urine, it is not an immediate priority in this situation. The client may need more urgent assessment and possible medical intervention rather than just dietary changes.
D.   Although protective isolation may be warranted given the client’s immunocompromised state due to chemotherapy and radiation, it is not the immediate priority based on the current symptoms. The focus should first be on assessing and addressing the potential UTI.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. This response is relevant and helps assess the characteristics of the lump. Pain can be an important factor in differentiating between conditions, such as epididymitis, testicular torsion, or tumors. However, while it is a useful question, it may not provide a comprehensive assessment of the situation.
B. This question can be relevant depending on the underlying cause of the lump. Issues with urination may suggest a problem related to the prostate or bladder rather than the testicle itself. While it can help assess urinary tract involvement, it may not directly address the significance of the lump in the testicle.
C. This question is important in the context of sexually transmitted infections (STIs), which can cause scrotal swelling or lumps due to conditions like epididymitis or orchitis. However, it does not directly assess the lump itself, making it less focused on the immediate concern.
D. This question addresses the possibility of an STI and related conditions. While it is relevant, it is not the best immediate question concerning the lump in the testicle. The presence of discharge may not directly correlate with the testicular lump itself.

A. A right sided calcaneal spur B. A blood pressure of 222/112 mmHg C. Glycosylated hemoglobin of 5.9% D. Recent endoscopy

Correct Answer is B

Explanation

A. A calcaneal spur, or heel spur, is a bony growth on the heel bone. This condition is primarily related to foot pain and does not have a direct link to the risk of stroke. It is not relevant in assessing stroke risk.
B. This elevated blood pressure reading indicates hypertension, which is a significant risk factor for both ischemic and hemorrhagic strokes. Chronic high blood pressure can lead to damage of the blood vessels, making them more susceptible to rupture, thus increasing the risk of a hemorrhagic stroke.
C. A glycosylated hemoglobin (HbA1c) level of 5.9% indicates well-managed diabetes, typically within the normal range for most individuals. While uncontrolled diabetes is a risk factor for vascular disease, this level suggests adequate control and does not specifically indicate an increased risk for a hemorrhagic stroke.
D. A recent endoscopy itself does not indicate a direct risk for a hemorrhagic stroke. However, if the endoscopy was performed due to gastrointestinal bleeding or if it resulted in complications, there could be indirect implications, but this option alone does not signify an increased risk for hemorrhagic stroke.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a male patient who complains about a small "lump" that he discovered in his right testicle. What would be the best response by the nurse?

Correct Answer is A

Explanation

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?

Correct Answer is B

Explanation

The client has developed graft versus host disease (GVHD) during treatment for acute lymphoblastic leukemia (ALL). The client has a generalized pruritic rash on the trunk and the extremities. What nursing measures should the nurse use to address this problem?

The nurse is caring for a client who had a thrombotic stroke in the Emergency Department. It has been less than 3 hours since the onset of symptoms. The rationale for using tissue plasminogen activator (t-PA) for this client is to:

The nurse is caring for the client who has dysphagia following an ischemic stroke. The client is ordered a pureed diet starting today. Which intervention would be appropriate for this client?

Match the type of bone marrow transplant to the appropriate donor. The nurse is caring for a client who was diagnosed with Acute Myelogenous Leukemia (AML). The client is in need of a bone marrow transplant. Match the type of bone marrow transplant to the appropriate donor:

The nurse is planning care for client who is recovering from a total abdominal hysterectomy for uterine cancer. The nurse would include which intervention to decrease the risk of an embolic event?

A 78-year-old client is admitted to the Emergency Department (ED) with numbness and weakness of the right arm and slurred speech. Which nursing intervention is a priority?

Which initial assessment finding(s) would the nurse expect in a client diagnosed with acute lymphocytic leukemia (ALL)?

A client diagnosed with a stroke is experiencing homonymous hemianopia. The most appropriate nursing intervention to help the client learn to compensate for this deficit during rehabilitation period would be to: