The nurse is caring for a client receiving chemotherapy for acute leukemia. The client reports chills and weakness.
Assessment findings include a temperature of 101 F (38.3 C), heart rate 142 beats per minute, blood pressure 80/40 mm Hg, respiratory rate 32 breaths per minute, and O2 saturation 94 Which interpretation by the nurse is most accurate?
The client is demonstrating neutropenic sepsis with septic shock.
The client is experiencing tumor lysis syndrome.
The client is showing expected chemotherapy-related fatigue.
The client is developing superior vena cava syndrome.
The Correct Answer is A
Identifying life-threatening complications in immunocompromised patients is critical. Knowledge of the systemic inflammatory response syndrome and hemodynamic instability in neutropenic patients must be applied to differentiate between oncological emergencies like sepsis, tumor lysis syndrome, and superior vena cava obstruction.
Choice A rationale
Sepsis in neutropenic patients often leads to septic shock, characterized by hypotension (80/40 mm Hg) and tachycardia (142/min). The high fever and rapid breathing indicate a systemic response to infection and inadequate tissue perfusion.
Choice B rationale
Tumor lysis syndrome results from rapid cell destruction, causing hyperkalemia, hyperuricemia, and renal failure. While it is an oncological emergency, it does not typically present with the acute hemodynamic collapse and profound hypotension seen in this scenario.
Choice C rationale
While chemotherapy induces fatigue, it does not cause severe hypotension, high fever, or extreme tachycardia. These findings represent a critical physiological crisis rather than the expected side effects of exhaustion or malaise during oncological treatment.
Choice D rationale
Superior vena cava syndrome involves obstruction of blood flow from the upper body, causing facial edema, neck vein distention, and dyspnea. It does not primarily present with acute fever, sepsis symptoms, or profound hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
Step 1 is 1 mg ÷ (0.1 mg ÷ 1 mL).
Step 2 is 1 mg ÷ 0.1 mg/mL = 10 mL. Final answer is 10 mL..
Correct Answer is A
Explanation
Discharge teaching for post-radiation brain tumor patients requires understanding oncology and pharmacology. Knowledge of medication adherence, symptom monitoring for increased intracranial pressure, and integumentary protection is needed. Identifying misconceptions ensures patient safety and prevents potential neurological relapse or secondary injury.
Choice A rationale
Abrupt cessation of medications, especially anticonvulsants or steroids used in neuro-oncology, can trigger rebound edema or seizures. Maintaining therapeutic blood levels is critical for managing potential complications after radiation therapy has concluded to ensure neurological stability.
Choice B rationale
Headaches and visual disturbances are primary indicators of increased intracranial pressure or tumor recurrence. Patients must recognize these signs as urgent neurological changes that require immediate medical evaluation to prevent brain herniation or permanent functional loss.
Choice C rationale
Radiation therapy damages the DNA of skin cells, leading to thinning and increased sensitivity. Protecting the scalp from ultraviolet radiation prevents severe dermatitis and secondary burns on tissue that already has compromised healing capabilities.
Choice D rationale
Gradual reintegration into daily life is standard post-treatment advice. While energy levels dictate activity, resuming normal routines as tolerated is appropriate, provided the patient avoids hazardous activities if they have residual neurological deficits or seizure risks.
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