The nurse is caring for a patient with acute leukemia who has been in the hospital for treatment for three weeks.
The patient states, "I am so tired, I feel too exhausted and breathe fast when I try to get out of bed and do anything.” What is the best intervention for the nurse to implement for this patient?

Refer the patient to the psychiatrist for anti-depressant medications.

Provide portable oxygen therapy via nasal cannula during physical activity.

Instruct the patient to increase their oral iron supplement dose until fatigue subsides.

Encourage the patient to perform light exercises daily.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Referring the patient to a psychiatrist for anti-depressant medications may not address the immediate issue of fatigue and breathlessness related to acute leukemia. While psychological support is important, the primary focus should be on managing the patient's physical symptoms and improving oxygenation during activities.

Choice B rationale

Providing portable oxygen therapy via nasal cannula during physical activity is the best intervention for this patient. Oxygen therapy can help alleviate the patient's symptoms of breathlessness and fatigue by ensuring adequate oxygen levels during physical exertion. This intervention allows the patient to engage in activities with less discomfort and prevents further complications related to hypoxia.

Choice C rationale

Instructing the patient to increase their oral iron supplement dose until fatigue subsides is not appropriate without medical supervision. Iron supplementation should be based on the patient's iron levels and hematologic status. Over-supplementation can lead to adverse effects and may not address the underlying cause of fatigue in patients with acute leukemia.

Choice D rationale

Encouraging the patient to perform light exercises daily can be beneficial for overall health, but it may not be practical for someone experiencing severe fatigue and breathlessness. The patient's immediate need for oxygen support during activities takes precedence, and physical activity should be tailored to their current capabilities and medical condition. .

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Free Nursing Study Resources

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

Explanation

Choice A rationale

Administering filgrastim (G-CSF) as ordered is crucial for patients with a low ANC. Filgrastim stimulates the production of neutrophils in the bone marrow, helping to reduce the risk of infections. For a patient with an ANC of 500/mm³, which indicates severe neutropenia, this intervention can significantly enhance the immune response and decrease susceptibility to infections.

Choice B rationale

Keeping the patient's central line insertion site clean and open to air is incorrect and could increase the risk of infection. Central line sites must be covered with a sterile dressing to prevent bacterial contamination and infection. Open exposure to air can introduce pathogens, especially in a patient with neutropenia.

Choice C rationale

Educating the patient and family about food safety and hygiene is essential for preventing infections in patients with neutropenia. Proper food handling and hygiene practices reduce the risk of bacterial and other infections. This education can help patients and their families implement measures to protect the patient from potential sources of infection.

Choice D rationale

Providing a high-protein, high-calorie diet is appropriate for supporting the patient's overall health and recovery. High-protein and high-calorie foods support the body's immune function, repair tissues, and maintain energy levels. Proper nutrition is vital for patients with leukemia to help them cope with the demands of their illness and treatment.

A. Thyroid storm and elevated triiodothyronine. B. Homans sign and deep vein thrombosis. C. Trousseau sign and overt tetany. D. Chvostek sign and hypocalcemia.

Correct Answer is C

Explanation

Choice A rationale

Thyroid storm is a severe complication of hyperthyroidism and is characterized by high fever, tachycardia, and altered mental state, not carpopedal spasm.

Choice B rationale

Homans sign is an indicator of deep vein thrombosis (DVT) and is not related to carpopedal spasms observed here.

Choice C rationale

Trousseau sign is a clinical sign of latent tetany seen in patients with hypocalcemia, characterized by carpopedal spasm when blood flow is occluded.

Choice D rationale

Chvostek sign is another sign of hypocalcemia, but it is indicated by facial muscle contraction when tapping the facial nerve, not carpopedal spasm.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with leukemia who has an absolute neutrophil count (ANC) of 500/mm³. What interventions will the nurse include in the plan of care for this patient related to this finding? Select All That Apply.

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

Explanation

The nurse is caring for a patient who is admitted to a surgical unit after a thyroidectomy.The nurse takes and maintains the inflated blood pressure cuff on the patient and observes a carpopedal spasm.What does this result indicate to the nurse?

Correct Answer is C

Explanation

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