The nurse is teaching a patient about taking immunosuppressant medications after an allogeneic stem cell transplant to treat leukemia.
What will the nurse teach is the indication for this treatment?
Prevent graft versus host disease.
Prevent graft rejection.
Prevent hospital acquired infections.
Prevent a relapse of the leukemia.
The Correct Answer is A
Choice A rationale
Prevent graft versus host disease (GVHD) is a common complication following an allogeneic stem cell transplant. Immunosuppressant medications are given to prevent the donor immune cells from attacking the recipient's body tissues, which is GVHD. This prevention is crucial for the success of the transplant and the patient's overall recovery.
Choice B rationale
Prevent graft rejection is more commonly associated with solid organ transplants like kidney or liver transplants. In the context of stem cell transplants, preventing GVHD is the primary concern rather than preventing graft rejection.
Choice C rationale
Preventing hospital-acquired infections is important for all patients, especially those with compromised immune systems. However, this is not the primary indication for immunosuppressant medications following an allogeneic stem cell transplant. Other measures, such as infection control protocols, are more directly related to this.
Choice D rationale
Preventing a relapse of leukemia is a key goal of the overall treatment plan for leukemia patients. However, immunosuppressant medications do not directly prevent a relapse; instead, they help manage complications like GVHD that can arise from the transplant process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Pain from mucositis and oral tissue injury is a significant concern for patients undergoing chemotherapy. However, it is not typically life-threatening and can be managed with appropriate pain relief measures and oral care.
Choice B rationale
Weakness and fatigue with activity are common side effects of chemotherapy and the disease process itself. While these symptoms impact the patient's quality of life, they do not usually require urgent intervention.
Choice C rationale
Blood pressure of 90/64 mmHg, pulse of 102 beats per minute, and oral temperature of 38.5 degrees Celsius suggest possible sepsis or severe infection. These vital signs indicate an urgent need for intervention to prevent further deterioration and potentially life-threatening complications.
Choice D rationale
Scattered ecchymosis and petechiae are signs of thrombocytopenia (low platelet count), which is a common complication of leukemia and its treatment. While important to monitor and manage, these findings are not typically as urgent as signs of sepsis or severe infection.
Correct Answer is B
Explanation
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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