The nurse on the oncology unit is caring for a patient receiving chemotherapy for treatment of leukemia.
Which patient finding is the nurse's priority for implementing interventions?

Pain 6/10 from mucositis and oral tissue injury.

Weakness and fatigue with activity.

Blood pressure 90/64 mmHg, pulse 102 beats per minute, oral temperature 38.5 degrees C.

Scattered ecchymosis and petechiae noted on arms.

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is C

Explanation

Choice A rationale

Dosimeter badges are used for monitoring radiation exposure, not for handling chemotherapy. They are worn by healthcare workers working in areas with ionizing radiation to track their cumulative exposure and ensure it stays within safe limits.

Choice B rationale

Lead aprons are also used to protect against radiation exposure, not chemotherapy. They shield the body from ionizing radiation but do not provide protection from the cytotoxic effects of chemotherapy agents.

Choice C rationale

Personal protective equipment (PPE), including gloves and gowns, is essential for safely handling chemotherapy drugs to prevent skin contact and inhalation of hazardous chemicals. This reduces the risk of exposure to these toxic agents, protecting both the nurse and the patient.

Choice D rationale

Chemotherapy waste should be disposed of in designated chemotherapy waste containers, not in standard sharps containers. These specialized containers ensure that hazardous waste is handled according to safety regulations, reducing the risk of environmental contamination and exposure.

A. "I have lost weight since taking this medication.” B. "I perspire a lot throughout the entire day.” C. "I have excess energy throughout the day.” D. "I am able to sleep and rest at night.”

Correct Answer is D

Explanation

The correct answer is Choice D.

Choice A rationale

Weight loss in a patient with hyperthyroidism typically occurs due to an increased metabolic rate. Propylthiouracil (PTU) is used to decrease thyroid hormone production. Effective treatment would stabilize metabolism and prevent further weight loss, but not necessarily result in weight gain.

Choice B rationale

Excessive sweating (perspiration) is a common symptom of hyperthyroidism due to an overactive thyroid gland. PTU aims to reduce thyroid hormone levels. Effective treatment should lead to a decrease in sweating as the metabolic rate normalizes.

Choice C rationale

Excess energy and hyperactivity are signs of untreated or inadequately treated hyperthyroidism. PTU reduces the production of thyroid hormones, and effective treatment should alleviate symptoms of excessive energy, resulting in more balanced energy levels.

Choice D rationale

Improved sleep and rest at night indicate effective management of hyperthyroidism. Reduced thyroid hormone levels from PTU help alleviate symptoms such as anxiety, restlessness, and insomnia, allowing the patient to achieve better sleep quality. .

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The nurse on the oncology unit is caring for a patient receiving chemotherapy for treatment of leukemia.Which patient finding is the nurse's priority for implementing interventions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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The nurse on the oncology unit is caring for a patient receiving chemotherapy for treatment of leukemia.
Which patient finding is the nurse's priority for implementing interventions?