The practical nurse (PN) is caring for an older client who is receiving chemotherapy for lung cancer. Which finding is the highest priority for the PN to report to the charge nurse?
Reference ranges:
- Blood urea nitrogen (BUN): [Adult: 10 to 20 mg/dL or 3.6 to 7.1 mmol/L]
- Platelets: [150,000 to 400,000/mm3 or 150 to 400 x 10^9/L]
Periodic nausea and vomiting
Decreased deep tendon reflexes
Platelet count 135,000/mm3 or 135 x 10^9/L
Blood urea nitrogen 75 mg/dL or 12.9 mmol/L
The Correct Answer is D
A high blood urea nitrogen (BUN) level indicates impaired renal function, which can be caused by dehydration, infection, or nephrotoxic drugs. Chemotherapy can damage the kidneys and increase the risk of renal failure. The PN should report this finding to the charge nurse, as it may require fluid replacement, dose adjustment, or discontinuation of the chemotherapy.
The other options are not correct because:
- Periodic nausea and vomiting are common side effects of chemotherapy that can be managed with antiemetics, hydration, and dietary modifications. They are not as urgent as a high BUN level.
- Decreased deep tendon reflexes may indicate hypocalcemia, hypomagnesemia, or peripheral neuropathy, which can be caused by chemotherapy or other factors. They are not as urgent as a high BUN level.
- A platelet count of 135,000/mm3 or 135 x 10^9/L is slightly below the normal range, but not significantly low. Chemotherapy can cause thrombocytopenia, which increases the risk of bleeding. The PN should monitor the client for signs of bleeding, but this finding is not as urgent as a high BUN level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct- Electrolyte imbalances, particularly involving electrolytes like potassium, can lead to cardiac arrhythmias. Elevated blood pressure can strain the cardiovascular system, and mental status changes could indicate potential neurologic and cardiovascular involvement. Auscultating for an irregular heart rate helps identify any immediate cardiac issues that require intervention.
B) Incorrect- While monitoring sodium intake is important for clients with chronic kidney disease, it is not the most urgent action in this scenario. The presence of electrolyte imbalance, elevated blood pressure, and changes in mental status indicate a more acute concern that requires immediate assessment.
C) Incorrect- Documenting abdominal girth is relevant for assessing fluid status, but in this situation, the presence of electrolyte imbalance, elevated blood pressure, and mental status changes indicates a more critical issue that requires prompt intervention.
Correct Answer is C
Explanation
Croup is a respiratory infection that causes inflammation and narrowing of the airway, resulting in a barking cough, hoarseness, and stridor. The PN should monitor the child's oxygen saturation level via pulse oximetry, as it can indicate the severity of the airway obstruction and the need for supplemental oxygen or other interventions.
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