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","B","D"]
Explanation
A) Correct - Clear beef broth is appropriate for a postoperative full-liquid diet, as it is a clear liquid and meets the dietary restrictions.
B) Correct - Vegetable juice can be included in a postoperative full liquid diet, as long as it is free of solid particles.
C) Incorrect - Canned fruit cocktails may contain solid pieces of fruit, which are not suitable for a full-liquid diet.
D) Correct - Vanilla frozen yogurt is a suitable option for a postoperative full-liquid diet, as it is in a liquid state when consumed.
E) Incorrect - Creamy peanut butter is not appropriate for a full-liquid diet, as it is a solid food and does not meet the diet's requirements.
Correct Answer is C
Explanation
- A radial pulse is the pulse felt at the wrist, where the radial artery runs along the thumb side of the forearm. It is one of the most common sites for measuring a person's heart rate.
- To measure a radial pulse, the examiner should place two or three fingers over the radial artery, just below the wrist crease, and apply gentle pressure until a pulsation is felt. The examiner should not use the thumb, as it has its own pulse and may interfere with the accuracy of the measurement. The examiner should count the number of beats for 15, 30, or 60 seconds, depending on the regularity and rate of the pulse.
- In the picture, the unlicensed assistive personnel (UAP) is using the thumb to measure the radial pulse, which is incorrect. The practical nurse (PN) should demonstrate the correct pulse site to the UAP and explain why using the thumb is not appropriate. This will help to ensure that the UAP obtains an accurate and reliable pulse rate for the client.
Therefore, option C is the correct answer, while options A, B, and D are incorrect.
Option A is incorrect because instructing the UAP to report any abnormal findings does not address the error in technique.
Option B is incorrect because reminding the UAP to check the pulse volume does not address the error in technique.
Option D is incorrect because confirming the accuracy of the pulse rate obtained by the UAP does not address the error in the technique.
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