Which intervention is most important for the nurse to implement to prevent complications from tumor lysis syndrome during chemotherapy?

Applies pressure to all injection sites for 5 minutes

Monitors telemetry every hour during therapy

Ensures the client has a fluid intake of 3000 to 5000 mL/day

Assists the client in all ambulatory activities

Answer and Explanation

The Correct Answer is C

A. Applying pressure to injection sites helps reduce bleeding but does not directly prevent tumor lysis syndrome.
B. Monitoring telemetry is important for patients with potential cardiac issues but is not specifically related to preventing complications from tumor lysis syndrome.
C. Ensuring a high fluid intake of 3000 to 5000 mL/day helps dilute electrolytes and reduce the risk of acute kidney injury and other complications associated with tumor lysis syndrome, making this the most crucial intervention.
D. Assisting the client in ambulatory activities may support their overall well-being but does not address the prevention of tumor lysis syndrome.

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Correct Answer is B

Explanation

A. While a diet of soft foods and liquid protein may be beneficial for a client undergoing chemotherapy, it is not the most critical intervention related to thrombocytopenia. Nutritional needs can be managed but do not address the immediate risk of bleeding or injury.
B. Teaching safety in the home to reduce injury and falls is the most important intervention. Clients with thrombocytopenia have a significantly increased risk of bleeding and bruising, making it essential to prevent falls and injuries that could lead to serious complications.
C. Spacing activities throughout the day can help manage fatigue, but it is not as urgent as ensuring the client is safe from injuries related to low platelet counts.
D. Frequent hand hygiene is important to prevent infections, especially in immunocompromised patients, but it does not directly address the primary concern of preventing injuries related to thrombocytopenia.

A. Measure abdominal girth. B. Continue to monitor the drainage. C. Notify the physician. D. Irrigate the nasogastric tube.

Correct Answer is B

Explanation

A. Measuring abdominal girth may be relevant for assessing potential complications like abdominal distention, but it is not the immediate priority in response to serosanguinous drainage from the nasogastric tube.
B. Continuing to monitor the drainage is appropriate, as serosanguinous fluid is common immediately after surgery and may gradually change as healing progresses. Monitoring allows for the identification of any changes that may require further intervention.
C. Notifying the physician may be necessary if the drainage increases or changes significantly, but immediate action is to observe and assess the drainage trend.
D. Irrigating the nasogastric tube is not warranted unless there is an obstruction or significant change in the drainage; it should only be done based on specific orders or protocols.

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Electrolyte	Normal Value Range
Serum sodium	135-145 mEq/L
Serum chloride	97-107 mEq/L
Serum potassium	3.5-5:3 mEq/L
Serum magnesium	1.6-2.2 mg/dL
Total serum calcium	8.2-10.2 mg/dL
lonized calcium	4.6-5.3 mg/dL
Serum phosphorus	2.5-4.5 mg/dL
Serum osmolality	275-295 mOsm/kg
Urine osmolality	250-900 mOsm/kg

Which intervention is most important for the nurse to implement to prevent complications from tumor lysis syndrome during chemotherapy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives chemotherapy with an agent that causes thrombocytopenia. Which intervention is most important to teach the client?

Correct Answer is B

Explanation

The nurse notes serosanguinous drainage from the nasogastric tube in the immediate postoperative period of a client who had a gastrectomy for gastric cancer. Which nursing action is appropriate?

Correct Answer is B

Explanation

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