Which of the following nursing diagnoses (nursing problem) would be of highest priority for the patient hospitalized for a bone marrow transplant to treat relapse of acute myelocytic leukemia?
Disturbed body image
Anxiety
Ineffective protection
Imbalanced nutrition: less than body requirements
The Correct Answer is C
Choice A reason: While disturbed body image is a concern, it is not the highest priority for a patient undergoing a bone marrow transplant.
Choice B reason: Anxiety is important to address but does not take precedence over physical health concerns in the immediate post-transplant period.
Choice C reason: Ineffective protection is the highest priority because patients undergoing bone marrow transplants have compromised immune systems and are at high risk for infection.
Choice D reason: Imbalanced nutrition is a concern but is secondary to the risk of infection in the immediate care of a patient post bone marrow transplant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Placing suction equipment at the bedside is a preparatory measure but not a preventive intervention for pulmonary complications.
Choice B reason: Performing ROM exercises is beneficial for overall mobility but does not directly prevent pulmonary complications.
Choice C reason: Administering an expectorant may help clear secretions but is not the primary preventive measure for pulmonary complications.
Choice D reason: Encouraging the use of incentive spirometry is a proven intervention to prevent pulmonary complications by promoting lung expansion and preventing atelectasis, especially in patients with a history of smoking.
Correct Answer is C
Explanation
Choice A reason: Respiratory Acidosis is characterized by a low pH and a high PCO2, which is not the case here.
Choice B reason: Respiratory Alkalosis would involve a high pH and a low PCO2, which is not consistent with the patient's PCO2 level.
Choice C reason: Metabolic Alkalosis is indicated by a high pH and a high HCO3, which matches the patient's blood gas values.
Choice D reason: Metabolic Acidosis would show a low pH and a low HCO3, which is the opposite of this patient's presentation.
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