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: An INR of 0.9 is within the normal range (0.8-1.2) and does not support the presence of bruising or bleeding disorders.
Choice B reason: A hematocrit level of 28% is below the normal range (36%-50% for women, 40%-54% for men), indicating anemia, but it does not directly explain bruising or petechiae.
Choice C reason: A WBC count of 4500 is within the normal range (4500-11000), suggesting that there is no active infection or leukocytosis that would explain the bruising.
Choice D reason: A platelet count of 60000 is below the normal range (150000-450000), which can lead to easy bruising and petechiae, supporting the nurse's observation.
Correct Answer is C
Explanation
Choice A reason: The recovery position is not typically recommended for patients with acute pulmonary edema as it does not facilitate optimal breathing.
Choice B reason: The prone position is not generally recommended for acute pulmonary edema as it may not aid in improving oxygenation or breathing.
Choice C reason: The sitting up position, especially at an angle of 45 degrees or greater, is recommended for patients with acute pulmonary edema as it helps to facilitate breathing and decrease venous return to the heart.
Choice D reason: The Trendelenburg position is not recommended for acute pulmonary edema as it can increase the pressure in the chest and worsen breathing difficulties.
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