A client with acute myelogenous leukemia is receiving induction phase chemotherapy. Which assessment information is of most concern?

Correct Answer: A

Rationale: In the context of a client with acute myelogenous leukemia undergoing induction chemotherapy, the most concerning assessment information is a serum potassium level of 7.8 mEq/L (Option A). Chemotherapy, especially in the induction phase, can lead to tumor lysis syndrome, causing a rapid release of intracellular contents into the bloodstream, including potassium. Hyperkalemia can lead to serious cardiac arrhythmias and must be addressed promptly. Option B, urine output less than intake by 400 mL, may indicate renal dysfunction, but hyperkalemia poses a more immediate threat to the client's life. Option C, inflammation and redness of oral mucosa, and Option D, ecchymoses present on the anterior trunk, are common manifestations of leukemia and its treatment but do not pose immediate life-threatening risks compared to severe hyperkalemia. Educationally, this question highlights the importance of prioritizing assessments in clients undergoing chemotherapy, specifically focusing on identifying potentially life-threatening complications. Understanding the significance of laboratory values and their implications for client care is crucial in providing safe and effective nursing interventions in oncology settings.

Correct Answer: C

Rationale: In hematology, understanding the different blood cells and their significance is crucial for diagnosing various conditions. In this question, the correct answer is C) Reticulocyte. Reticulocytes are immature red blood cells that are released by the bone marrow into the bloodstream. An increase in reticulocyte count indicates an increased rate of erythropoiesis, which is the process of red blood cell production. This can occur in response to conditions such as anemia or blood loss, where the body needs to produce more red blood cells to maintain oxygen-carrying capacity. Now, let's analyze why the other options are incorrect: A) Basophil: Basophils are a type of white blood cell involved in allergic reactions and parasitic infections. They are not directly related to erythropoiesis. B) Monocyte: Monocytes are another type of white blood cell that plays a role in immune response and inflammation. They are not involved in red blood cell production. D) Lymphocyte: Lymphocytes are a type of white blood cell critical for immune function. They are not associated with erythropoiesis. Understanding the correlation between different blood cells and their functions is essential for healthcare professionals, especially in hematology and oncology settings where blood disorders are commonly encountered. By knowing which blood cell indicates increased erythropoiesis, clinicians can better interpret blood test results and make informed clinical decisions for their patients.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Lymphedema. Lymphedema is the swelling that occurs due to the accumulation of lymph fluid in the tissues when the lymphatic system is impaired or damaged. In the case of a woman who has undergone a right breast mastectomy, lymph nodes may have been removed or damaged during surgery, leading to impaired lymphatic drainage and resulting in swelling in the affected arm, known as lymphedema. Option B) Right-sided heart failure is incorrect as it does not typically present with isolated severe swelling in the right arm. Option C) Wound on her right hand is irrelevant to the situation described. Option D) Refusal to use her right arm would not cause severe swelling but rather disuse atrophy or weakness. Educationally, understanding the potential complications of breast surgery, such as lymphedema, is crucial for healthcare providers involved in the care of these patients. Recognizing the signs and symptoms of lymphedema allows for early intervention and management to improve the patient's quality of life and prevent further complications. This case underscores the importance of post-operative monitoring and patient education regarding lymphedema prevention strategies.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Bleeding. When laboratory test results show increased fibrin split products (FSPs), it indicates that there is an increased breakdown of fibrin clots in the body. This breakdown can lead to a state of hypercoagulability, where the blood is more prone to clotting. Monitoring the patient for signs of bleeding is crucial because although paradoxical, an increased risk of bleeding can occur due to the consumption of clotting factors in the process of fibrinolysis. This can manifest as abnormal bleeding from various sites. Option A) Fever is not directly related to increased FSPs and would not be the most appropriate nursing action in this context. Option C) Faintness is also not directly related to the breakdown of fibrin clots and is not a typical manifestation of increased FSPs. Option D) Thrombotic episodes might seem plausible due to the hypercoagulable state, but the primary concern in this scenario is monitoring for bleeding complications. Educationally, understanding the implications of abnormal laboratory results like increased FSPs is crucial for nurses caring for patients with hematologic or oncologic conditions. Recognizing the significance of these results and knowing the appropriate nursing actions can help prevent serious complications and improve patient outcomes.

Correct Answer: A

Rationale: In the assessment of a patient with anemia, it is crucial for the nurse to ask about a history of stomach surgery (Option A) as the correct answer. Stomach surgery can lead to malabsorption of essential nutrients like iron, which can contribute to the development of anemia. By inquiring about stomach surgery, the nurse can gather important information regarding the potential cause of the patient's anemia and tailor the treatment plan accordingly. Recurring infections (Option B) are more indicative of a compromised immune system rather than a direct cause of anemia. While infections can contribute to anemia in some cases, it is not the most specific information to gather during the assessment of anemia. Corticosteroid therapy (Option C) is more relevant when assessing conditions like autoimmune disorders or inflammatory diseases. While corticosteroids can affect blood cell production, they are not typically a primary consideration when evaluating anemia unless the patient has been on long-term therapy. Oral contraceptive use (Option D) is not directly associated with the development of anemia unless it has led to underlying conditions such as gastrointestinal bleeding or hormonal imbalances. While it is important to gather a comprehensive medication history, oral contraceptives are not a common cause of anemia unless in specific circumstances. In an educational context, understanding the rationale behind each potential question is essential for nurses to develop critical thinking skills in patient assessment. By exploring different aspects of a patient's history, nurses can better identify potential causes of anemia and provide holistic care tailored to the individual patient's needs.