A nursing student is caring for a patient with acute myeloid leukemia who is preparing to undergo induction therapy. In preparing a plan of care for this patient, the student should assign the highest priority to which nursing diagnoses?

Correct Answer: B

Rationale: The correct answer is B: Risk for Infection. During induction therapy for acute myeloid leukemia, the patient's immune system is compromised, increasing the risk of infections. Priority is given to preventing infections to avoid complications. Activity Intolerance (A) may be a concern but is secondary to infection risk. Acute Confusion (C) may occur but is not as critical as preventing infections. Risk for Spiritual Distress (D) is important but addressing physical needs like infection prevention takes precedence for this patient population.

Correct Answer: A

Rationale: The correct answer is A: Protective isolation and vigilant use of standard precautions. This is the priority because patients with AML undergoing induction therapy are immunocompromised and at high risk for infection. Isolating the patient and using standard precautions help prevent exposure to pathogens. B: Providing a high-calorie, low-texture diet and oral hygiene is important but not the priority as infection control takes precedence. C: Including the family in planning activities of daily living is beneficial for holistic care but not the priority compared to infection prevention. D: Monitoring and treating pain is essential, but in this case, infection prevention is the priority due to the patient's immunocompromised state.

Correct Answer: B

Rationale: The correct answer is B because assisting the patient to a chair during awake times allows for gradual physical activity, promoting mobility without overwhelming the patient. This option supports the patient's need for movement while considering their current level of fatigue. A is incorrect because educating the patient about the benefits of exercise may not be feasible or appropriate given the patient's current fatigue levels. C is incorrect as stair exercises may be too strenuous for a patient experiencing debilitating fatigue, potentially leading to further exhaustion and risk of injury. D is incorrect because deep breathing and coughing exercises primarily focus on respiratory health and may not directly address the patient's need for physical activity to combat fatigue.

Correct Answer: A

Rationale: The correct answer is A: Clarify the prescription with the provider. Desmopressin is a medication that can cause hyponatremia, especially in patients with low sodium levels like this client. Before administering desmopressin, the nurse should consult with the provider to ensure it is safe to administer the medication given the client's sodium level. Administering the drug without clarifying may worsen the hyponatremia. Choice B is incorrect because administering the drug with an analgesic is not necessary or relevant in this situation. Choice C is incorrect because desmopressin is typically administered via injection, not orally. Choice D is incorrect because assessing factor IX levels is not directly related to the administration of desmopressin in this scenario.

Correct Answer: D

Rationale: The correct answer is D: Thrombocytopenia. Clopidogrel is an antiplatelet medication that works by inhibiting platelet aggregation. Therefore, monitoring for thrombocytopenia, a decrease in platelet count, is crucial to assess the drug's effectiveness and potential side effects. Hyperuricemia (A) is not directly associated with clopidogrel use. Hyponatremia (B) is not a common adverse reaction of clopidogrel. Lymphocytopenia (C) is not typically linked to clopidogrel and is more commonly seen with other medications or conditions.