An elderly client develops severe bone marrow depression from chemotheraphy for cancer of the prostate. The nurse should;

Correct Answer: A

Rationale: Monitoring intake and output of fluids is essential for an elderly client who develops severe bone marrow depression from chemotherapy for prostate cancer. Bone marrow depression can result in decreased production of blood cells, including red blood cells, white blood cells, and platelets. Monitoring intake and output of fluids helps assess hydration status and kidney function. Decreased fluid intake or output may indicate kidney damage or dehydration, which are common concerns in clients with bone marrow depression. Therefore, it is crucial for the nurse to monitor the client's fluid balance closely to ensure optimal functioning of the kidneys and prevent complications related to bone marrow suppression.

Correct Answer: D

Rationale: The sudden onset of fever early in a blood transfusion can indicate a transfusion reaction, such as a febrile non-hemolytic reaction or a hemolytic reaction. The nurse's first action in this situation should be to stop the transfusion immediately to prevent further complications. Continuing to administer the blood product could worsen the reaction and harm the client. Once the transfusion is stopped, the nurse can then assess the client's condition, provide appropriate interventions, and notify the healthcare provider as needed.

Correct Answer: B

Rationale: The nurse's best response is, "The medication blocks reverse transcriptase, the enzyme required for HIV replication." This response provides the client with a clear and accurate explanation of how zidovudine (AZT) works. AZT is a nucleoside reverse transcriptase inhibitor (NRTI) that works by blocking the activity of reverse transcriptase, an enzyme needed for HIV replication. By inhibiting this enzyme, AZT helps to slow down the replication of the virus, reducing the viral load in the body and slowing the progression of the disease. It is important for the client to understand that while AZT can help manage HIV/AIDS, it is not a cure and will not completely eliminate the infection.

Correct Answer: B

Rationale: Clients with multiple myeloma are at increased risk for pathologic bone fractures due to the disease's effects on bone tissue. Multiple myeloma is a cancer of plasma cells, a type of white blood cell found in the bone marrow. The growth of abnormal plasma cells weakens the bone structure, leading to bone lesions and an increased risk of fractures. The bone lesions can cause pain, bone deformities, and complications such as hypercalcemia. Therefore, nurses caring for clients with multiple myeloma should prioritize interventions to prevent pathologic bone fractures and manage bone health.

Correct Answer: C

Rationale: Administering metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed should be the highest priority intervention for a client experiencing nausea and vomiting after cancer chemotherapy. Metoclopramide is a commonly used antiemetic medication that helps to reduce nausea and vomiting by enhancing gastric emptying and decreasing nausea. Dexamethasone, a corticosteroid, can also help alleviate inflammation that may contribute to the nausea and vomiting. By administering these medications as prescribed, the nurse can effectively address the client's symptoms and improve their comfort level. The other options, such as serving small portions bland food, encouraging rhythmic breathing exercises, and withholding fluids, are important interventions but should not take precedence over providing the prescribed antiemetic medications to manage the client's post-chemotherapy symptoms.