the nurse is developing a plan of care for the client with multiple myeloma and includes which priority intervention in the plan
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Nursing Elites

ATI RN

Oncology Test Bank

1. The nurse is developing a plan of care for the client with multiple myeloma and includes which priority intervention in the plan?

Correct answer: A

Rationale: The correct answer is A: Encouraging fluids. In a client with multiple myeloma, encouraging fluids is a priority intervention to prevent kidney damage from high calcium levels. Adequate hydration helps maintain renal function and prevents complications. Providing frequent oral care (Choice B) is essential for clients at risk of mucositis or oral infections, such as those undergoing chemotherapy. Coughing and deep breathing exercises (Choice C) are commonly used for clients at risk of respiratory complications, like postoperative patients. Monitoring the red blood cell count (Choice D) is important for conditions like anemia but is not the priority in a client with multiple myeloma, where fluid management is crucial.

2. During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which symptom as typical of the disease?

Correct answer: D

Rationale: Abdominal distention is a common symptom in advanced ovarian cancer due to several factors, including the accumulation of ascites (fluid in the abdominal cavity) and the presence of tumors that can increase abdominal girth. As the disease progresses, the pressure from growing masses or fluid buildup can lead to noticeable swelling and discomfort in the abdomen. This symptom often prompts further evaluation and can significantly impact the patient’s quality of life.

3. The nurse is assessing a client with leukemia who is receiving chemotherapy. Which of the following findings would be of most concern?

Correct answer: D

Rationale: The correct answer is D, 'Mouth sores.' Mouth sores (stomatitis) are a common and potentially serious side effect of chemotherapy. They can lead to difficulty eating, increased risk of infection, and overall decreased quality of life for the client. While alopecia, fatigue, and nausea/vomiting are also common side effects of chemotherapy, they are generally manageable and do not pose the same level of immediate concern as the development of mouth sores in a client undergoing chemotherapy.

4. In caring for a patient with a diagnosis of acute myeloid leukemia (AML) receiving induction therapy on the oncology unit, what nursing action should be prioritized in the patient's care plan?

Correct answer: A

Rationale: The correct answer is A: Protective isolation and vigilant use of standard precautions. Induction therapy for acute myeloid leukemia (AML) can lead to neutropenia, significantly increasing the risk of infections. Therefore, the priority is to protect the patient from potential pathogens by implementing protective isolation measures and adhering to strict standard precautions. This action is crucial for the patient's survival. Choice B is incorrect as nutritional support and oral hygiene are important but not the priority in this situation. Choice C, involving the family in planning activities, is a valuable aspect of care but not the priority during induction therapy. Choice D, monitoring and treating pain, is essential but ensuring protection against infection takes precedence due to the high risk of neutropenia.

5. The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment?

Correct answer: A

Rationale: The correct answer is A: The client's pain rating. Pain assessment should primarily rely on the client's self-report for the most accurate determination of pain intensity. Nonverbal cues from the client (choice B) can provide additional information but should not replace the client's self-report. The nurse's impression of the client's pain (choice C) may be subjective and less reliable than the client's self-assessment. Pain relief after appropriate nursing intervention (choice D) is an important outcome but does not replace the initial assessment of the client's pain.

Similar Questions

Mina, who is suspected of an ovarian tumor is scheduled for a pelvic ultrasound. The nurse provides which preprocedure instruction to the client?
A home health nurse is caring for a patient with multiple myeloma. Which of the following interventions should the nurse prioritize when addressing the patients severe bone pain?
Nurse Ben is reviewing the laboratory results of a client undergoing chemotherapy. Which of the following values would require immediate intervention?
The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor?
The nurse has educated a client on precautions to take with thrombocytopenia. What statement by the client indicates a need to review the information?

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