The nurse assesses a patient with non-Hodgkin's lymphoma who is ...

[stephzh]

The nurse assesses a patient with non-Hodgkin's lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse?
 
  a. Shortness of breath
  b. Temperature 100.2 F (37.9 C)
  c. Shivering and complaint of chills
  d. Generalized muscle aches and pains

Question 2

The nurse receives change-of-shift report on the oncology unit. Which patient should the nurse assess first?
 
  a. 35-year-old patient who has wet desquamation associated with abdominal radiation
  b. 42-year-old patient who is sobbing after receiving a new diagnosis of ovarian cancer
  c. 24-year-old patient who received neck radiation and has blood oozing from the neck
  d. 56-year-old patient who developed a new pericardial friction rub after chest radiation

[daiying98]

Answer to Question 1

ANS: A
Rituximab (Rituxan) is a monoclonal antibody. Shortness of breath should be investigated rapidly because anaphylaxis is a possible reaction to monoclonal antibody administration. The nurse will need to rapidly take actions such as stopping the infusion, assessing the patient further, and notifying the health care provider. The other findings will also require action by the nurse, but are not indicative of life-threatening complications.

Answer to Question 2

ANS: C
Because neck bleeding may indicate possible carotid artery rupture in a patient who is receiving radiation to the neck, this patient should be seen first. The diagnoses and clinical manifestations for the other patients are not immediately life threatening.

[stephzh]

Excellent

[steff9894]

TYSM