Author Question: The nurse caring for a client who has had a bone marrow transplant assesses a rash over a large part ... (Read 79 times)

RRMR · **on:** Jul 22, 2018

The nurse caring for a client who has had a bone marrow transplant assesses a rash over a large part of the client's body and discovers, upon questioning, that the client has had diarrhea and vomiting on day 30 following the transplant.

The nurse reviews laboratory results and sees liver enzymes are elevated.The nurse suspects that this client has: 1. Veno-occlusive liver disease.
2. Renal insufficiency.
3. Gastrointestinal toxicity.
4. Acute graft-versus-host disease.

Question 2

The nurse would measure vital signs more frequently than every 4 hours for which of the following clients?

1. The client with a diagnosis of terminal cancer admitted for palliative care
2. The client who is 6 days postoperative and is to be discharged tomorrow
3. The client admitted as an outpatient for 12 hours while receiving a blood transfusion
4. The client who is 36 hours postoperative and stable

kjohnson · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

4
Rationale: These are classic symptoms of acute graft-versus-host disease following a bone marrow transplant, as the body attempts to destroy the bone marrow seen as a foreign antigen.

Answer to Question 2

3
Rationale: A client receiving blood transfusions requires vital signs before beginning the transfusion, 15 minutes after starting the transfusion and then hourly from that point onward until the transfusion is completed. The other clients would require vital signs every 4 hours unless a complication or change in condition arose.