A patient diagnosed with leukemia underwent a bone marrow transplant. Which of the following are specific interventions for post-transplant nursing care?


• The following options are nursing care measures for the post-transplant phase: 

• Monitoring for fever or any other signs of infection is high priority, due to the immunosuppression of this patient.

• Providing skin care is necessary because skin breakdown can occur from profuse diarrhea after the transplant.

• Documenting intake and output, as well as the moisture of mucous membranes, helps to assess and maintain fluid and electrolyte balance and to promote nutrition.

• Incorrect: Immunosuppression with total body irradiation (TBI) is given immediately prior to the transplant to eradicate existing disease and to suppress immune reactions. This is not a post-transplant nursing intervention.

• Incorrect: Visitors should NOT bring in any fresh fruit or flowers (or vegetables) because the patient is immunocompromised and fresh fruits, vegetables, and plants can increase the risk for infection (bacteria and/or fungus are commonly present on fresh fruit, vegetables, or flowers).

Visit our website for other NCLEX topics now!