A client on neutropenic precautions asks the nurse if visitors can bring gifts. How should the nurse respond?

"Visitors can bring you a potted plant for your room."

"Visitors can bring you fresh fruit from the market."

"Visitors can bring you paper flower arrangements."

"Visitors can bring you your favorite raw vegetables."

Answer and Explanation

The Correct Answer is C

A. "Visitors can bring you a potted plant for your room.": Live plants can harbor mold and bacteria, which pose a serious infection risk for immunocompromised clients on neutropenic precautions. Soil and water in potted plants are common sources of pathogens. Plants are contraindicated in neutropenic client rooms.

B. "Visitors can bring you fresh fruit from the market.": Fresh fruits and vegetables may carry bacteria, fungi, or pesticides that can cause infections in clients with neutropenia. Even if washed, they are not considered safe. Raw or unprocessed produce is restricted to minimize infection risk.

C. "Visitors can bring you paper flower arrangements.": Artificial items such as paper flowers do not carry microbes and are safe for clients on neutropenic precautions. They allow for decorative gifts without increasing infection risk. This aligns with safety guidelines for immunocompromised individuals.

D. "Visitors can bring you your favorite raw vegetables.": Raw vegetables can harbor pathogens despite cleaning and present a high risk of infection. Clients with neutropenia are advised to avoid raw produce, including salads and uncooked vegetables. Only thoroughly cooked or processed foods are considered safe.

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Free Nursing Study Resources

Correct Answer is ["B","D","E"]

Explanation

A. Adjust the walker height so the client's arms are fully extended when holding the handles: The walker should be adjusted so the elbows are slightly flexed (about 20–30 degrees), not fully extended. Full extension can cause poor posture and increased risk of falls.

B. Stand slightly behind and on the affected side of the client when they are using a walker: Positioning yourself slightly behind and on the weaker or affected side allows the nurse to provide support and assist with balance, reducing fall risk during ambulation.

C. Have the client lift the device up and forward. Do not allow them to skid it along the floor: Standard walkers are designed to slide or “roll” along the floor; clients should not lift the walker. Lifting can cause instability and increase fatigue.

D. Instruct the client to move the walker forward and then move their affected side forward: Proper technique for weight-bearing ambulation with a walker involves moving the walker first, then stepping with the affected limb, followed by the unaffected limb. This ensures support and safety.

E. Ensure the client is wearing non-skid footwear before ambulating with the walker: Non-skid footwear improves traction and decreases the risk of slips and falls, which is essential for safe ambulation postoperatively.

A. Disregard client facial grimacing during the procedure and continue quickly. B. Administer pain medication at least 30 minutes before the dressing change. C. Cleanse the wound with cold solution to help numb the area. D. Remove the dressing quickly and without warning to reduce anxiety.

Correct Answer is B

Explanation

A. Disregard client facial grimacing during the procedure and continue quickly: Facial grimacing is a nonverbal indicator of pain and should prompt reassessment rather than be ignored. Continuing without addressing discomfort can increase pain perception and anxiety. Client-centered care requires ongoing pain evaluation during wound care.

B. Administer pain medication at least 30 minutes before the dressing change: Pre-medicating allows analgesics sufficient time to reach therapeutic levels before the procedure. Adequate pain control reduces physiologic stress responses and improves tolerance of wound care. This intervention is a standard evidence-based approach to minimizing procedural pain.

C. Cleanse the wound with cold solution to help numb the area: Cold solutions can increase discomfort and cause vasoconstriction, which may impair local circulation and healing. Wound cleansing solutions are typically warmed to body temperature to enhance comfort. Cold application is not recommended for routine wound care.

D. Remove the dressing quickly and without warning to reduce anxiety: Sudden removal can increase pain and distress, particularly if the dressing adheres to the wound bed. Explaining the procedure and removing dressings slowly with appropriate moisture reduces tissue trauma. Clear communication supports comfort and trust during care.

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A client on neutropenic precautions asks the nurse if visitors can bring gifts. How should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Review the electronic health record. Which action(s) should the nurse take when assisting the client to use a weight-bearing gait with a standard walker? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

The nurse plans care for a client with a wound. What action should the nurse incorporate into the client's care plan to minimize discomfort during wound care?

Correct Answer is B

Explanation

A nurse is planning client education about active range of motion (ROM) exercises. Which instruction should the nurse plan to include in the teaching?

The nurse plans to perform a sterile procedure on a client at the bedside. Which action should the nurse plan to take first when setting up their sterile field?

The nurse cares for a group of clients in the emergency department. Which client should the nurse see first?

The nurse is planning to assist a client to transfer from the bed to the chair. Which healthcare provider order should the nurse consider in planning for the client's transfer to the chair?

The nurse observes a visitor of a client with meningitis. Which finding should concern the nurse?

The nurse has provided education to a client and their family member about how to change wound dressings. Which client statement indicates the need for additional teaching?

The nurse is caring for a group of clients who all need bed alarms to prevent falls. Which client should the nurse ensure has the bed alarm enabled first?

The nurse is observing a student nurse complete a urinary catheter insertion. What finding should cause the nurse to pause the procedure and obtain sterile equipment?