A client with multiple myeloma receiving chemotherapy has a temperature of 102.2 degrees Fahrenheit. The temperature was 99.2 degrees Fahrenheit six hours ago. The PRIORITY nursing intervention is to:

Administer the prescribed antipyretic and notify the primary health care provider.

Assess the color and content of the urine specimen for urinalysis.

Note the consistency of respiratory secretions and obtain a specimen for culture.

Compare all prior vital signs and continue to monitor every hour.

Answer and Explanation

The Correct Answer is A

Choice A reason: Administering an antipyretic to reduce the fever and notifying the primary health care provider are the priority actions. A rapid rise in temperature in a client with multiple myeloma receiving chemotherapy could indicate a serious infection, which requires prompt medical attention.

Choice B reason: Assessing the color and content of the urine specimen for urinalysis is important but is not the immediate priority. The rapid rise in temperature is a more urgent concern.

Choice C reason: Noting the consistency of respiratory secretions and obtaining a specimen for culture is important but not the immediate priority. The primary concern is addressing the fever and notifying the healthcare provider.

Choice D reason: Comparing prior vital signs and continuing to monitor every hour is necessary but not the immediate priority. Immediate action is required to address the fever and potential infection.

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Correct Answer is C

Explanation

Choice A reason: Clear-colored outflow is normal and indicates that the dialysis process is functioning correctly.

Choice B reason: Outflow amount exceeding inflow amount may be noted and reported, but it is not an immediate cause for concern unless accompanied by other symptoms.

Choice C reason: Cloudy opaque colored outflow indicates possible peritonitis, an infection of the peritoneum. This is a serious complication that requires immediate medical attention to prevent further complications.

Choice D reason: Non-purulent outflow is not an immediate cause for concern and indicates that there is no infection present.

A. Are you taking any medications? B. Have you had a recent infection? C. Have you traveled overseas? D. Do you have a history of chronic alcohol abuse?

Correct Answer is B

Explanation

Choice A reason: While knowing if the client is taking any medications is important, it does not directly relate to diagnosing Guillain-Barré syndrome.

Choice B reason: Guillain-Barré syndrome often follows a recent infection, such as a respiratory or gastrointestinal infection. The immune response to the infection can trigger an autoimmune reaction that damages the peripheral nerves, leading to the symptoms of GBS. Therefore, asking about recent infections helps establish a potential cause for the syndrome.

Choice C reason: Travel history can be relevant for certain infectious diseases, but it is not a primary question for diagnosing GBS.

Choice D reason: A history of chronic alcohol abuse is more relevant to other neurological conditions, such as peripheral neuropathy, but not specifically to Guillain-Barré syndrome.

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A client with multiple myeloma receiving chemotherapy has a temperature of 102.2 degrees Fahrenheit. The temperature was 99.2 degrees Fahrenheit six hours ago. The PRIORITY nursing intervention is to:

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is undergoing peritoneal dialysis. What should the nurse report IMMEDIATELY to the provider?

Correct Answer is C

Explanation

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

Correct Answer is B

Explanation

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