A nurse is admitting a client who has neutropenia. Which of the following precautions should the nurse take?
Monitor vital signs at least every 4 hr.
Insert an indwelling urinary catheter.
Change the client's linens three times a day.
Place the client in a room with negative airflow.
The Correct Answer is A
A. Frequent vitals monitoring to allow for early detection of infection. Clients with neutropenia are at increased risk of infections.
B. Indwelling catheter and other devices should be avoided in individuals with neutropenia die to risk of sepsis.
C. Changing the client’s linen is important. However, doing it 3 times a day is not necessary.
D. Clients should be placed in a positive airflow room to prevent contracting infections from infected persons
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Restraints should be avoided whenever possible. Addressing the underlying cause of wandering (such as anxiety, discomfort, or confusion) is essential.
A. In cases where restraints are deemed necessary to prevent harm to the client, such as preventing them from dislodging their tube feeding, it may be appropriate.
C. The use of an abduction pillow is a common preventive measure to maintain proper hip alignment and prevent hip dislocation, especially after hip surgery.
D. Soft heel protectors are used to prevent pressure ulcers and protect the heels from injury while the client is in bed.
Correct Answer is B
Explanation
B. Supporting the feet with a rolled pillow helps prevent foot drop (a common issue in hemiplegia). It maintains the ankle in a neutral position, preventing contractures.
A. When lying on the stomach (prone position), the neck should be neutral (neither flexed nor extended). Flexing the neck backward can strain the cervical spine and compromise airway alignment.
C. For a client with right-sided hemiplegia, the affected leg (right leg) should be supported to prevent foot drop.
D. A thick pillow under the head can cause neck hyperextension.
The head should be supported with a small, firm pillow to maintain a neutral neck position.
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