A nurse is assisting in the plan of care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?

Limit the number of health care workers entering the room.

Insert an indwelling catheter to monitor for sediment in the urine.

Take the client’s temperature once per shift

Provide the client with fresh fruit to avoid constipation

Answer and Explanation

The Correct Answer is A

A.   Limiting the number of health care workers entering the room helps reduce the risk of exposure to infections.
B.   Inserting an indwelling catheter is not a routine intervention for immunosuppressed clients and may increase the risk of infection.
C.   Monitoring temperature more frequently than once per shift is crucial to detect early signs of infection in immunosuppressed clients.
D.   Fresh fruit may carry a risk of bacterial contamination, and caution should be exercised in providing it to immunosuppressed clients.

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Correct Answer is D

Explanation

A. While discomfort can occur, it is not an expected or acceptable part of end-of-life care. Effective pain management is a key priority, and discomfort should be addressed promptly to ensure the client’s comfort and dignity.

B. While true, this statement does not directly address the expectation of discomfort at the end of life.
C. While pain can be present in older adults, the statement does not specifically address the end-of-life context.
D.Fear of addiction is a common concern among clients and families, even at the end of life. Nurses should educate clients and families about the importance of managing pain effectively and emphasize that addiction is not a concern when opioids are used appropriately for end-of-life care. This helps alleviate anxiety and encourages adherence to prescribed pain management regimens.

A. Instruct client to use an incentive spirometer every 4 hr. B. Place the client in a room with negative-pressure airflow. C. Serve cooked fruit with meals. D. Report temperatures greater than 39.5 C (102.3 F lasting more than 4 hr.)

Correct Answer is D

Explanation

A. The use of an incentive spirometer is more relevant for preventing respiratory complications, not related to the client's low WBC count.
B. Negative-pressure airflow rooms are typically used for clients with airborne infections, not those with low WBC counts.
C. Cooked fruits may be advisable to reduce the risk of bacterial contamination in immunosuppressed clients, but it does not directly address the low WBC count.
D. Reporting temperatures greater than 39.5°C (102.3°F) lasting more than 4 hours is crucial as it may indicate an infection, and prompt intervention is needed in immunosuppressed clients.

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A nurse is assisting in the plan of care for a client who has immunosuppression following chemotherapy. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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