A nurse is caring for a 60-year-old female client in the oncology unit who is currently receiving chemotherapy for breast cancer. The client presents with a recent onset of symptoms, and the nurse must evaluate the best actions to take based on the exhibits provided.
Which of the following actions should the nurse take?
Place the client on contact precautions.
Place the client in a private room.
Encourage the client to increase fluid intake.
Wear a mask when caring for the client.
Prepare to administer an antibiotic to the client.
Correct Answer : B,C,D
Choice A rationale: Contact precautions are not necessary in this situation as the client is presenting symptoms of a possible infection related to chemotherapy-induced immunosuppression, not a contagious disease.
Choice B rationale: Placing the client in a private room is crucial to protect her from potential infections, given her compromised immune system due to chemotherapy.
Choice C rationale: Encouraging the client to increase fluid intake can help manage fever and muscle aches and keep her hydrated, which is important when dealing with symptoms of infection and fatigue.
Choice D rationale: Wearing a mask when caring for the client is necessary to protect both the client and the healthcare provider from potential infections, considering the client’s immunocompromised state.
Choice E rationale: Preparing to administer an antibiotic should be based on the healthcare provider's orders and further diagnostic results. While it might be necessary, it is not an immediate nursing action without provider confirmation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Providing 1,000 mL of water every 12 hours is not directly related to preventing infection or other complications post-transplant.
Choice B rationale
Keeping blood pressure equipment in the client's room helps prevent cross-contamination and infection by not sharing equipment with other clients.
Choice C rationale
A negative airflow room is used for clients with airborne infections, not for those undergoing a stem cell transplant.
Choice D rationale
Monitoring vital signs every 8 hours is insufficient; more frequent monitoring is needed post-transplant to detect complications early.
Correct Answer is ["A","D"]
Explanation
Choice A rationale
Weighing a client with heart failure is a non-invasive and routine task that can be performed by an assistive personnel (AP). Accurate daily weights are essential for monitoring fluid balance in these clients.
Choice B rationale
Incorrect, as providing discharge instructions for a client requires professional nursing judgment and assessment, tasks outside the scope of practice for APs.
Choice C rationale
Incorrect, as performing an admission assessment requires critical thinking and clinical judgment, which are responsibilities of a licensed nurse.
Choice D rationale
Ambulating an older adult client with hypertension can be safely done by an AP. This helps in maintaining the client's mobility and preventing complications such as blood clots and muscle atrophy.
Choice E rationale
Incorrect, as checking a blood product with another nurse prior to administration involves a critical safety check that must be performed by licensed nurses to ensure the right blood is given to the right patient.
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