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
Metastatic bone cancer does not typically result in an increase in platelet count. Platelets are involved in blood clotting, and their levels are not usually affected by bone metastases.
Choice B rationale
Calcium levels are often increased in clients with metastatic bone cancer due to the breakdown of bone tissue releasing calcium into the bloodstream.
Choice C rationale
Absolute neutrophil count (ANC) is not typically increased in metastatic bone cancer. ANC levels are more directly related to infections and bone marrow function.
Choice D rationale
White blood cell (WBC) count is not typically increased in metastatic bone cancer. Elevated WBC levels are more commonly associated with infection or inflammation.
Correct Answer is B
Explanation
Choice A rationale
Increasing carbohydrate intake is not recommended for clients with Cushing's disease. Excessive carbohydrates can lead to weight gain and worsen hyperglycemia, common in Cushing's.
Choice B rationale
Restricting sodium intake is essential in Cushing's disease management. Excess sodium can exacerbate hypertension and fluid retention, common issues in Cushing's.
Choice C rationale
Limiting potassium-rich foods is not advised in Cushing's disease. Patients often need more potassium due to potassium loss caused by increased cortisol levels.
Choice D rationale
Decreasing protein intake is not recommended as it can lead to muscle wasting. Protein is necessary to maintain muscle mass and strength, especially with the catabolic effects of cortisol.
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