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 ["A","B","C"]
Explanation
Choice A rationale
Immunosuppressed clients are at increased risk for infections from foodborne pathogens. Eating only cooked foods helps to kill potentially harmful bacteria, reducing the risk of infection. Raw foods can harbor bacteria and parasites that cooked foods do not.
Choice B rationale
Wearing a mask, gloves, and gown protects both the immunosuppressed client and the healthcare provider from the transmission of pathogens. This personal protective equipment (PPE) barrier reduces the likelihood of infection by preventing the transfer of pathogens.
Choice C rationale
Visitors with active infections pose a high risk to immunosuppressed clients due to their weakened immune systems. Restricting such visitors helps in minimizing the exposure to infectious agents and therefore decreases the risk of infections.
Choice D rationale
Incorrect, as disposing of linen in the trash is not a standard infection control practice. Linens should be handled according to hospital protocols, typically involving proper laundering to prevent contamination and spread of infections.
Choice E rationale
Limiting bathing is not recommended. Regular bathing helps in maintaining skin integrity and preventing skin infections. However, excessive bathing might lead to dry skin, so balanced hygiene practices should be maintained.
Correct Answer is C
Explanation
Choice A rationale
Metabolic acidosis can occur in renal failure but is not directly linked to tumor lysis syndrome.
Choice B rationale
Elevated white blood cell count is not a primary contributor to renal failure in tumor lysis syndrome.
Choice C rationale
Crystallization of uric acid in the renal tubules can obstruct urine flow and cause acute renal failure, which is a direct pathophysiologic event in tumor lysis syndrome.
Choice D rationale
Hypocalcemia is a consequence of tumor lysis syndrome but does not directly cause renal failure.
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