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 C
Explanation
Choice A rationale
Monitoring for fluid volume excess is not typically a concern for children with Addison's disease, as they are more prone to fluid volume deficit due to adrenal insufficiency.
Choice B rationale
Placing the child on a low-sodium diet is inappropriate for Addison's disease, as these patients often need increased sodium intake due to their impaired ability to retain sodium.
Choice C rationale
Teaching the parents about cortisol replacement therapy is crucial in managing Addison's disease, as the condition involves adrenal insufficiency requiring hormone replacement to manage symptoms and prevent adrenal crisis.
Choice D rationale
Discussing the manifestations of hyperglycemia is not relevant, as Addison's disease is more commonly associated with hypoglycemia due to reduced cortisol production.
Correct Answer is B
Explanation
Choice A rationale
Hyperactive deep tendon reflexes are not associated with thrombocytopenia (low platelet count). Thrombocytopenia primarily affects bleeding and clotting functions rather than neuromuscular reflexes.
Choice B rationale
Spontaneous bleeding is a significant risk with a platelet count of 9,000/mm³, which is critically low. Platelets are essential for blood clotting, and severe thrombocytopenia increases the risk of spontaneous bleeding.
Choice C rationale
Oliguria, or decreased urine output, is not directly related to thrombocytopenia. It may be associated with kidney function issues, but it is not a consequence of low platelet counts.
Choice D rationale
Infection is not directly related to a low platelet count. While patients with severe thrombocytopenia may be at risk for bleeding complications, their susceptibility to infections is more related to their white blood cell counts and immune function.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.