A nurse is caring for a 63-year-old female client in the emergency department (ED) with a history of colorectal cancer. The client is receiving chemotherapy and radiation. She presents with complaints of fatigue, unexplained bruising, and recurring headaches. The nurse must evaluate the situation based on the exhibits provided to determine the client’s risk factors and findings.

Exhibits

The client is at risk for developing
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due to their
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Choice A rationale:

The client's low platelet count (90 x 10⁹/L) is a significant risk factor for developing Disseminated Intravascular Coagulation (DIC), a condition characterized by abnormal blood clotting and bleeding. The client's history of cancer and symptoms such as unexplained bruising and fatigue further support this risk.

Choice B rationale:

Hyperkalemia is characterized by high potassium levels, but the client's potassium level is within the normal range (4.1 mmol/L), so this is not a risk factor.

Choice C rationale:

Hyponatremia is a condition of low sodium levels in the blood. The client's sodium level is normal (137 mmol/L), so this is not a risk factor.

Choice D rationale:

Pneumonia is a lung infection, and the client's oxygen saturation is normal (98% on room air), indicating no immediate risk of pneumonia.

Choice E rationale:

Acute nephritic syndrome is a kidney disorder that can cause elevated blood urea nitrogen (BUN) and creatinine levels. The client's BUN is slightly elevated (22 mg/dL), but her creatinine level is normal (1.0 mg/dL), making this less likely.

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Correct Answer is A

Explanation

Choice A rationale
Exercise, in general, is beneficial and should not exacerbate systemic lupus erythematosus (SLE). In fact, regular, gentle exercise can improve overall health and reduce symptoms.
Choice B rationale
Infection can trigger or exacerbate SLE flares by activating the immune system, which can cause increased inflammation.
Choice C rationale
Sunlight exposure can exacerbate SLE due to photosensitivity, leading to skin rashes and triggering systemic flares.
Choice D rationale
Pregnancy can exacerbate SLE due to hormonal changes and the additional strain on the immune system.

A. Instruct the client to eat cooked foods only. B. Don a mask, gloves, and gown. C. Restrict visitors who have active infections. D. Dispose of all linen in the trash after use. E. Limit the client from bathing daily.

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.

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Naxlex Comprehensive Predictor Exams

A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE?

Correct Answer is A

Explanation

A nurse is creating the plan of care for a client who is immunosuppressed.Which of the following precautions should the nurse include in the plan? (Select all that apply)

Correct Answer is ["A","B","C"]

Explanation

On a hot humid day, a nurse is caring for a client who is confused and presents with these vital signs: temperature 104.1°F (40.1°C), pulse 132 beats/min, respirations 26 breaths/min, and blood pressure 106/66 mmHg. What action would the nurse take to provide immediate appropriate care?

A nurse is planning to assign tasks for a group of clients.Which of the following tasks should the nurse plan to assign to an assistive personnel (AP)? (Select all that apply)

A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take?

A nurse is reviewing a client's CBC findings and discovers that the client's platelet count is 9,000/mm³. The nurse should monitor the client for which of the following conditions?

A nurse is planning care for a client who is to undergo a stem cell transplant. Which of the following actions should the nurse plan to take?

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