A nurse is caring for a 66-year-old client who has a new diagnosis of lung cancer.
For each potential healthcare provider's prescription at 4 weeks, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.
Place the client on droplet precautions.
Insert an indwelling urinary catheter.
Place the client in a private room
Check the client's rectal temperature once daily.
Rinse the client's mouth with 0.9% sodium chloride every 4 hours
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}
Placing the client on droplet precautions is anticipated as it is a standard practice to prevent infection, especially in immunocompromised patients like those undergoing chemotherapy.
A private room is also anticipated to reduce the risk of infection and provide a controlled environment for the patient's comfort and monitoring.
The insertion of an indwelling urinary catheter may be nonessential unless there is a specific indication, such as urinary retention or close monitoring of output in a critically ill patient, as it can increase the risk of urinary tract infections.
Checking the client's rectal temperature once daily could be contraindicated due to the risk of causing trauma or bleeding, especially considering the client's decreased platelet count, which could lead to increased bleeding risk.
Lastly, rinsing the client's mouth with 0.9% sodium chloride every 4 hours is anticipated to help manage the sore mouth, a common side effect of chemotherapy, and to maintain oral hygiene, which is crucial in preventing infections in immunocompromised patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Droplet precautions are not appropriate for anthrax exposure. Precautions would be based on the specific form of anthrax (cutaneous, inhalation, or gastrointestinal).
B. Anthrax is treated with antibiotics, not antiviral therapy. Ciprofloxacin or doxycycline is typically used for prophylaxis and treatment.
C. While assessing for hemorrhage might be relevant in cases of severe anthrax, it is more critical initially to focus on respiratory assessment, particularly for inhalation anthrax.
D. Assessing the respiratory system is crucial for clients exposed to anthrax, particularly inhalation anthrax, as it can cause severe respiratory symptoms and complications. Prompt assessment is essential for early detection and treatment of respiratory distress.
Correct Answer is C
Explanation
A. A subdural hematoma is typically caused by venous bleeding, not arterial bleeding. An arterial rupture would more likely cause an epidural hematoma, which is not the case here.
B. High platelet counts are not commonly associated with the formation of subdural hematomas. Subdural hematomas are usually due to bleeding related to anticoagulant use or trauma.
C. Taking a blood thinner like warfarin increases the risk of bleeding and hematoma formation, particularly when combined with head trauma. This statement correctly links the anticoagulant therapy and head injury as contributing factors to the subdural hematoma.
D. Low bleeding times are not a cause of hematomas. In fact, elevated bleeding times due to anticoagulant therapy would increase the risk of bleeding, not low bleeding times.
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