A nurse is caring for a client who has a white blood cell (WBC) count of 15,000/mm3. Which of the following actions should the nurse take?
Place the client in a private room.
Monitor the client's temperature every 4 hr.
Administer an antihistamine as prescribed.
Encourage the client to increase fluid intake.
The Correct Answer is B
Choice A reason: Placing the client in a private room is not necessary for a client who has a high WBC count, unless they have other indications for isolation, such as an infectious disease. A high WBC count may indicate inflammation, infection, or other conditions that affect the immune system.
Choice B reason: Monitoring the client's temperature every 4 hr is an appropriate action for a nurse to take for a client who has a high WBC count. A fever is a common sign of infection or inflammation, and it may require further intervention, such as antibiotics or antipyretics.
Choice C reason: Administering an antihistamine as prescribed is not related to a high WBC count. Antihistamines are used to treat allergic reactions, which may cause a low WBC count due to the release of histamine from mast cells.
Choice D reason: Encouraging the client to increase fluid intake is not specific to a high WBC count. Fluid intake should be based on the client's hydration status, urine output, and other factors. Increasing fluid intake may help flush out toxins or bacteria, but it is not a priority action for a client who has a high WBC count.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This test measures the level of antibodies that the body produces against the streptolysin O enzyme, which is produced by some strains of streptococcal bacteria. A high level of ASO titer indicates that the child had a recent streptococcal infection, which may trigger rheumatic fever in some cases.
Choice B reason: This test does not directly indicate if the child has rheumatic fever. Rheumatic fever is a complication of untreated or inadequately treated streptococcal infection, which causes inflammation of the heart, joints, skin, and brain. The diagnosis of rheumatic fever is based on clinical criteria, such as the presence of carditis, polyarthritis, chorea, erythema marginatum, or subcutaneous nodules.
Choice C reason: This test does not confirm if the child has immunity to streptococcal bacteria. Immunity is the ability of the body to resist or fight off an infection. A high level of ASO titer does not mean that the child is immune to streptococcal bacteria, but rather that the child was exposed to them recently.
Choice D reason: This test does not indicate if the child has a therapeutic blood level of an aminoglycoside. Aminoglycosides are a class of antibiotics that are used to treat serious bacterial infections, such as endocarditis or septicemia. The blood level of an aminoglycoside is measured by a different test, called a peak and trough level, which determines the effectiveness and safety of the drug.
Correct Answer is A
Explanation
Choice A reason: Your baby will receive a hepatitis B vaccine prior to discharge is correct, as this is the recommended schedule for the first dose of the hepatitis B vaccine for all newborns, regardless of maternal hepatitis B status.
Choice B reason: Your baby will have the first diphtheria, tetanus, pertussis vaccine at the 2 week well-baby visit is incorrect, as this is too early for the first dose of the DTaP vaccine. The first dose of the DTaP vaccine should be given at 2 months of age.
Choice C reason: Your baby should receive the pneumococcal conjugate vaccine on his first birthday is incorrect, as this is too late for the first dose of the PCV13 vaccine. The first dose of the PCV13 vaccine should be given at 2 months of age, followed by three more doses at 4, 6, and 12-15 months of age.
Choice D reason: Your baby should receive the measles, mumps, rubella vaccine at 6 months is incorrect, as this is too early for the first dose of the MMR vaccine. The first dose of the MMR vaccine should be given at 12-15 months of age, followed by a second dose at 4-6 years of age.
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