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 B
Explanation
Choice A reason: Haemophilus influenzae type b (Hib) vaccine is not the correct choice, as it is usually given to children at 2, 4, 6, and 12 to 15 months of age. A 4-year-old child should have already completed the Hib vaccine series.
Choice B reason: Varicella (VAR) vaccine is the correct choice, as it is recommended for children at 12 to 15 months and 4 to 6 years of age. A 4-year-old child is due for the second dose of the VAR vaccine.
Choice C reason: Hepatitis B (HepB) vaccine is not the correct choice, as it is usually given to children at birth, 1 to 2 months, and 6 to 18 months of age. A 4-year-old child should have already completed the HepB vaccine series.
Choice D reason: Meningococcal (MCV4) vaccine is not the correct choice, as it is not routinely recommended for children younger than 11 years of age. MCV4 vaccine is given to children at 11 to 12 years and 16 years of age, or to children with certain high-risk conditions.
Correct Answer is C
Explanation
Choice A reason: This is not a correct instruction for the nurse to include in the teaching. Emphasizing the quantity, rather than the quality, of food consumed may lead to overeating, obesity, or malnutrition. The nurse should encourage the mother to offer a variety of healthy foods in appropriate portions and avoid forcing or bribing the child to eat.
Choice B reason: This is not a correct instruction for the nurse to include in the teaching. Expecting that food consumption might not decrease significantly may cause the mother to ignore the signs of poor nutrition or growth in the child. The nurse should advise the mother to monitor the child's weight, height, and development regularly and consult the provider if there are any concerns.
Choice C reason: This is a correct instruction for the nurse to include in the teaching. Adding fruit juice to the child's diet can increase the vitamin intake, especially vitamin C, which is important for immune function and wound healing. The nurse should recommend the mother to choose 100% fruit juice and limit the amount to 4 to 6 oz per day.
Choice D reason: This is not a correct instruction for the nurse to include in the teaching. Having the child remain at the table after meals to increase food intake may create a negative association with eating and cause more resistance or frustration. The nurse should suggest the mother to make mealtime a pleasant and relaxed experience and respect the child's appetite and preferences.
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