A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm3.
Which of the following actions should the nurse take?
Instruct the client to avoid eating raw fruit.
Apply pressure to venipuncture sites for 10 min.
Move the client to a negative pressure room.
Use contact isolation while providing care to the patient.
The Correct Answer is A
Choice A rationale: A client who has bladder cancer and a low WBC count is at risk for infection due to impaired immunity. Raw fruit can harbor bacteria and fungi that can cause infections in the client.
Choice B rationale: Applying pressure to venipuncture sites for 10 min is not necessary for a low WBC count and is not related to bladder cancer.
Choice C rationale: Moving the client to a negative pressure room is not necessary for a low WBC count related to bladder cancer. It is used for clients who have airborne infections, such as tuberculosis or chickenpox, to prevent the spread of pathogens to other clients and staff.
Choice D rationale: This is not a correct answer because contact isolation is used for clients who have infections that can be transmitted by direct or indirect contact, such as Clostridium difficile or scabies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Thrombocytopenia (a low platelet count) is a contraindication to heparin therapy because heparin can further increase the risk of bleeding in individuals with reduced platelet levels.
Choice B rationale: Rheumatoid arthritis is not a contraindication to heparin therapy. It is an autoimmune condition affecting the joints.
Choice C rationale: COPD (Chronic Obstructive Pulmonary Disease) is not a contraindication to heparin therapy. Heparin primarily affects the circulatory system.
Choice D rationale: Thalassemia is not a contraindication to heparin therapy.
Thalassemia is a genetic blood disorder affecting hemoglobin production.
Correct Answer is D,B,C,A
Explanation
Choice A rationale: Finally, the nurse should transfer the client to the CCU for close monitoring of vital signs, neurological status, and bleeding complications.
Choice B rationale: Then, the nurse should weigh the client to calculate the correct dose of tPA, which is based on body weight.
Choice C rationale: This comes after checking for the contraindications and weighing the client to determine the dose to be administered. The nurse should administer the tPA within 3 hours of symptom onset to dissolve the clot and restore blood flow to the brain.
Choice D rationale: The nurse should first check for contraindications to tPA, such as recent surgery, bleeding disorders, or uncontrolled hypertension.
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