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.

Use contact isolation while providing care.

Apply pressure to venipuncture sites for 10 min.

Move the client to a negative pressure room.

Answer and Explanation

The Correct Answer is A

The client has neutropenia, which is a low number of neutrophils, a type of white blood cell that fights infection. The client is at risk for developing infections from bacteria and fungi that are normally present in the environment. Raw fruits may contain these microorganisms and should be avoided.

Contact isolation is not necessary for neutropenic clients, unless they have an active infection. Applying pressure to venipuncture sites for 10 min is a standard precaution for all clients, not specific to neutropenic clients. Moving the client to a negative pressure room is indicated for clients with airborne infections, not neutropenic clients.

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Free Nursing Study Resources

Correct Answer is B,A,C,D

Explanation

The nurse should first check for contraindications to tPA, such as hemorrhagic stroke, recent surgery, bleeding disorder, or uncontrolled hypertension. Then, the nurse should weigh the client to calculate the correct dose of tPA based on body weight. Next, thenurse should administer the tPA within three hours of symptom onset to improve the chances of recovery. Finally, the nurse should transfer the client to the CCU for close monitoring of vital signs, neurological status, and possible complications.

A. Urine output 45 mL/hr B. Potassium 5.2 mEq/L C. Capillary refill 1.5 seconds D. PaCO2 37 mm Hg

Correct Answer is B

Explanation

This indicates hyperkalemia, which is a common complication of severe burn injuries due to massive cell destruction and fluid lossfrom damaged tissues. Hyperkalemia can lead to cardiac dysrhythmias and arrest, which are signs of hypovolemic shock.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B,A,C,D

Explanation

A nurse is caring for a client who has a severe burn injury. The nurse should recognize which of the following client findings as an indication of hypovolemic shock?

Correct Answer is B

Explanation

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