A nurse is caring for a client who has HIV and is neutropenic. Which of the following findings should the nurse identify as increasing the risk for the client to develop an infection?
The client is assigned to a room with negative airflow.
The client's meal tray includes ice cream with fresh fruit.
The client has artificial flowers in the room.
The client's meal tray contains hard-boiled eggs.
The Correct Answer is B
A. A room with negative airflow helps prevent the spread of airborne pathogens, which is helpful for immunocompromised clients like those with HIV, but it doesn't directly increase the risk of infection.
B. Correct. Neutropenic clients have reduced immune responses, and consume fresh fruit (which might carry bacteria. can increase the risk of infection.
C. Artificial flowers might be removed due to infection control concerns, but their presence doesn't significantly increase infection risk.
D. Hardboiled eggs are not necessarily a high-risk food for infection in neutropenic clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Pancreatitis typically results in elevated serum lipase and amylase levels due to pancreatic inflammation.
B. Incorrect. Decreased albumin might be seen in conditions affecting liver function or malnutrition but is not specific to pancreatitis.
C. Incorrect. Elevated ammonia levels are often associated with liver dysfunction rather than pancreatitis.
D. Incorrect. Prolonged PT/INR are indicators of impaired clotting, usually associated with liver disease rather than pancreatitis.
Correct Answer is ["A","C","D","F","G","H"]
Explanation
A.The heart rate increased from 90/min on Day 1 to 110/min on Day 2, indicating tachycardia. This can signify an underlying issue, such as hypovolemia or sepsis, especially given the other concerning findings.
B.While the pain level increased from 3/10 to 6/10, pain itself is subjective and should be monitored closely. It may require adjustment in pain management but is not immediately life-threatening compared to other findings.
D.The client's confusion and slow response can indicate a change in neurological status, possibly related to electrolyte imbalances, dehydration, or infection. This is a significant finding that requires immediate attention.
C. The client's skin changed from warm and dry to pale, cool, and clammy, suggesting possible shock or hypoperfusion. This is a critical sign that needs to be communicated to the provider.
E.The respiratory rate increased from 18/min to 22/min, indicating mild respiratory distress. While concerning, it does not represent an acute emergency compared to other findings and should be monitored.
F.The blood pressure dropped from 126/78 mm Hg on Day 1 to 80/60 mm Hg on Day 2, indicating possible hypotension. This change could signify worsening clinical status, potentially indicating shock or significant fluid loss.
G.The urine output decreased significantly from 400 mL over 8 hours to 100 mL over 6 hours, indicating possible acute kidney injury or dehydration.
H.The client’s temperature has increased from 37.2°C (99°F) to 38.4°C (101.1°F), indicating a possible infection or inflammatory response.
I.The sodium level remains within normal limits (144 mEq/L) and does not show significant changes. Therefore, it does not require immediate reporting.
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