A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client?

Wear an N95 respirator.

Insert an indwelling urinary catheter to monitor urinary output.

Monitor the client's vital signs every 8 hr.

Use a dedicated stethoscope.

Answer and Explanation

The Correct Answer is D

A. Wearing an N95 respirator is not necessary when caring for a client with neutropenia due to HIV unless the client has respiratory symptoms or is undergoing procedures that generate aerosols.

B. Inserting an indwelling urinary catheter should be avoided unless necessary, as it can

introduce the risk of infection, which is particularly concerning in clients with neutropenia.

C. Monitoring vital signs every 8 hours may not provide sufficient frequency for detecting changes in a client with neutropenia who may be at risk for rapid deterioration.

D. Using a dedicated stethoscope helps prevent the spread of infection to other clients by avoiding cross-contamination, which is especially important when caring for a client with neutropenia who is at increased risk of infection.

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Correct Answer is B

Explanation

A. Administering furosemide may also be appropriate for managing heart failure symptoms, but the priority action based on the client's condition is to withhold digoxin.

B. The client's vital signs indicate bradycardia (pulse 52/min), which is a common adverse effect of digoxin, especially in the setting of heart failure. Withholding digoxin is necessary to prevent further exacerbation of bradycardia and potential toxicity.

C. Withholding spironolactone may be considered if there are concerns about electrolyte imbalances, but it is not the priority action in this scenario.

D. Administering ferrous sulfate is not indicated based on the client's chart findings; there is no indication of anemia or iron deficiency.

A. Insist the client use direct eye contact during the interview. B. Seat the client at least 3.7 m (12 feet) from the nurse. C. Position the client's chair between the nurse's chair and the door. D. Lean in slightly when speaking to the client.

Correct Answer is D

Explanation

A. Insisting the client use direct eye contact may be intimidating or uncomfortable for the client, especially in a mental health setting where individuals may have varying levels of comfort with eye contact.

B. Seating the client at such a distance may create a physical barrier and hinder effective communication between the nurse and the client.

C. Positioning the client's chair between the nurse's chair and the door may make the client feel trapped or uncomfortable, especially during a sensitive interview.

D. Leaning in slightly when speaking to the client demonstrates attentiveness and facilitates a sense of closeness and engagement in the conversation, which can help build rapport and trust.

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A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

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Correct Answer is D

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