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A nurse is caring for an immunocompromised client on chemotherapy. The family would like to visit. What teaching should the nurse provide to the family regarding protective isolation?

Visitors may bring a fruit basket to increase client's nutrition.

Visitors should be taught to refrain from bringing flowers.

A sick family member can visit as long as they wear a surgical mask.

All visitors must complete hand washing and wear an N95 mask.

Answer and Explanation

The Correct Answer is B

A reason:

Visitors may bring a fruit basket is incorrect. Fresh fruit can carry bacteria and should be avoided.

B reason:

Refraining from bringing flowers is correct. Flowers can carry bacteria and fungi, posing a risk to immunocompromised clients.

C reason:

A sick family member visiting, even with a mask, is incorrect. Sick visitors should avoid contact with immunocompromised clients to prevent infection.

D reason:

All visitors must complete hand washing, but wearing an N95 mask is not necessary unless specifically required. Standard masks are typically sufficient.

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Correct Answer is D

Explanation

A reason:

Troponin levels are not directly related to malnutrition. Troponin is a cardiac biomarker used to diagnose myocardial infarction (heart attack) and other heart-related conditions.

B reason:

Total bilirubin is primarily used to assess liver function and diagnose conditions like jaundice and liver disease. It is not specifically related to nutritional status.

C reason:

Creatine kinase is an enzyme found in the heart, brain, and skeletal muscle. Elevated levels can indicate muscle damage but are not directly associated with malnutrition.

D reason:

Albumin is a protein made by the liver, and its levels can be significantly affected by malnutrition. Low albumin levels are often seen in individuals with poor nutritional status, as adequate protein intake is essential for maintaining normal albumin levels.

A. Provide the client a sip of warm water, wait 5 minutes, and measure the temperature B. Document that the nurse was unable to measure the client's temperature C. Proceed to measure the oral temperature D. Wait 30 minutes and return to measure the oral temperature

Correct Answer is D

Explanation

A reason:

Providing a sip of warm water and waiting 5 minutes is not sufficient to ensure an accurate oral temperature reading. The temperature of the mouth needs to stabilize, which takes longer than 5 minutes.

B reason:

Documenting that the temperature could not be measured should be a last resort. The nurse should make an effort to obtain an accurate reading after an appropriate waiting period.

C reason:

Proceeding to measure the oral temperature immediately after consuming ice chips will likely yield an inaccurate reading, as the cold temperature can lower the reading artificially.

D reason:

Waiting 30 minutes before measuring the oral temperature is the correct action. This allows the oral cavity to return to its baseline temperature, ensuring a more accurate measurement.

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A nurse is caring for an immunocompromised client on chemotherapy. The family would like to visit. What teaching should the nurse provide to the family regarding protective isolation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?

Correct Answer is D

Explanation

A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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