A nurse is contributing to the plan of care for a client who has leukemia and is experiencing chronic fatigue.

Which of the following interventions should the nurse plan to include?

Increase protein in the diet.

Increase the client's fluids to 4 L per day.

Encourage the client to have continual bed rest.

Encourage strength-training exercise.

Answer and Explanation

The Correct Answer is A

A. Protein supports tissue repair, maintains muscle mass, and provides sustained energy. Leukemia and its treatments can lead to muscle wasting and general weakness, so additional protein can help counteract these effects and improve energy levels. It is also essential for immune support as well.

B. Increasing fluids to 4 L per day is generally excessive and may not be appropriate for this client. Excessive fluid intake can place strain on the cardiovascular system, which could be problematic, especially if the client is receiving chemotherapy or other treatments that may impact fluid balance.

C. Continual bed rest is not recommended, as it can contribute to deconditioning, muscle atrophy, and worsening fatigue over time. While rest periods are essential for clients experiencing fatigue, it is equally important to incorporate balanced, low-intensity activity to maintain strength and circulation.

D. Such exercises require significant energy and exertion, which might not be tolerable and could exacerbate fatigue. Instead, gentle, low-impact activities like walking or stretching are more appropriate for maintaining function without overwhelming the client’s energy reserves.

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Correct Answer is E

Explanation

Adequate fluid intake helps to soften the stool, prevent constipation, and ease bowel movements. It can also help with bladder function and prevent urinary tract infections. This intervention is particularly relevant given the client's complaint of abdominal cramping and a small, hard, painful bowel movement.

The other options are not appropriate based on the information provided:

"Encourage prolonged dangling before ambulation" is not necessary or relevant in this case. The client is already transferring out of bed to a chair independently and ambulating independently in the hallway, indicating sufficient mobility.
"Irrigate indwelling catheter with 500 mL of fluid" is not indicated based on the provided information. The urinary catheter is intact, and the client is producing an appropriate amount of urine. There is no indication of urinary retention or need for irrigation.
"Administer an enema" is not necessary at this point. The client has reported a small, hard, painful bowel movement, which indicates constipation. However, conservative measures such as encouraging oral fluid intake and possibly adding dietary fiber should be tried first before considering an enema.
"Assist the client with a sitz bath" is not directly related to the client's current symptoms. A sitz bath is typically used for perineal hygiene, pain relief, or healing after certain surgical procedures, but it does not address the reported abdominal cramping or constipation.

A. Soiled linens are placed on the floor B. Waste containers are lined with single bags C. Dampened cloths are used for dusting the area D. Uncapped sharps are put in a puncture-resistant container

Correct Answer is A

Explanation

Placing soiled linens on the floor can lead to cross-contamination and the spread of infectious agents. This can pose a risk to the immunocompromised client, who may be more susceptible to infections.

Lining waste containers with single bags helps contain potentially infectious waste and facilitates proper disposal. This reduces the risk of contamination and exposure to infectious materials.

Using dampened cloths for dusting helps minimize the spread of dust and airborne particles. Dampening the cloth can help capture the dust and prevent it from becoming airborne, reducing the potential for respiratory exposure.

Placing uncapped sharps in a puncture-resistant container is an essential practice to prevent needlestick injuries and the transmission of bloodborne pathogens. This ensures safe disposal of sharps and reduces the risk of accidental needlestick injuries to healthcare workers and clients.

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A nurse is contributing to the plan of care for a client who has leukemia and is experiencing chronic fatigue. Which of the following interventions should the nurse plan to include?

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Naxlex Comprehensive Predictor Exams

Correct Answer is E

Explanation

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Correct Answer is A

Explanation

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A nurse is contributing to the plan of care for a client who has leukemia and is experiencing chronic fatigue.

Which of the following interventions should the nurse plan to include?