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A nurse is contributing to the plan of care for an adolescent client.

Exhibits

Which of the following actions should the nurse identify as part of the plan of care? Select all that apply.

Provide oxygen at 6 L/min via nasal cannula.

Apply cold compresses to joints.

Perform passive ROM exercises.

Administer IV fluids

Obtain consent for a blood transfusion

Restrict fluid intake to 1,400 mL/day

Administer meperidine

Encouraging bedrest

Answer and Explanation

Correct Answer : B,C,G,H

A.   Providing oxygen at 6 L/min via nasal cannula is not indicated based on the information provided. The client denies shortness of breath, and vital signs are within normal limits.
B.   Applying cold compresses to joints can help reduce swelling and alleviate pain in the extremities.
C.   Performing passive range of motion (ROM) exercises is appropriate to maintain joint flexibility and prevent contractures.
D.   Administering IV fluids is not explicitly indicated based on the information provided. Fluid management should be individualized based on the client's condition and underlying factors.
E.   Obtaining consent for a blood transfusion is not necessary unless the client has severe anemia or bleeding.
F.   Restricting fluid intake to 1,400 mL/day may cause dehydration and electrolyte imbalance.
G.   Administering meperidine (a narcotic analgesic) may be considered for pain relief.
H.   Encouraging bedrest is appropriate to minimize joint stress and promote healing, especially when there is pain and swelling in the extremities.

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Correct Answer is D

Explanation

A. Creatine kinase is an enzyme associated with muscle damage, not an indicator of infection.
B. Hemoglobin (Hgb) measures the amount of oxygen-carrying pigment in the blood and is not specific to infection.
C. Platelet count reflects the number of platelets in the blood and is not a direct indicator of infection.
D. An elevated white blood cell (WBC) count is indicative of an immune system response to infection.

A. Standards of care published by the Oncology Nursing Society B. Recommendations from a nurse who has worked in an outpatient chemotherapy clinic C. A qualitative study exploring clients’ perspectives on receiving chemotherapy D. A chapter on chemotherapy in a published textbook

Correct Answer is A

Explanation

A. Standards of care published by reputable organizations, such as the Oncology Nursing Society, provide evidence-based guidelines and best practices.
B. While the experience of a nurse in a chemotherapy clinic is valuable, it may not represent standardized, evidence-based practices.
C. A qualitative study may provide insights into clients' perspectives but may not necessarily offer specific interventions for oral care.
D. Published textbooks can be valuable resources, but standards of care from professional organizations are generally more up-to-date and evidence-based.

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A nurse is contributing to the plan of care for an adolescent client. Exhibits Which of the following actions should the nurse identify as part of the plan of care? Select all that apply.

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A nurse is contributing to the plan of care for an adolescent client.

Exhibits

Which of the following actions should the nurse identify as part of the plan of care? Select all that apply.