A nurse is planning care for a client who has chemotherapy-related immunosuppression. Which of the following interventions should the nurse add to the client's plan of care?
Measure the client's rectal temperature daily.
Encourage ambulation in the facility's hallways.
Monitor the client's temperature every 8 hr.
Monitor the client's WBC count daily.
The Correct Answer is D
A. Measure the client’s rectal temperature daily: Rectal temperature measurement is contraindicated in immunosuppressed clients due to the risk of mucosal injury, which can introduce bacteria into the bloodstream and lead to sepsis.
B. Encourage ambulation in the facility’s hallways: While ambulation is beneficial for overall health, hallway ambulation exposes immunosuppressed clients to environmental pathogens and increases their infection risk. Exercise should be encouraged in a protected and sanitized space.
C. Monitor the client’s temperature every 8 hr: More frequent temperature monitoring is required in clients undergoing chemotherapy with immunosuppression, as even a slight elevation may signal an early infection. Monitoring every 8 hours may not be adequate.
D. Monitor the client’s WBC count daily: Daily monitoring of white blood cell count is essential to detect neutropenia early. A low WBC count increases the risk for infection, and frequent monitoring allows for timely interventions like protective isolation or treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Secure the catheter to the client's thigh: Securing the catheter prevents unnecessary movement and traction at the urethral site, reducing irritation and the risk of introducing bacteria. Stabilizing the catheter is a critical step in preventing catheter-associated urinary tract infections (CAUTIs).
B. Obtain urinary samples by disconnecting the tubing connections: Disconnecting the system increases the risk of introducing pathogens into the closed drainage system. Urine samples should be obtained using the designated sampling port with aseptic technique.
C. Loop the tubing so that it is lower than the collection bag: The tubing should flow downward in a straight, unobstructed line to the collection bag. Looping it lower than the bag can lead to urine backflow, increasing the risk of infection.
D. Keep the urinary bag at bladder level when ambulating: The drainage bag should always remain below bladder level to prevent urine backflow into the bladder. Keeping it at bladder level raises infection risk by allowing potentially contaminated urine to re-enter the bladder.
Correct Answer is D
Explanation
A. Measure the client’s rectal temperature daily:Rectal temperature measurement is contraindicated in immunosuppressed clients due to the risk of mucosal injury, which can introduce bacteria into the bloodstream and lead to sepsis.
B. Encourage ambulation in the facility’s hallways:While ambulation is beneficial for overall health, hallway ambulation exposes immunosuppressed clients to environmental pathogens and increases their infection risk. Exercise should be encouraged in a protected and sanitized space.
C. Monitor the client’s temperature every 8 hr:More frequent temperature monitoring is required in clients undergoing chemotherapy with immunosuppression, as even a slight elevation may signal an early infection. Monitoring every 8 hours may not be adequate.
D. Monitor the client’s WBC count daily:Daily monitoring of white blood cell count is essential to detect neutropenia early. A low WBC count increases the risk for infection, and frequent monitoring allows for timely interventions like protective isolation or treatment.
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