A nurse is planning care for a client who has leukemia and a platelet count of 130,000/mm3. Which of the following interventions should the nurse include in the plan of care?

Check the IV site for bleeding every 8 hr

Obtain a rectal temperature every 8 hr.

Check the client for proteinuria.

Limit, IM injections.

Answer and Explanation

The Correct Answer is D

A. Checking the IV site for bleeding is important for clients with low platelet counts, but it should be monitored more frequently, ideally every 1-2 hours.
B. Obtaining a rectal temperature is routine nursing care but does not specifically address the risk associated with the client's platelet count.
C. Checking for proteinuria may be relevant in other conditions but is not directly related to the client's current hematologic condition.
D. Limiting IM injections is crucial in clients with leukemia and low platelet counts to prevent bleeding complications from puncture sites.

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Correct Answer is D

Explanation

A. Monitoring vital signs every 8 hours is not sufficient for a client undergoing a stem cell transplant, who requires frequent assessment due to potential complications.
B. Providing the client with water is important, but specific fluid volumes and intervals depend on individual needs and should not be standardized.
C. Keeping blood pressure equipment in the client's room is necessary but does not directly address infection control, which is critical in stem cell transplant recipients.
D. Placing the client in a negative airflow room is crucial to reduce the risk of infections, which are a major concern in immunocompromised clients undergoing stem cell transplantation.

A. Rinse the client's mouth with 0.9% sodium chloride every 4 hr. B. Check the client's rectal temperature once daily. C. Place the client in a private room. D. Insert an indwelling urinary catheter. E. Place the client on droplet precautions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}

Explanation

This prescription helps maintain oral hygiene and comfort, which is important during chemotherapy to prevent and manage mucositis.
Routine daily temperature checks may not be necessary unless there are specific concerns about infection or fever.
Placing the client in a private room can reduce the risk of infection, which is crucial due to the client's immunocompromised state from chemotherapy.
Unless there is a specific medical indication (e.g., urinary retention), inserting an indwelling urinary catheter increases the risk of infection, which should be minimized in an immunocompromised client.
Droplet precautions are typically used for respiratory infections transmitted by large droplets. Lung cancer itself does not typically require droplet precautions unless there is an active respiratory infection.

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A nurse is planning care for a client who has leukemia and a platelet count of 130,000/mm3. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is to undergone a stem cell transplant. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

A nurse is caring for a client who has a new diagnosis of lung cancer. Exhibits For each potential provider's prescription at 4 weeks, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}

Explanation

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